*** ^*-
 
 THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIIT. 
 
 VOLUME XXX VI.
 
 A COLLECTION 
 
 THE PUBLISHED WRITINGS 
 
 OF T1IE LATE 
 
 THOMAS ADDISON, M.D., 
 
 PHYSICIAN TO GUY'S HOSPITAL. 
 
 EDITED, WITH INTRODUCTORY PRE1ACES TO SEVERAL OF THE PAPER?, 
 
 BY 
 
 DR. WILKS AND DR. DALDY. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLXVIII.
 
 LONDON : 
 . E. ADLAKD, 1'KIMEB, BAHXllOLOMJin' CLOSE.
 
 CONTENTS. 
 
 PAGE 
 BIOGRAPHY . . . . . . . ix 
 
 I. OBSERVATIONS ON THE ANATOMY OF THE LUNGS . . i 
 
 II. OBSERVATIONS ON THE DIAGNOSIS OF PNEUMONIA . . 7 
 
 III. OBSERVATIONS ON PNEUMONIA AND ITS CONSEQUENCES . . 17 
 
 IV. ON THE PATHOLOGY OF PHTHISIS . . . . -39 
 
 V. ON THE DIFFICULTIES AND FALLACIES ATTENDING PHYSICAL 
 
 DIAGNOSIS IN DISEASES OF THE CHEST . . . .65 
 
 VI. OBSERVATIONS ON TATTY DEGENERATION OF THE LIVER . . 99 
 
 VII. ON THE DISORDERS OF FEMALES CONNECTED WITH UTERINE 
 
 IRRITATION . . . . . . . 109 
 
 VIII. CASE OF OVARIAN DROPSY REMOVED BY THE ACCIDENTAL RUPTURE 
 
 OF THE CYST . . . . . . 155 
 
 IX. ON A CERTAIN AFFECTION o? THE SKIN, VITILIGOIDEA a. PLANA, 
 
 ft. TUBEROSA ....... 157 
 
 X. ON THE KELOID OF ALIBERT AND ON TRUE KELOID . .165 
 
 XI. ON THE DISORDERS OF THE BRAIN CONNECTED -WITH DISEASED 
 
 KIDNEYS ....... 187 
 
 XII. ON THE INFLUENCE OF ELECTRICITY AS A UEMEDY IN CERTAIN 
 
 CONVULSIVE AND SPASMODIC DISEASES . . . 195 
 
 XIII. ON THE CONSTITUTIONAL AND LOCAL EFFECTS OF DISEASE OF 
 
 THE SuPKA-EENiL CAPSULES . . . .211 
 
 INDEX . , . . . . . 241 
 
 205609-1
 
 BIOGRAPHY. 
 
 THE records of Addison's early life are so difficult of 
 ascertainment that any account of his actual life, in 
 reference to the object of these papers, must date from 
 the commencement of his association with Guy's Hos- 
 pital about the year 1819 or 1820. That must have 
 been nearly the period at which he attached himself to 
 the hospital, where his enterprising and spirited 
 activity in the search after a definite explanation of 
 every form of disease presented to his observation, 
 attracted the attention of the observant and large- 
 minded treasurer ; who was then by common acknow- 
 ledgment the great administrative benefactor, and, 
 through the appreciation of his minute, vigorous, and 
 just guidance of its business from the smallest details 
 to the highest principles involved in its government, 
 the accepted dictator of the affairs of the institution. It 
 was not easy in those days to overcome the prevailing 
 i at'/ rained prejudice that unless a man had been origi- 
 nally a pupil of the hospital he was not fairly eligible 
 to the duties of its offices. Addison's may be cited? 
 indeed, as one of the earliest (if not the first) instances 
 of those traditional trammels being broken through ; 
 for in 1824 he was appointed assistant-physician to the 
 hospital, his previous association with it consisting only 
 in his entry there as a student after having taken his 
 degree at Edinburgh. 
 
 It cannot be doubted that Mr. Harrison's intelligent
 
 X BIOGRAPHY. 
 
 and scrutinising attention to the qualities of the gen- 
 tlemen then about the hospital in reference to the 
 appointments to future vacancies induced him to select 
 Addison as a physician highly calculated to carry out 
 the two foremost objects of his life, the promotion of 
 the usefulness of the charity, and the extension of the 
 reputation of the school. 
 
 There is always an interest attaching to the history 
 of any man who has made a prominent position for 
 himself in whatever career of life ; the question " how 
 he did it" excites the interest of the younger members 
 of any profession in which it has been achieved. In 
 the instance of Addison the old answer must be given 
 he " did it" by indomitable perseverance in the pur- 
 suit of one object of study ; making it, as it were, the 
 one day-dream and night-dream of his existence. 
 
 He seems to have been born of humble parents at 
 Long Benton, near Newcastle, about 1793, to have 
 been sent to the village school there, and afterwards 
 to the Grammar School at Newcastle. Thence he 
 migrated to Edinburgh, where he graduated M.D. in 
 1815, selecting for the subject of his inaugural thesis 
 " De Siphilide." 
 
 His familiarity with Latin was at this time exempli- 
 fied by a habit of taking down lecture-notes in that 
 language ; and this mental peculiarity may have led to 
 his habitual exactitude of diction in whatever he wrote 
 or spoke in after life. 
 
 On his arrival in London, he took up his residence 
 at Skinner Street, Snow Hill, in one of the so-called 
 "haunted houses" (possibly from some association 
 with the Cock Lane ghost story of Dr. Johnson), and 
 was soon after appointed house-surgeon to the Lock 
 Hospital, where he acquired so great an interest in the
 
 BIOGRAPHY. XI 
 
 subject of syphilis, that, although a topic not in strict 
 accord with the branch of the profession which he had 
 adopted, he always spoke on it authoritatively. 
 
 The next step in his career which we can gather is 
 his residence in Hatton Garden, and his attachment to 
 the General Dispensary. At this time he studied with 
 the celebrated Bateman, and thus became so great a 
 proficient in skin-disease as to acquire the acknowledg- 
 ment of those cognisant of his skill, that after the death 
 of the great dermatologist his mantle had fallen upon 
 Addison. From his desire to avoid the pursuit of this 
 subject as a specialty, this competency was not gene- 
 rally known ; but it is certain that until a comparatively 
 recent period Addison' s accuracy in the discrimination 
 of cutaneous eruptions was scarcely matched; an 
 assertion which a careful examination of the unrivalled 
 wax models in the museum of Guy's Hospital (studi- 
 ously prepared during many years under his own 
 superintendence) will fully bear out. It is also believed 
 that he entered as a student at St. George's Hospital, 
 but of this we can obtain no proof, and know only that 
 he became successively a student at Guy's, was 
 promoted early to the office of assistant-physician 
 (1824), when, from the recognition of his great prac- 
 tical knowledge, his fame spread rapidly among the 
 pupils, and he became a brilliant acquisition to the new 
 school. This recognition placed him, in consequence 
 of an early vacancy (1827), in the chair of Materia 
 Medica. At that time, when medical students paid 
 fees for separate courses of lectures, they sought 
 throughout the metropolis for the most attractive 
 teachers. Armstrong then drew a large class to the 
 Webb Street school by his instruction in the practice 
 of medicine ; most of his pupils remained to listen to
 
 x ji BIOGRAPHY. 
 
 Addison, and so great was the attendance that his 
 lecture-fees must have amounted to 700 or 800 a 
 
 year. 
 
 In the year 1837 he received the appointment of 
 physician to the hospital, and was at the same time 
 selected as the colleague of the late Dr. Bright in the 
 duties of the chair of Medicine. 
 
 At this period he commenced, conjointly with his 
 colleague, a work on * Medicine.' From the high esti- 
 mation in which this work was held it must be a matter 
 of regret that one volume only was- published. Now 
 that both these widely -known authors have departed 
 from their labours, it cannot be harmful to assert (what 
 was then generally known) that the greater portion of 
 the work was from the pen of Dr. Addison. 
 
 He had now achieved the desired position for the 
 development, or rather the showing forth, of the quali- 
 ties which he had cultivated with so much care ; those 
 of the eminently practical physician. And he certainly 
 exhibited them in a remarkable degree ; his strong, 
 positive, and perpetual insistance upon the term "prac- 
 tical" in reference to disease, constitutes, indeed, the 
 key to Addison' s character and professional career. 
 He was always ready to discuss newly-started theories, 
 but he never, for a moment, allowed them to interfere 
 with the results of his matured experience. Possessing 
 unusually vigorous perceptive powers, being shrewd 
 and sagacious beyond the average of men, the patient 
 before him was scanned with a penetrating glance from 
 which few diseases could escape detection. He never 
 reasoned from a half-discovered fact, but would remain 
 at the bedside, with a dogged determination to track 
 out the disease to its very source for a period which 
 constantly wearied his class and his attendant friends.
 
 BIO GK A HIT. Xlll 
 
 So severely did he tax his niind with the minutest 
 details bearing upon the exact exposition of a case, that 
 he has been known to startle the sister of the ward in 
 the middle of the night by his presence ; after going 
 to bed with the case present to his mind, some point of 
 what he considered important detail in reference to it 
 occurred to him, and he could not rest until he had 
 cleared it up. He has also been known after seeing a 
 patient within the radius of eight or ten miles to have 
 remembered on his near approach to London, thinking 
 over the case on his way, that he had omitted some 
 seemingly important inquiry, and to have posted back 
 some miles for the purpose of satisfying his mind on 
 the doubt which had occurred to it. If at last he could 
 lay his finger on the disease, his victory was attained, 
 and his painstaking satisfactorily rewarded. For with 
 him accurate " diagnosis" was the great, and too often 
 the ultimate, object of an industry of search, a correla- 
 tion of facts deduced from scientific observation, and a 
 concentration of thought rarely combined in the indivi- 
 dual physician/ To those who knew him best his 
 power of searching into the complex framework of the 
 body, and dragging the hidden malady to light, appeared 
 unrivalled ; but we fear that the one great object being 
 accomplished, the same energetic power was not 
 devoted to its alleviation or cure. Without accusing 
 Addison of a meditated neglect of therapeutics, we 
 fancy that we can trace the dallying with remedies 
 which has been the characteristic of more recent times. 
 " I have worked out the disease ; if it be remediable, 
 Nature, with fair play, will remedy it. I do not clearly 
 see my way to the direct agency of special medica- 
 ments, but I must prescribe something for the patient, 
 at least, to satisfy his or her friends," seems to have
 
 xiv BIOGRAPHY. 
 
 been a part of the habit of mind which can deal satis- 
 factorily only with the " observable and proven" and 
 shrinks from the " uncertain and questionable" 
 
 His discovery of the heretofore unsuspected disease 
 of the supra-renal capsules was the result of an ex- 
 haustive analysis of every organ of the body, without 
 elucidating any evident reason for a remarkable form 
 of ansemia : for a time he was constrained to the 
 expression " idiopathic anaemia," accompanied by a 
 prognosis of its fatal issue. This prognosis was so 
 constantly verified that, following up the doctrine of 
 exclusion, he at last, in the absence of any other 
 noticeable cause for it, observed an association between 
 it and a peculiar appearance of the supra-renal capsules. 
 Here we trace the advantage of the large study of 
 clinical facts ; at that time skin disease was sup- 
 posed to be confined to the province of the surgeon, 
 and it is probable that but for Addison's accurate 
 observation of the various cutaneous deviation from its 
 ordinary and healthy condition, the bronzed skin would 
 not have rivetted his attention so forcibly as to have 
 incited him to prosecute his inquiries to their ultimate 
 issue. 
 
 We recognise the necessity for some brief remarks 
 on Addison's disposition from the conviction that it 
 was not generally understood. Viewed in its profes- 
 sional aspect, no character on record has presented in 
 a higher degree the sterling hard qualities of true pro- 
 fessional honesty. We have never heard a single 
 instance in which a word of disparagement against a 
 professional brother escaped him. He would always 
 strenuously and with all his natural vigour maintain 
 what he believed to be the truth, but never for the 
 purpose of underrating the opinions of others. His
 
 BIOGRAPHY. XV 
 
 whole bearing in the profession was to the last degree 
 honorable, and anything like jealousy or ill-will against 
 another professional man never entered his mind. 
 
 The admirable bust by Towne, which now adorns 
 the museum of Guy's Hospital, is the best exposition of 
 the estimation in which he was held by his colleagues, 
 from whose subscriptions it resulted. 
 
 He was for many years acknowledged as the spirit 
 which influenced the medical doings at Guy's Hospital, 
 and to Addison is due, in great measure, the prominent 
 character which the medical department of that insti- 
 tution has of late years held in public professional 
 estimation. 
 
 Yet in professional intercourse his disposition presented 
 peculiarities often misinterpreted by the professional 
 observer : he, the observer, saw what appeared to him a 
 rudeness, a certain bluntness of expression conveying 
 to him the idea of a haughtiness, or at least of Addison' s 
 assumption of superiority; so that he parted with 
 him impressed with the dignity of his bearing, a full 
 appreciation of the accurate and well-sifted opinion 
 which he had obtained, but at the same time carrying 
 with him the notion that, judging from his apparently 
 unapproachable manner, and what seemed to many 
 "hauteur," he was a man of large self-esteem. This 
 is one of the commonest mistakes in the estimation of 
 character. In what degree a resoluteness of expres- 
 sion and an undue energy of manner is unconsciously 
 adopted to cloak a covert physical nervousness, no one 
 but the wearer of the cloak can fully estimate. We 
 have reason to know that Addison suffered most acutely 
 from this physical enervation ; he has even said, " I 
 never rose to address the Guy's Junior Physical Society 
 without feeling nervous," and yet his listeners would
 
 xv i BIOGRAPHY. 
 
 depart with the feeling that he had spoken to them in 
 what may almost be termed a tone of " bluster ;" they 
 went away impressed with the dignity of his bearing, 
 and crediting him with great physical and moral 
 energy ; not recognising that a quick, hasty, and im- 
 passioned manner of expression is not infrequently the 
 result of a deficient controlling power. We know that 
 his mind was to the last degree susceptible, and that 
 although wearing the outward garb of resolution, he 
 was, beyond most other men, most liable to sink under 
 trial. We lay some stress upon this peculiarity for 
 the purpose of vindicating his character from the 
 unamiable spirit which we have heard sometimes laid to 
 his charge. If there be any of our readers who may 
 have been vexed by the apparent discourteousness of his 
 manner, let them carefully consider the explanation of 
 it which we have attempted to depict, and give thanks 
 to God that they have been blessed with a calmer and 
 less perturbable spirit. 
 
 His last communication addressed to the pupils of 
 the hospital in answer to a letter of condolence 
 written to him on his retirement from the hospital on 
 account of his ill-health conveys most markedly the 
 seemingly latent kindliness of his nature, his entire 
 devotion to whatever would aid to place medicine on a 
 more scientific basis, his affectionate regard for those 
 of his juniors who were fellow-helpers in the work, and 
 his own powerful style of expressing what he sincerely 
 and heartily felt. 
 
 " March 17th, 1860. 
 "MY DEAR SlR, 
 
 "A considerable break-down in my health has 
 scared me from the anxieties, responsibilities, and
 
 BIOGRAPHY. XVII 
 
 excitement of the profession : whether temporarily or 
 permanently cannot yet be determined ; but, whatever 
 may be the issue, be assured that nothing was better 
 calculated to soothe me than the kind interest mani- 
 fested by the pupils of Guy's Hospital during the many 
 trying years devoted to that institution. 
 
 " I can truly affirm that I ever found my best sup- 
 port and encouragement in the generous gratitude and 
 affectionate attachment, as well as my proudest reflec- 
 tions, in the honorable and most exemplary conduct of 
 its pupils. Present niy sincere regards and best wishes 
 to every one of them, and believe me, 
 
 " Yours truly and affectionately, 
 
 " THOMAS ADDISON." 
 
 "E. Gallon, Esq."
 
 PREFACE 
 
 TO THE FIVE FOLLOWING PAPERS, RELATING TO 
 
 DISEASES OF THE LUNGS. 
 
 ONE of the conspicuous features of medical literature 
 is tke amount of valuable information which it contains 
 in a scattered and disjointed form. 
 
 Two of the prominent causes of this result are the 
 honest modesty which induces some men to shrink 
 from publication in a concrete form, under the sincere 
 belief that others are as well informed on their special 
 subject of pursuit as themselves, and the lack of 
 industry in many to gather up what they know in a 
 succinct and constructed shape. 
 
 The prior cause or fault (if fault it be) must be 
 imputed to Addison ; for as one of the early expositors 
 of, and progressionists in, the teachings of Laennec, 
 Addison held a foremost position in this country : yet 
 we find him more than thirty years since reading 
 papers on the subject of lung disease, of which the 
 importance and great value seem not yet to be fully 
 estimated, to the Physical Society of Guy's Hospital
 
 XX PREFACE TO PAPERS ON 
 
 and the South London Medical Society. These papers 
 would, we believe, under the more ready diffusion of 
 information adopted at the present time, have then 
 attracted the attention of the most learned physicians 
 of Europe, and would thus have contributed to an 
 earlier knowledge of the pathology of pneumonia and 
 phthisis. 
 
 With lack of industry and constructive arrangement 
 Addison certainly cannot be reproached ; for his con- 
 clusions were deduced from the most accurate necro- 
 scopic inquiries, pursued, not only at the well-directed 
 post-mortem examinations of Guy's Hospital, but at 
 his own residence also, with an assiduousness and a 
 sedulous perseverance comparable to the zeal of a 
 Harvey or a Hunter ; and his conclusions are expressed 
 in a terse, forcible, and readily intelligible language 
 similar to theirs. 
 
 The main ground for the belief of the Council of the 
 New Sydenham Society that a collection of Addison' s 
 papers would be acceptable to its members originated 
 in the impression that the views of Addison on pneu- 
 monia and phthisis, taught during so many years, had 
 not yet received due consideration : for even now the 
 term " phthisis," implying simply a state of lung prone 
 to disorganization, is regarded by too many of our pro- 
 fession as having always a basis of tubercle; and a 
 consequent uniform mode of treatment is adopted, 
 having commonly for its object a combat with this 
 imaginary deposit. 
 
 For the fulfilment of the Society's object it seemed 
 to the editors necessary either to republish what
 
 DISEASES OF THE LUNGS. XXI 
 
 Addison had written on diseases of the lung and their 
 diagnosis only, which would have formed a small but 
 incomplete volume; or to include all the separate 
 papers which he had written, under the conviction that 
 all he wrote was the outcome of sterling honest reflec- 
 tion upon carefully deduced facts : and that admitting, 
 as they distinctly do, the various degrees of merit in 
 his several papers, their publication, as a whole, would 
 be advantageous to the members. 
 
 It must be remembered that Addison's influence, as 
 an instructive physician, was great rather by his oral 
 teachings as a lecturer than by his contributions to 
 medical literature ; and that in the latter sphere essays, 
 having great value and originality at the time of their 
 production, have in the course of a quarter of a century 
 lost much of their initiative merit by subsequent 
 absorption into general medical literature. Although 
 his fame may for ever rest on the disease which bears 
 his name, we may remind our readers that his reputa- 
 tion as a teacher had been established long before the 
 publication of his monograph on disease of the supra- 
 renal capsules at the close of his career. 
 
 Foremost amongst his oral and written teachings 
 were those which related to " diseases of the lungs" 
 He had insisted from the outset of his public profes- 
 sional life that the then taught doctrine concerning 
 the condition of the lung in pneumonia was erroneous, 
 and based upon a false view of the anatomy of the 
 organ. He first controverted the opinion that pneu- 
 monia depended upon an inflammation of the then 
 called "parenchyma " of the organ (i. c., of a supposed
 
 PREFACE TO PAPERS ON 
 
 areolar tissue connecting the cells, arranged according 
 to the then adopted ideas of Riessessen) by denying 
 that any such tissue existed except between the 
 lobules. 
 
 In the first paper which we transcribe, read before 
 the Medico-Chirurgical Society (1840, and taught in 
 his lectures some years before this publication), he 
 shows that there is no such connective tissue between 
 the air-cells, as Riessessen conceived ; that Reissessen's 
 notion of every cell having a separate communication 
 with a capillary bronchial tube was incorrect, and that 
 consequently the inflammatory material exuded under 
 the process of pneumonia could obtain no other locali- 
 sation than in the air-cells themselves. 
 
 As the object of this publication is to inculcate 
 peculiarly the doctrines of Addison, we may be allowed 
 to lay some stress upon this incipient truth, from which 
 so much of his ultimate deduction proceeded. If a 
 comparison be made between his expressed opinions 
 and those of both contemporary and subsequent writers, 
 his inception will stand out more prominently. 
 
 For instance, so late as February, 1856, a reviewer 
 of Dr. Barlow's 'Manual of the Practice of Medicine,' 
 in which he reproduces Addison's ideas, writes, " Dr. 
 Barlow defines pneumonia to be inflammation of tie 
 air-cells of the lungs," a definition not only calculated to 
 give erroneous ideas to the student, but certainly not 
 correct. True pneumonia nearly all authorities we 
 thought were now agreed in regarding as an inflam- 
 mation of the interstitial tissue, or parenchyma of the 
 lungs : a view all but definitely settled by the experi-
 
 DISEASES OF THE LUNGS. XXlll 
 
 ments of Gendrin. It may, it is true, originate in the 
 air-cells, but it may also have its point-de-depart in the 
 mucous membranes of the bronchial tubes or in the 
 pleura." 
 
 In 1843, Addison writes, " There are probably some 
 present who remember the time and occasion when, in 
 this Society and in opposition to all existing authorities, 
 I ventured to call in question the long-cherished notion 
 that pneumonia had its seat in a supposed parenchyma 
 of the lungs, and that the products of pneumonic 
 inflammation were poured into that parenchyma. Since 
 that time I have had the satisfaction of witnessing a 
 gradual but comparatively rapid renunciation of the 
 latter views, and the adoption of those advanced in 
 this Society so many years ago, viz., that pneumonia 
 has its original and essential seat in the air-cells of the 
 lungs, and that the ordinary pneumonic deposits are 
 poured into these cells. It is nevertheless true that 
 some of our most recent authorities are opposed to this 
 opinion, and maintain that the pneumonic deposits are 
 poured into an interstitial tissue ; a conclusion which 
 I find myself unable to reconcile with either the healthy 
 or the morbid anatomy of the lungs." 
 
 It would thus appear that Addison was the sug- 
 gestor of our present notions of the pathology of 
 pneumonia. 
 
 In the second paper, which we reprint, " On the 
 Diagnosis of Pneumonia," it may be remarked that at 
 the time when it was written the stethoscope was not 
 in general use ; and that Addison, therefore, addressed 
 his observations both to those who placed a full confi-
 
 xx i v PREFACE TO PAPERS ON 
 
 dence in their recognition of the general signs of its 
 existence, without reference to the local or physical 
 signs ; and to those who, enchanted with this new phy- 
 sical aid to diagnosis, relied entirely on its indications, 
 ignoring the general signs which had guided many of 
 their acutely observant predecessors into an accuracy 
 of differential opinion in lung disease which often 
 excited the admiration, and even wonder, of the early 
 auscultators. 
 
 It would seem that in his earliest teaching and early 
 writing his dominant idea was that a simple inflamma- 
 tory deposit in the lung-cells or interlobular tissue was 
 often mistaken for tubercle ; he next observed that the 
 characteristic pungent heat of the skin was an almost 
 pathognomonic sign of pneumonia, which has been 
 quoted and adopted by most succeeding authors ; and 
 that the pain which usually accompanies pneumonia 
 was present only when pleurisy co-existed with it. 
 
 In the third paper, entitled " Observations on Pneu- 
 monia, and its consequences," after discussing the first 
 stage of pneumonia, and admitting the analogy between 
 an early stage of inflammation of the air-cells and that 
 of serous membranes generally, an analogy taught about 
 that time by Dr. Stokes in the Dublin school, he proceeds 
 to illustrate the difference between red and grey hepa- 
 tization. In the former, he shows that the great 
 vascularity of the basement membrane and deterioration 
 of the cell-walls produce consolidation by a jamming 
 together, as it were, of the interior surfaces of the cells 
 without any effusion into them ; and that in the latter 
 an albuminoid effusion into the cells, varying in its
 
 DISEASES OF THE LUNGS. XXV 
 
 quality with the constitutional state of the patient, is 
 the cause of the consolidation, and that this solid effu- 
 sion may present post-mortem the appearance of 1st, 
 the uniform albuminous effusion ; 2nd, the granular 
 induration ; and, 3rd, the grey induration. These con- 
 ditions of the lung, he contends, may in the course of 
 their various stages of disintegration present many of 
 the aspects commonly confounded with those of tuber' 
 cular phthisi*. 
 
 So important did this part of their subject appear to 
 the editors, that they have thought it desirable to 
 devote that portion of the limited amount which the 
 funds of the Society permitted them to employ in 
 coloured illustration to its especial exemplification. 
 
 The amplification of this conception will be found 
 fully treated of in the fourth paper on " The Pathology 
 of Phthisis," a paper judged by us to be the most im- 
 portant of his writings, because he therein matures his 
 long- cherished notions concerning the chronic affections 
 of the lungs recognised under the name of " Phthisis." 
 In the dead-house this was for years the one absorbing 
 subject of his investigation, as well as of his subsequent 
 cogitation. 
 
 Addison declared that in the days of his early profes- 
 sional life it was not unusual to hear medical men 
 express themselves, even in cases presenting the gravest 
 pulmonary symptoms, hopeful of the issue, because 
 there was as yet no proof that tubercles were formed ; 
 and that even when a fatal issue was evident the pre- 
 sence of tubercle was urged in reference to the question 
 of prognosis.
 
 xxvi PREFACE TO PAPERS ON 
 
 With these impressions Addison devoted himself 
 enthusiastically to unravel pathologically what appeared 
 to him clinically inexplicable; and in the course of hi* 
 investigations he so frequently found the deposit result- 
 ing from inflammation confounded with tubercle that he 
 came gradually to look on the term " tubercular" in 
 reference to what was customarily called " phthisis," 
 as a bugbear obstructing the true and scientific 
 explanation of chronic disorganization of the lung. 
 
 During the whole of the period that he occupied the 
 chair of medicine at Guy's Hospital, he endeavoured to 
 combat the prevailing idea that tubercle was the sole 
 deadly ingredient in chronic pulmonary disease ; and 
 constantly asserted that in a large proportion of cases 
 in which persons died of so-called " phthisis" tubercles 
 were not present. He thought that the material de- 
 posited in the lung with a tendency to break up is often 
 of an inflammatory kind, and may be produced under a 
 variety of conditions. 
 
 He allowed, of course, that in a certain, perhaps 
 large, number of cases tubercles were present, and that 
 in persons of tuberculous constitution the formation of 
 lowly-organized deposits occurred ; but he held, at the 
 same time, that similar deposits might be produced (in 
 the absence of tubercle) under a great variety of condi- 
 tions, especially under different forms of cachexia ; or 
 that an attack of pneumonia might proceed to disorga- 
 nization, and be attended by all the symptoms usually 
 accompanying " phthisis ;" but he would not allow such 
 
 a case to be ranked in the same category with a purely 
 
 tuberculous affection. The most striking example of
 
 DISEASES OF THE LUNGS. XXV11 
 
 this idea is to be found in the instance of a case of pneu- 
 monic phthisis illustrated by Plate 7 attached to this 
 paper. Here is shown a complete disintegration of the 
 lung taken from a person who died of diabetes mellitus 
 without a trace of tubercle. In this case, as in many 
 others referred to, there is no corroboration of the idea 
 that the adventitious deposit in the lung is " tubercle" 
 by the discovery of it in any other organ ; a fact not 
 lightly assumed, but resulting from most careful necro- 
 scopic investigation, which lends great force to Addi- 
 son's teaching. 
 
 We believe that if funds and space would have 
 admitted the publication of the numerous drawings de- 
 posited in the museum of Guy's Hospital, which Addi- 
 son had made from specimens prepared by himself, to 
 illustrate the various forms of disease grouped under the 
 names of "phthisis and pneumonia," no more valuable 
 contribution to the knowledge of these subjects could 
 have been offered to the profession. 
 
 These drawings exhibit almost every variety of 
 chronic pulmonary disease which is met with ; and it 
 may repay any member of the New Sydenham Society 
 who is interested in the subject to study them with 
 care. He will be prepared, after our remarks, to find 
 that in Addison's mind the subjects of pneumonia and 
 phthisis were inseparably connected, and that when for 
 the purpose of nosological arrangement he treats of the 
 one, the other is inseparably blended with it. 
 
 At page 10, Dr. Addison writes : " It has been 
 observed that these deposits (albuminous) may remain 
 passive for an unlimited period, and without undergoing
 
 xxviii PREFACE TO PAPERS ON 
 
 any very appreciable change ; except, perhaps, a con- 
 version of some of them into calcareous or chalky 
 masses, especially when deposited in the upper lobe of 
 the lung. It would nevertheless appear that the vital 
 influence by which they are maintained in their integrity 
 is so extremely slender that if inflammation happen 
 to be set up around them by an accidental cause, and 
 especially if the vital powers of the patient have been 
 greatly impaired, that influence is so far exhausted that 
 they lose their cohesion and soften." Although in these 
 papers we find no definite application of the same con- 
 ception to the instance of miliary tubercle, Addison 
 orally taught with some emphasis that this form of 
 tubercle might exist in a quiescent state for an indefi- 
 nite time without serious apprehension on the part of 
 the friends or the medical practitioner (the suspicion of 
 its existence being induced only by dry, frequent irrita- 
 ble cough and uniform feeble respiratory murmur over 
 the whole extent of the pulmonary walls, and a defec- 
 tive nutrition of the tissues of the body generally), until 
 inflammation was set up in the cells where the tubercles 
 were located, and that then the lungs disintegrated so 
 rapidly and extensively as to give rise to the expression 
 " galloping consumption." * 
 
 * The only occasion on which I ever met the late Dr. Chambers in 
 consultation was a case of this kind, in 1848. I represented to him that 
 the lady, set. 34, had been the victim of miliary tubercle for certainly 
 four years, that within the] last month inflammation had been set up 
 around the tubercles, and that she was dying rapidly of lung disorga- 
 nization, and that I had eighteen months since forwamed her friends of 
 this probable result. After examination of the patient, Dr. Chambers 
 said to me, " Well, sir, I can only tell you that you are more fortunate
 
 DISEASES OF THE LUNGS. XXIX 
 
 This subject is incidentally alluded to at page 79, 
 proposition 23. 
 
 The forty-two " propositions " laid down by Addison 
 in his paper on the " Difficulties and Fallacies attending 
 Physical Diagnosis in Diseases of the Chest," are as 
 true, as cogent, as applicable to the emergencies of 
 daily practice now, as when they were published twenty- 
 two years ago. Although many of the " fallacies " 
 therein described have become familiar to, and conse- 
 quently avoided by, the experienced stethoscopist, his 
 axioms must be ever useful, not only to the student, as 
 a " systematic code of probable errors," but to the prac- 
 titioner as a memorial refresher of the difficulties which 
 he has to encounter in the formation of a definite, 
 well-grounded, and explicable opinion upon diseases of 
 the thoracic viscera. 
 
 At the time when the paper on " Fatty Degeneration 
 of the Liver" was written, a prevailing notion existed 
 that it occurred only in association with phthisis. The 
 lapse of thirty years since it was written has not 
 diminished its interest ; for the true pathology of the 
 disease and its relation to many other morbid conditions 
 are not yet fully understood. The purport of the 
 paper was to show that fatty liver was not a mere 
 accident attendant upon phthisical or scrofulous disease, 
 but that it should be regarded as a more positive 
 
 than I : I saw the only child (a daughter) of one of the first noblemen 
 of this country several times, and from the absence of physical signs, in 
 spite of the dry cough, I assured him that there was no disease of the 
 lung ; an inflammation of this kind set in, and she died in six weeks. I 
 have never been forgiven." Our patient died ten days after this inter- 
 view. T. M. D.
 
 xxx PREFACE TO PAPERS OX 
 
 affection; either as a primary or substantive malady, 
 or indicative of a wide-spread morbid process affecting 
 the whole body. Addison had observed that in many 
 forms of cachexia a fatty liver was the most important, 
 or, at least, the most obvious morbid alteration found 
 in the body after death : he noticed also that it was 
 associated with a fatty change elsewhere, and that 
 patients suffering from it exhibited a peculiar anaemic 
 aspect, and possessed a remarkably white, soft, ami 
 smooth skin. It was to the recognition of fatty liver 
 by these signs that he more particularly drew the 
 attention of his readers. 
 
 "We may state that, at the present time, when a large 
 fatty liver is found after death as the most striking 
 morbid condition present, it cannot always be satisfac- 
 torily determined how far it is indicative simply of a 
 fatty decay of all the tissues, or how far it is to be 
 regarded as the essential disease. 
 
 This short paper shows that Addison was fully alive 
 to the importance of the subject. 
 
 To the minds of those who can look back upon the 
 ill-defined pathology of lung disease which existed 
 thirty-five years since, notwithstanding the memo- 
 rable, exact, and incomparable teachings of the great 
 Laennec up to a certain point, and the paper of Dr. 
 Alison read before the Medico-Chirurgical Society of 
 Edinburgh, 1822* (of which there is no evidence that 
 
 * Tliis great, thoughtful, and philosophic physician then read an 
 elaborate paper on the " Pathology of Scrofulous Diseases." It included, 
 of course, that of phthisis, and he enlisted the testimony of the accurate
 
 DISEASES OF THE LUNGS. XXXI 
 
 Addison had any cognisance). We believe that a 
 careful study of these five collective papers will convey 
 an accurate impression of the definite, staunch, and 
 truth-seeking mind, which, with the aid of an indo- 
 mitable will, enabled Addison to unravel what must 
 have appeared to him then the tangled problem of slow 
 lung disorganization. 
 
 To those less advanced in life, who have imbibed 
 from their instructors much of what Addison taught, 
 without a knowledge of its derivation, it will convey 
 the useful lesson that there is one only way of over- 
 coming the difficulties which beset practical medicine ; 
 the way adopted by Addison. Nothing short of a 
 laborious investigation of clinical facts and the patho- 
 logical corroboration of them could satisfy his accuracy 
 and his rigid causality. 
 
 Dr. Abercrombie as to the variety of morbid structure found in the 
 lung, after death from phthsis, at different periods of life ; but neither 
 Alison nor Abercrombie appear to have formed any accurate appre- 
 ciation of the textural changes which had occurred in the lung, nor the 
 relation of those changes to the actual existence or non-existence 
 of tubercle.
 
 OBSERVATIONS 
 
 ANATOMY OF THE LUNGS. 
 
 (Read before the Royal Medical and Chiruryical Society, 1840.) 
 
 MANY others must have felt as I do, .that it requires some 
 nerve to make a demand upon the time and attention of such a 
 society as this; they must have been' conscious, as I am, that how- 
 ever interesting or apparently important the intended communication 
 may have been in their own estimation, it may, nevertheless, be 
 deemed by the society at large altogether unworthy the character 
 and experience of the majority of its members. 
 
 On the present occasion I hardly know whether such apprehen- 
 sions ought to be diminished or enhanced by the brevity and incom- 
 pleteness of this communication, its brevity and incompleteness 
 being almost a necessary consequence of its subject, forming a mere 
 part or portion of the results of a much more extended inquiry into 
 the healthy and morbid anatomy of the lungs an inquiry by far 
 too extensive and of too much practical importance to be quickly 
 accomplished, or hastily presented to the notice of the profession. 
 
 In the presence of any body of professional men in any part of 
 the world, but especially in our own country, it would be in exceed- 
 ingly bad taste to insist upon the importance of all and everything 
 appertaining to either the healthy or morbid anatomy of the lungs ; 
 nor would it be less superfluous to add anything to what has been 
 so repeatedly urged in proof of the necessity of acquiring an inti- 
 mate knowledge of the former in order clearly to understand and 
 satisfactorily to demonstrate the latter ; it is not, however, by any 
 means so certain that the converse of this familiar proposition has 
 met with its full and legitimate share of attention ; it is by no means 
 so apparent 1 that morbid anatomy has been sufficiently rendered 
 available to explain or demonstrate the function or structure of 
 
 1
 
 2 OBSERVATIONS ON THE 
 
 obscure, intricate, and complicated parts of the body in a state of 
 health. 
 
 Tor my own part, if I may be pardoned the egotism, I would 
 venture to express my belief that very much assistance indeed may 
 be derived from this source ; whilst, on the other hand, the increase 
 of knowledge thus acquired respecting healthy anatomy prepares us 
 for still further advances in the investigation of changes induced by 
 disease. 
 
 Proceeding on this principle of rendering healthy and morbid 
 anatomy mutually subservient to the elucidation of each other, I am 
 not without a hope that I have succeeded in illustrating, if not in 
 demonstrating, certain points of great interest as regards the lungs, 
 some of which have already been pretty generally established ; whilst 
 others are familiar as mere matters of opinion, or are perhaps 
 altogether novel. 
 
 The results of my investigations, for example, seem to prove 
 almost beyond dispute, first, that the aerial cellular tissue of the 
 lungs is made up of well- denned, rounded, or oval lobules, united 
 to each other by interlobular cellular membrane, each lobule con- 
 stituting a sort of distinct lung in miniature, having its own separate 
 artery and vein. Secondly, that these lobules do not communicate 
 directly with each other. Thirdly, that they do not, as Reissesseu 
 and others have supposed, consist of the globular extremities of as 
 many bronchial tubes, but, on the contrary, as my friend Dr. 
 Hodgkin has suggested, are made up of a collection of cells, in 
 which, by a common opening, a minute filiform bronchial tube 
 abruptly terminates. Fourthly, that the pulmonary artery accom- 
 panies the bronchi, branch for branch, to the minutest divisions of 
 the latter, Fifthly, that pneumonia consists essentially in inflamma- 
 tion of the aerial cells. Sixthly, that pneumonia and inflammatory 
 tubercle are identical. Seventhly, that acute pneumonia in mode- 
 rately good constitutions scarcely ever leads to the formation of an 
 abscess, unless deposit previously existed ; but that when it occurs 
 in cachectic or broken-down constitutions, or supervenes in the 
 process of chronic or organic diseases, it occasionally causes one or 
 more distinct and separate lobules to soften down into an ill- 
 conditioned abscess. Eighthly, that ordinary tubercles present the 
 same varieties in the lungs as they do in serous membranes. Ninthly, 
 that emphysema of the lungs consists chiefly of mere dilatation of 
 the cells, but in part also sometimes of more or less extensive lacera-
 
 ANATOMY OF THE LUNGS. 3 
 
 tion of them. And, lastly, that the circumscribed gangrene of 
 Laennec is commonly, if not uniformly, a mere effect or advanced 
 stage of pulmonary apoplexy. It is not, however, to any of these 
 matters that I presume to solicit attention at present, my object on 
 this occasion being merely to point out a mode of distribution of 
 the pulmonary vein, which, so far as I know, has not been noticed 
 by any preceding anatomist or pathologist, and which, on that 
 account, I have thought would prove not unacceptable to the 
 members of this society. 
 
 The uncertainty and discrepancy which at present prevail respect- 
 ing the origin and course of the pulmonary vein may be gathered 
 from the descriptions given of it in the works of some of the most 
 distinguished modern authorities, the quotations of a few of which 
 may not, perhaps, be altogether superfluous or misplaced here. 
 
 Cloquet, in his large work, 'Anatomic de 1'Homme/ sec. 509, 
 observes: "Les dernieres ramifications de I'^tere pulmonaire 
 donnent naissance aux radicules des veines du meme nom. Ces 
 veines qui augmentent successivement de volume, marchant a cote 
 et au-dessous des arte'res correspondantes" &c. &c. 
 
 Meckel, in his ' Manuel d' Anatomic/ translated and amended by 
 Jourdan and Breschet, torn, iii, p. 518, in speaking of the lungs, 
 says, " Dans I'interieur de Porgane, les veines pulmonaires accom- 
 pagnent les ramifications bronchiques de plus pres que les arteres." 
 
 Adelon, again, in his ' Physiologic de THomme/ seconde edition, 
 torn, iii, p. 147, on the subject of the pulmonary veins, observes, 
 "Ces veines commencent par des radicules qui sont aussi inaper- 
 cevables, et par consequent aussi peu connus que les dernieres rami- 
 fications des bronches et de Fartere pulmonaire : dissemines dans le 
 parenchyme du poumon, peut-etre continus aux ramifications de 
 1'artere pulmonaire. Situes probablement aux memes lieux ou abou- 
 tissent ces ramifications et celles des bronches et ou se fait la respira- 
 tion," &c. &c. 
 
 Ollivier, in the article Poumon of the ' Dictionuaire de Me'decine/ 
 observes, " Que les troues des arteres' et'penetrent dans la poumon 
 et en sortent par le meme porrit et que les ramifications des veines 
 pulmonaires sont plus voisines des canaux bronchiques que celles des 
 artires pulmonaires." 
 
 Bichat, 1 on the same subject, speaks thus: "Les veines pul- 
 monaires nees du systeme capillaire de ces organes, suivent une 
 1 'Anatomic Descriptive,' torn, iv, p. 65.
 
 4 OBSERVATIONS ON THE 
 
 direction analogue a celle des divisions arterielles. Voisines, des 
 leur origine, des ramuscules aeriens, elles n 3 abandonnent jamais ces 
 conduits dans leur trajet. Elles se reuniesent successivement en 
 rameaux plus volumineux que Von trouve toujours appliques sur des 
 rameaux broncJiiqiies d'un volume proportionne. Ordinaireinent la 
 veine est inferieure a la bronclie tandis que 1'artere lui est superieure ; 
 c'est du moins ce que 1'on trouve tant que Tceil peut suivre ces 
 vaisseaux." 
 
 In none of the accounts given by these high authorities do I dis- 
 cover the slightest allusion to the mode of distribution of this 
 important vessel, which my own dissections appear so clearly and 
 unequivocally to demonstrate ; but, on the contrary, find them to 
 be totally at variance with it. 
 
 In order to accomplish this demonstration the pulmonary artery 
 was injected with size, coloured red, whilst the vein was injected 
 with the same material coloured yellow. The lung was then laid 
 aside, and kept moistened in a cool place for several days, with the 
 view of softening, by approaching decomposition, the connecting 
 cellular membrane distributed throughout the lungs. 
 
 In this way the common cellular membrane beneath the pleura 
 became so lacerable that the pleura itself was stripped off without 
 much difficulty, and without inflicting any breach whatever in the 
 aerial cellular structure of the lung which it had covered. 
 
 The lung, thus divested of its pleura, presents to the eye, more or 
 less distinctly, lines on its surface which indicate the situation of 
 what maybe called the pulmonary fissures a term more correctly 
 applicable than that of interlobular, inasmuch as by the term inter- 
 lobular is usually understood a something situated between either 
 the longer lobes or smaller lobules ; whereas by the term pulmonary 
 fissures is meant eertain spaces occupied by common cellular mem- 
 brane, and which descend from the surface towards the interior, 
 but without penetrating the aerial cellular tissue of the lung, thereby 
 dividing more or less deeply the surface of the organ into a number 
 of insular portions, some of which may comprise a great number of 
 lobules. Guided by the linear indications on the surface of the now 
 naked lung, we can in general, with the aid of a pair of points let 
 into handles, or a pair of fine scissors, and without much difficulty, 
 succeed in laying open and exposing the pulmonary fissures, at the 
 bottom of which, marely surrounded by a loose cellular membrane, 
 and resting on the unbroken aerial pulmonary tissue, we discover a
 
 ANATOMY OF THE LUNGS. 5 
 
 vessel ; that vessel is the pulmonary vein, alone, and unaccompanied 
 by any artery whatever. 
 
 This vessel may be distinctly traced from larger to smaller trunks 
 towards its source, until we reach the common cellular membrane 
 between the ultimate lobules, from the exterior of which the vein ap- 
 pears to originate; whilst on the other hand, by continuing the 
 mechanical operation towards the root of the lungs, we with almost 
 equal facility trace the vessels still lying at the bottom of the pul- 
 monary fissures, and becoming gradually larger and larger by the 
 addition of branches, which proceed into the pulmonary fissure, 
 and are derived either from the neighbouring smaller pulmonary 
 fissures, or from the uniting cellular membrane between the ultimate 
 lobules themselves, until at length it joins the large trunks at the 
 root of the lungs, to form the great pulmonary veins. A small 
 artery is not unfrequently observed running across the pulmonary 
 fissures, from a portion of lung on one side to a portion of lung on 
 the other ; and in one instance I have found an exceedingly narrow 
 strip of healthy lung passing like a bridge across the fissure on the 
 very surface of the lung. 
 
 Thus, then, the human lung may be said to be made up essen- 
 tially of a vast expanse of membrane, the interior of which during 
 the whole of extra-uterine life is unceasingly exposed to the influence 
 of atmospheric air, and upon the surface or in the substance of which 
 are spread out the capillary ramifications of the pulmonary artery ; 
 these arterial capillaries passing from thence to the exterior of the 
 membrane to form the pulmonary vein, which throughout its whole 
 course is found to be situated on the exterior of the aerial cellular 
 structure of the organs. It is unwise to be too sanguine, yet I 
 cannot help indulging a hope that with a knowledge of the striking 
 and distinct distribution of the pulmonary vein, we shall be more 
 successful in our investigations into some of the most interesting 
 and important diseases of the lungs ; that it will be the means of 
 throwing additional light on the origin and progress of that fatal 
 scourge, phthisis pulmonalis ; and that it will enable us, almost with- 
 out a doubt or difficulty, to set at rest the long agitated questions 
 respecting the origin and seat of pulmonary apoplexy, and more 
 especially of what has been called oedema pulmonum, or dropsy of 
 the lungs. 
 
 In these investigations I am at present engaged, and may take the 
 liberty of adding that for the future I hope to hare the co-operation
 
 6 OBSERVATIONS ON ANATOMY OF THE LUNGS. 
 
 of my friend and colleague, Mr. Hilton, demonstrator of morbid 
 anatomy at Guy's Hospital, to whom I am already much indebted, 
 and from whose extensive acquirements both as an anatomist and 
 pathologist I anticipate much assistance and instruction.
 
 OBSERVATIONS 
 
 OK THE 
 
 DIAGNOSIS OF PNEUMONIA, 
 
 Read before the Guy's Physical Society, 1837. 
 
 ANY attempt at a further elucidation of pneumonia, after the 
 splendid performances of Laennec, may probably appear presump- 
 tuous ; and especially so, when made by one who acknowledges 
 himself indebted for almost all that he knows of thoracic diseases to 
 that truly great man, at once the most distinguished and most suc- 
 cessful cultivator of medical science that ever adorned the profession. 
 When, however, it is recollected how vast and barren was the field 
 of his inquiries when he commenced his brilliant career and when 
 our former ignorance is compared with the knowledge that resulted 
 from his unprecedented discoveries our astonishment is, not that he 
 should have left something undone, but that he should have done so 
 much. It is with the most profound deference and respect for his 
 memory, therefore, that I venture to add this tributary mite to the 
 riches of one of his favourite essays. I cannot but feel, also, that 
 some apology is due to the profession, for presuming to direct atten- 
 tion to a subject with which the works of Laennec must already have 
 made them familiar, and particularly to those who have so far re- 
 sisted the influence of prejudice as to have made themselves conver- 
 sant with the use of the stethoscope. My apology is that the very 
 familiarity of the subject appears to have lulled medical men in 
 general, and even the stethoscopist, into a too passive confidence 
 in what is already known : and has probably proved a check to 
 tli at correction and improvement which Laennec himself was at all 
 times so eager to accomplish. 
 
 The main object of this brief communication is, to make some 
 addition, however trifling, to the ordinary means of diagnosis ; since 
 experience has forced upon me the conviction, that there are few
 
 8 OBSERVATIONS ON THE 
 
 acute diseases more frequently mistaken or overlooked than pneu- 
 monia, to the detriment of the patient, and the no small embarrass- 
 ment of the practitioner. 
 
 In order to make myself understood, I may perhaps be permitted 
 to take a very slight survey of the pathology, signs, and symptoms 
 of the disease ; merely observing at the outset, that, in doing so, I 
 shall adhere as closely as possible to the purely practical tenor of our 
 Reports; indulging in theory no more than is unavoidable, in 
 arranging and reasoning upon facts derived from the sick chamber 
 and the dissecting-room. To the facts, or supposed facts, alone, do I 
 attach any importance. The use of these facts must be left to the 
 judgment and discernment of the reader. 
 
 In pneumonia, the inflammation is manifestly seated in or around 
 the air-cells, or in both situations. It is, perhaps, of little impor- 
 tance whether we conclude it to be seated primarily and essentially 
 in the one or in the other of these structures ; although, for my 
 own part, I entertain no doubt whatever of its being primarily and 
 essentially seated in the interior of the cells themselves a belief 
 drawn from the successive local changes observed to take place as 
 the disease advances. In the first stage of the disorder, we find the 
 cells red, and filled with a serous-looking and sometimes bloody fluid, 
 rendering the lungs more heavy, dense, and cedematous, whilst they 
 still retain their tenacity. At a more advanced period, or second stage, 
 the cells are found filled up with red solid matter, which appears to 
 consist of the thickened parietes of the cells themselves ; for if the 
 lung be torn, and the torn surface examined with a magnifyiug- 
 glass, it seems to be made up of innumerable minute red grains, 
 just such as one might conceive to result from a filling-up of the 
 cells in the manner supposed. At this period, the serous-looking 
 fluid has disappeared, the lung is comparatively dry, and the tenacity 
 of the solidified part is so far diminished that it may be readily 
 broken down by forcing the finger into it : this is what has been called 
 red hepatization. At a later period, and sometimes apparently without 
 having been preceded by the red granules, the solidified lung pre- 
 sents a grey appearance, an albuminous matter seems to occupy the 
 place of the granules, or rather their centres, constituting the grey 
 hepatization. This albuminous matter is sometimes firm and fixed, 
 at other times it is less plastic, and occasionally, especially in bad 
 constitutions, takes on a more decidedly purulent aspect, and may 
 be squeezed out by pressure ; or, as the cohesion of the pulmonary
 
 DIAGNOSIS OF PNEUMONIA. 9 
 
 tissue is often, under such circumstances, very much diminished, 
 the slightest pressure of the finger causes it to break down into a 
 semi-fluid mass, resembling an abscess. 
 
 It is not necessary to be more minute in describing the patholo- 
 gical changes which take place in the progress of pneumonia ; it is 
 sufficient to remember, that, in the first stage, the cells contain air 
 and a serous-looking and sometimes bloody fluid, as shown by the 
 peculiar crackling sound, and escape of the fluid on squeezing a cut 
 surface ; that, in the second stage, the cells are solidified compara- 
 tively dry, and, sooner or later, have poured into them an albuminous 
 matter, either solid and fixed, or, more rarely, a matter approaching 
 the character of pus. The stethoscopic signs indicative of these re- 
 spective changes are such as might be expected, and are easily under- 
 stood. Whilst the cells contain air and serous fluid, there is little 
 or no dulness of sound on percussion, but during respiration, we hear 
 the crepitating rattle a rattle which undoubtedly depends upon the 
 presence of air and fluid in the cells, for it is observed in cases of 
 ffidema of the lungs, and in some instances of pituitous catarrh, as 
 well as in the first stage of pneumonia. When the cells are solidified 
 and admit no air we have dulness of sound on percussion, broncho- 
 phony, and bronchial respiration, at least when the consolidation is 
 considerable, and seated near the surface. Such are the stethoscopic 
 signs of simple pneumonia, they are quite characteristic, and are pretty 
 uniformly present, except under very peculiar circumstances. 
 
 If an opportunity present itself of examining the body, when a 
 lung consolidated by pneumonia is retrograding towards a recovery 
 of its normal state, we commonly find the cut surface of the portion 
 previously hepatized of a pale or pinkish hue ; or we find it present- 
 ing a mixture of pale, pink, and grey : it is still more friable and 
 lacerable than natural ; and the cells are again more or less loaded with 
 serous-looking fluid, rendered frothy by squeezing the lung, in con- 
 sequence of the presence of a considerable number of air-bubbles. 
 It would also appear that the further changes consist in the absorp- 
 tion of the effused fluids, a gradual increase of the tenacity of the 
 pulmonary tissue, and a more or less complete restoration of the 
 normal state. In some instances, however, when the albuminous 
 matter thrown out is of the more plastic or organisable kind, it fails 
 to be entirely absorbed, and part of it permanently remains. Under 
 these circumstances, we find it, at an after period, either in small, 
 detached, and more or less rounded masses, or more extensively and
 
 10 OBSERVATIONS ON THE 
 
 more irregularly diffused through the pulmonary tissue. "When dis- 
 tributed in small insulated portions, I believe it to constitute one of 
 the forms of albuminous deposit, indiscriminately called tubercles : 
 whereas, when more extensively and irregularly diffused, it has, in 
 like manner, been regarded as a form of tubercular infiltration. The 
 history, however, of the patient's case, in many instances, as well as 
 the local appearances themselves, lead me to the conclusion that they 
 are merely the result of a previous attack of pneumonia. We often 
 learn on inquiry that at some former period, perhaps years before, 
 the patient had had an attack of inflammation within the chest ; 
 whilst, if he die of some other disease, we almost uniformly discover 
 on dissection unequivocal evidence of antecedent inflammation. The 
 evidence consists in tliickening and adhesions of the pleura?, espe- 
 cially in the neighbourhood of the appearances in question, together 
 with induration and puckering of the pulmonary tissue immediately 
 surrounding each albuminous deposit : or, when the deposit is irre- 
 gular and extensive, we often have an actual deformity and puckering 
 of the pleura above the infiltrated parts. This view of the origin of 
 these albuminous deposits will probably serve in some measure to ex- 
 plain why they are much less uniformly found in the apices of the 
 lungs than ordinary tubercles. 
 
 It has been observed that these deposits may remain passive for 
 an unlimited period, and without undergoing any very appreciable 
 change, except perhaps a conversion of some of them into calcareous 
 or chalky masses, especially when deposited in the upper lobe of the 
 lung : it would nevertheless appear that the vital influence by which 
 they are maintained in their integrity is so extremely slender, that if 
 inflammation happen to be set up around them by any accidental 
 cause, and especially if the vital powers of the patient have been 
 greatly impaired, that influence is so far exhausted, that they lose 
 their cohesion and soften ; the softening commonly first taking place 
 in those portions most remote from the more highly organized living 
 structures ; they soften in the centre ; the softening proceeds out- 
 wards, and in the end causes the formation of a vomica, and so pro- 
 duces one of the modifications of phthisis pulmonalis. Such, at 
 least, are the conclusions to which repeated observation of the living 
 and dissection of the dead have led me in regard of this part of the 
 subject. 
 
 Having premised these very superficial remarks, I shall now 
 proceed to the repeated functional signs or symptoms of pneumonia ;
 
 DIAGNOSIS OF PNEUMONIA. 11 
 
 for it is to the unsteadiness and fallaciousness of these that errors in 
 diagnosis are chiefly attributable ; and, consequently, it is to them 
 more particularly that I am desirous of directing attention. 
 
 The characteristic symptoms of pneumonia enumerated by Laennec 
 are, an obtuse and deep-seated pain in the chest, dyspnoea, hurried 
 respiration, cough, and peculiar expectoration ; but, in reference to 
 these, he tells us that each of them individually may occasionally be 
 absent, and, indeed, that they may all be absent in the same case. 
 Now, were it quite correct to assume that the character of pneu- 
 monia is that which is expressed by the above symptoms, that the 
 reputed deviations and exceptions alluded to by Laennec are 'only of 
 very rare occurrence, and that obscurity happened only in the pneu- 
 monia of old people, and in cases complicated with other diseases, 
 there might probably be some excuse for resting satisfied with the 
 present position of the subject ; but if it be as true, as I am con- 
 vinced it is, that these reputed deviations and exceptions, regarded 
 as obscure, are of extremely frequent occurrence, that they are met 
 with at every period of life, and in every variety of constitution ; 
 and that they are very far indeed from being limited to old persons, 
 and to what have been called complicated cases ; I hope to be par- 
 doned if I make an attempt in some degree to unravel the difficulty, 
 and place the subject, if not in a more correct, at least in a more 
 safe and practical point of view. 
 
 I have been led to the conclusion that cases of pneumonia, charac- 
 terised by obtuse and deep-seated pain, dyspnoea, hurried respiration, 
 cough, and peculiar expectoration, are, in truth, themselves the 
 exceptions in a pathological sense; and that, although most fre- 
 quently met with in practice, they are, in fact, cases of complication. 
 It may be said if such cases of complication be those most commonly 
 encountered in practice, why interpose a mere pathological subtlety 
 to disturb the practical rule ? To this I oppose my belief that it 
 is an adherence to such a general character of pneumonia that has 
 led, and is constantly leading, to an oversight to a neglect of the 
 disease, when it occurs in what I am disposed to regard as its more 
 x'inipleform ; and as cases partaking more or less of this simple form 
 of pneumonia are of frequent occurrence, I am willing to persuade 
 myself that what follows may have the effect of diminishing the 
 liability to the errors alluded to. 
 
 In simple pneumonia, after chilliness, shivering, feebleness, and 
 depression, the patient experiences, for the most part, strongly-
 
 12 OBSERVATIONS ON THE 
 
 marked symptoms of febrile reaction, giddiness, confusion, and 
 sometimes intense pain in the head; occasionally delirium, especially 
 towards night; the skin acquires a pungent heat, generally accom- 
 panied by dryness, more rarely by moisture ; the pulse is full and 
 strong, perhaps labouring and sluggish ; the face is usually more or 
 less suffused with a livid flush, accompanied by an expression of 
 distress ; the tongue is foul, its substance is more injected than in 
 ordinary phlegmasise, and in a short time it manifests a tendency to 
 become dry and brownish ; the respiration is somewhat hurried, but 
 there is seldom any very obvious cougli or expectoration, and some- 
 times none at all ; in short, the whole assemblage of symptoms bears 
 a most striking resemblance to those of a severe attack of common, 
 continued fever of the typhoid type, for which it is so repeatedly 
 mistaken. If this form of the disease occur in moderately good con- 
 stitutions, and is overlooked, especially if stimulants be administered 
 on the supposition of its being a severe case of typhoid fever, it very 
 commonly happens that the general prostration increases, the deli- 
 rium or oppression of the brain is aggravated, the tongue gets dry 
 and black, and the teeth covered with sordes ; the breathing becomes 
 more hurried, occasionally with a frequent slight hacking cough, and 
 now and then a little bloody expectoration ; the pulse gets flaccid, 
 frequent, and feeble ; and at length the patient dies. 
 
 Notwithstanding its close resemblance to a severe ' attack of 
 continued fever a resemblance so great that even the stethoscopist 
 is occasionally thrown off his guard attentive observation will, in 
 most cases, enable us to recognise the difference. The attack in 
 general is more abrupt, and often follows some manifest exposure to 
 cold or wet. The countenance, though congested and somewhat 
 distressed, has not the dejection and stupidity so remarkable in 
 fever; it displays more intelligence; and, although confused and 
 perhaps slightly delirious, the patient, on being roused, commonly 
 evinces a clearness and vigour of intellect not found in fever. The 
 condition of the tongue also furnishes a valuable diagnostic sign. 
 We know that, at the onset of the fever, the contrast between the 
 vividly injected tongue and its white or grey fur is very striking ; it 
 is, in general, much less so in pneumonia. In the latter, if I may 
 be allowed the expression, it is more the tongue of a phlegmasia ; 
 the hurry of respiration in pneumonia is often not more than we 
 commonly perceive amid the general distress of fever ; and I repeat 
 that neither cough nor expectoration is necessarily present in a very
 
 DIAGNOSIS OF PNEUMONIA. 13 
 
 appreciable degree. But of all the symptoms of pneumonia, the 
 most constant and conclusive, in a diagnostic point of view, is a 
 pungent heat of the surface. By this symptom alone the first stage 
 of pneumonia may in most instances be readily recognised. By this 
 symptom alone I have repeatedly pronounced the existence of pneu- 
 monia before asking a single question, or making the slightest 
 stethoscopic examination of the chest. The presence of this symp- 
 tom has scarcely ever yet deceived me, even in the most complicated 
 forms of inflammation within the chest. I by no means contend 
 that it is necessarily present at some period of every case, although 
 I do not know to the contrary ; but I feel justified in affirming that 
 when inflammation is confined to the chest, however varied may be 
 the tissues involved in the inflammatory process, provided this symp- 
 tom be present, pneumonia may be confidently pronounced to form 
 a part in nineteen cases out of twenty, and I believe in a much larger 
 proportion. 
 
 A similar pungent heat of the surface is now and then'observed 
 in certain forms of renal dropsy ; more frequently in continued fever, 
 especially in children; and still more commonly in the eruptive 
 fevers of the exanthemata #nd erysipelas ; and as such cases may 
 supervene upon already existing disease within the chest, the fact 
 ought to be carefully remembered, lest the most valuable diagnostic 
 sign should rather mislead than assist us. It is in original inflam- 
 mation within the chest that it proves so constant and conclusive a 
 sign of pneumonia ; but on every occasion when present it ought to 
 lead to a most careful scrutiny by means of the stethoscope. 
 
 I am unwilling to swell this communication by a detailed recital 
 of individual cases : but were it otherwise it would be easy to in- 
 troduce a very great variety of instances in which simple pneumonia 
 has been mistaken for common fever of a typhoid type. I have re- 
 peatedly witnessed it in children, the first suspicion of it having 
 generally been suggested to me by recognising, on applying the hand 
 to the surface, the peculiar pungent heat already noticed. I not 
 long ago had an example in a young woman who was supposed to 
 be labouring under a severe attack of bilious fever; so called 
 because pneumonia of the right lung was accompanied, as is not un- 
 frequently the case, by a sallowness or almost jaundiced aspect of the 
 patient's countenance. I have a very similar case in Miriam's Ward 
 at this time, also occurring in a young female. In elderly persons 
 it is so common that when a case of typhus is represented to have
 
 14 OBSERVATIONS ON THE 
 
 occurred in any individual above fifty years of age, without evidence 
 of the existence of the disease in other branches of the family, I 
 confess that I consider it at all times an equal chance that it is, in 
 reality, a case of pneumonia. An instance of this kind I saw very 
 recently : the person was upwards of sixty, but of a hale constitu- 
 tion, and presented most of the ordinary signs of continued fever, 
 whilst the pulmonic symptoms were so slight as never to have 
 attracted the least attention. This brief representation may probably 
 suffice to fix attention upon the likelihood of the presence of pneu- 
 monia in cases of supposed continued fever. 
 
 The more simple form of pneumonia not unfrequently assumes 
 another appearance, which has occasionally led to a belief that the 
 brain was the seat of the disorder : the original affection of the 
 lungs being so obscure as to be entirely overlooked. I have, within 
 a short period, seen two cases of acute pneumonia in vigorous adults, 
 in which, at the commencement, and for some days, the disturbance 
 of the brain was such, that remedies were applied exclusively for the 
 relief of that organ. In both instances the inflammation was very 
 intense, and was, at a later period, attended with cough, expectora- 
 tion, and other signs commonly regarded as characteristic of 
 pneumonia. 
 
 Some time ago I was requested to see an elderly man, who 
 appeared to be labouring under obscure symptoms of mental aber- 
 ration, and was supposed to have become insane. He looked pale, 
 his countenance was somewhat anxious, his tongue was loaded, 
 slightly brown, and disposed to become dry, he was occasionally in- 
 coherent, and wandered about the ward in a wild and unaccountable 
 manner, but had neither cough nor expectoration sufficient to attract 
 any particular attention. On examination I found, him labouring 
 under pneumonia already advanced to hepatization, He recovered. 
 A similar case is now under treatment in the hospital. 
 
 In infants and very young children such cases are by no means 
 rare, and simulate hydrocephalus. In one instance, where hepatiza- 
 tion had taken place, the most prominent symptom was convulsions, 
 for which various applications had been made to the head. 
 
 Such are some of the affections of the brain, to which pneumonia 
 not unfrequently gives rise secondary affections, calculated to mis- 
 lead the most wary ; and such as must inevitably distract the atten- 
 tion, and perplex the judgment of those who do not habitually have 
 recourse to the stethoscope.
 
 DIAGNOSIS OF PNEUMONIA. 15 
 
 If the representations I have made be correct they certainly lead 
 to an inference, that even acute disease does not, when confined to 
 the air-cells, necessarily give rise either to cough or expectoration 
 symptoms, perhaps, too much relied upon in recognising, or even 
 suspecting, affections of the lungs. 
 
 Without arguing the question, whether it be possible to expecto- 
 rate a thin watery fluid, which must necessarily gravitate in the cells 
 of the lungs, I may venture to state that I entertain a very strong 
 suspicion that the cough and expectoration so commonly observed in 
 pneumonia depend altogether upon the accidental implication of the 
 bronchial tubes, and that, without a doubt, the degree of these 
 symptoms depends upon the degree of that implication. Certain it 
 is that the most intense pneumonia may exist, even in hale constitu- 
 tions, with cough and expectoration so slight as to pass unnoticed ; 
 and it is not difficult to suppose that, when so slight, they may 
 depend rather upon mere sympathetic irritation of the minute 
 bronchial tubes in the immediate neighbourhood of the inflamed 
 tissue, than upon any considerable degree of actual inflammation set 
 up in them. It is true that, on dissection, we very commonly find 
 the mucous membrane of the smaller tubes reddened ; but whether 
 from inflammation or not, is by no means so easily determined. I 
 am disposed to think that, in simple pneumonia, the small tubes are 
 either not at all inflamed, or only inflamed in a very slight degree, 
 and that, when more decidedly involved, their inflamed state gives 
 rise to the cough and peculiar viscid expectoration described as cha- 
 racteristic of pneumonia in general. This complication is indis- 
 putably more frequently present than absent ; a circumstance little 
 calculated to excite surprise, and one probably sufficient to 
 account for the symptoms which attend the complication, having 
 usually been described as those essential to, and characteristic of, 
 pneumonia. 
 
 When cough and expectoration are as well marked as they are 
 commonly described to be, they cannot fail to attract the attention 
 of every one, and all difficulty of diagnosis ceases. The same may 
 be said of those cases of pneumonia in which we have the mucous 
 membrane of the bronchial tubes involved to such an extent, that, 
 by universal consent, the disease is said to be complicated with 
 bronchitis, and in which we have the expectorated mucus, though 
 considerable in quantity, more or less tinged of a brownish or saffron 
 colour. It does not, however, necessarily follow that, when pneu-
 
 16 OBSERVATIONS ON DIAGNOSIS OF PNEUMONIA. 
 
 monia is present, the mucus of the accompanying bronchitis shall be 
 tinged brown; en the contrary, the discoloration is often in such 
 cases, altogether absent, its presence and degree depending upon 
 the quantity of blood which happens to be diffused ; exactly in the 
 same manner as the ordinary viscid sputa of pneumonia may be 
 colourless, or may be of a gamboge yellow, light green, or of a rusty 
 or red colour, according to the same accidental circumstance. Of 
 course, in these bronchial complications, we have, superadded to the 
 stethoscopic signs already mentioned, a mucous rattle, which, when 
 hepatization takes place, is rendered much more distinct, in con- 
 sequence of the consolidated lung being a better conductor of 
 sound. 
 
 In concluding this slender contribution to diagnosis, I shall 
 merely observe further, that unless complicated with pleurisy, pain 
 of any sort is rarely complained of by a patient affected with simple 
 pneumonia, in whatever position he may be placed. When, how- 
 ever, the bronchial complication is such as to produce severe cough, 
 he not unfrequently experiences a burning or tearing pain, or rather 
 soreness, more or less diffused through the affected parts a symp- 
 tom probably resulting from the violence inflicted upon the inflamed 
 tissue during the repeated fits of coughing.
 
 OBSERVATIONS 
 
 PNEUMONIA AND ITS CONSEQUENCES. 
 
 (Read before the Guy 's Physical Society, 1843.) 
 
 MY object in offering this communication to the Society is, to 
 direct attention to a few points connected with the pathology, dia- 
 gnosis, varieties, and effects of pneumonia. The general history and 
 ordinary details appertaining to the disease are, I believe, sufficiently 
 well known ; and might be deemed misplaced, or might even appear 
 impertinent, when addressed to a society which numbers amongst 
 its members those who have successfully directed much of their atten- 
 tion to the subject. The disorder, nevertheless, is one in the study 
 of which I have long felt a deep interest ; and the result of my in- 
 quiries and investigations is a conviction that much still remains to 
 be done for the satisfactory elucidation of those points to which I 
 have alluded. However unsuccessful I may be in my attempt to add a 
 trifle to the general stock, it is gratifying to hope that by exciting 
 discussion and thereby concentrating the practical knowledge of the 
 Society, much useful information may be elicited. 
 
 As I have already stated, I shall content myself with a very brief 
 notice of those parts only of my subject which seem more particu- 
 larly to require or admit of further elucidation : and in compliance 
 with such design, I shall first direct attention to what has been 
 termed simple pneumonia, by inquiring whether that which has been 
 so called be in reality the simplest form of the disease, and whether 
 the general impression that it is so has not led to many serious and 
 even fatal errors. 
 
 Every one knows that the symptoms said to characterise simple 
 pneumonia are phlegmasial fever, with dyspnosa, pain or uneasiness 
 in some part of the chest, cough, and peculiar expectoration. It is 
 true that Laennec and others have dwelt upon the variableness in 
 
 2
 
 18 OBSERVATIONS ON PNEUMONIA 
 
 degree of each of these symptoms, and have carefully pointed out a 
 certain class of cases in which they do not appear, and which on that 
 account have been designated latent pneumonia ; cases occurring in 
 the aged, the cachectic, in the intemperate, and towards the fatal 
 termination of various diseases, characterised in general by much 
 typhoid prostration, and thence occasionally called typhoid pneumonia. 
 An impression has thus been created, and is still very generally pre- 
 valent, that whenever pneumonia occurs in good constitutions, and 
 especially if the patient be young, the characteristic symptoms enu- 
 merated ought to be present. This impression is at variance with 
 my own experience ; and I am led to the conclusion that the simple 
 pneumonia of Laennec and others is not the simplest form of the com- 
 plaint, but a complication a broncho-pneumonia, and that a truly 
 simple pneumonia is not very unfrequently met with in young per- 
 sons, and in good constitutions, unattended by either cough, expec- 
 toration, or pain, or, at least, such a degree of either as to attract 
 particular attention ; but more of this when we come to the 
 diagnosis. 
 
 Seat of Pneumonia. There are probably some present who remem- 
 ber the time and occasion when, in this Society, and in opposition 
 to all existing authorities, I ventured to call in question the long 
 cherished notion that pneumonia had its seat in a supposed paren- 
 chyma of the lungs, and that the products of pneumonic inflamma- 
 tion were poured into that parenchyma. Since that time I have had 
 the satisfaction of witnessing a gradual, but comparatively rapid, 
 renunciation of the latter views, and the adoption of those advanced 
 for discussion in this Society so many years ago ; viz., that pneumo- 
 nia has its original and essential seat in the air-cells of the lungs, and 
 that the ordinary pneumonic deposits are poured into these cells. It 
 is nevertheless true that some of our most recent authorities are op- 
 posed to this opinion, and maintain that the pneumonic deposits are 
 poured into an interstitial tissue, a conclusion which I find myself 
 unable to reconcile with either the healthy or the morbid anatomy of 
 the lungs. I entirely fail to discover any structure to which the 
 terms interstitial and parenchyma can be fairly applied. Accom- 
 panied by a corresponding branch of the pulmonary artery, I trace a 
 filiform bronchial tube to a lobule or bunch of cells, in which it 
 abruptly terminates ; the blood distributed over these cells being 
 received by the pulmonary veins, which pass exteriorly to the air- 
 cells, in a loose and very distinct interlobular cellular tissue.
 
 AND ITS CONSEQUENCES. 19 
 
 But, notwithstanding the most careful investigation, aided by in- 
 jections into the tubes and cells, and by the use of magnifying-glasses, 
 I must confess myself unable to arrive at any positive conclusion, 
 either as regards the elementary tissues which compose the air-cells 
 of the lungs, or the exact construction and arrangement of the cells 
 themselves. These are questions which there is reason to hope will 
 ere long receive a satisfactory solution from those who have already 
 distinguished themselves as successful cultivators of microscopic 
 anatomy. In the mean time, without venturing to decide whether 
 the innumerable, minute, irregular, and manifestly elastic air-cells 
 constituting an individual lobule, partake more of the character of 
 areolar tissue or of a serous membrane, I am fully persuaded that 
 pathologically they present none of the attributes of a mucous mem- 
 brane, as Reissessen and others would lead us to believe ; and that, 
 so far as the changes induced by inflammation and other diseased con- 
 ditions are entitled to guide us, they must be ranked with one or 
 other of the first-named tissues. Neither do these changes enable 
 us to recognise any of that intercellular tissue which has been confi- 
 dently asserted to be the seat of some of the most important diseases 
 of the lungs, and into which, accordingly, the morbid deposits result- 
 ing from inflammation and dropsy have been supposed to be effused. 
 So far as my observation has extended, I should have as little hope 
 of finding this interstitial material in the pulmonary lobule as in a 
 mere bundle of common areolar or cellular tissue. 
 
 Effects of Pneumonia. I may venture to affirm that no one who 
 carefully traces the effects, either immediate or remote, of pneumonic 
 inflammation can fail to be struck with their close resemblance to 
 those of inflammation affecting a serous membrane or the common 
 uniting cellular tissue of the body; and if the pathological changes 
 induced in any tissue constitute a legitimate foundation for an opinion 
 respecting the physiological character of that tissue, one is almost 
 irresistibly led to the conclusion that the air-cells of the lungs are 
 a mere modification of one or other of these tissues. But to 
 proceed. 
 
 It is a plausible conclusion of one of our ablest writers on pneu- 
 monic inflammation that in the earliest stage of that morbid condi- 
 tion there is a preternatural dryness of the air-cells, from an arrest 
 of their natural secretions, and that this stage is characterised by an 
 excited state of the respiratory act, and by a murmur louder than 
 natural. To this belief I am inclined to subscribe, having recently
 
 20 OBSERVATIONS ON PNEUMONIA 
 
 met with a case in this hospital, which from the presence of a premo- 
 nitory symptom, to be mentioned more particularly by-and-by, I 
 anticipated would proceed to pneumonia, in which pneumonia 
 actually took place, and in which this excited state of the respiration 
 and a loud but rough respiratory murmur in the lung about to be 
 affected, were strongly marked. Further observation is, neverthe- 
 less, certainly still required fully and satisfactorily to establish this 
 Dr. Stokes's position ; and since the onset of inflammation as 
 positively checks the secretion of a mucous as it is affirmed to do 
 that of a serous membrane, the position, even if correct, bears hut 
 little upon the question regarding the mucous or serous character 
 of the air-cells. It is the effect which immediately succeeds to this, 
 and which is that usually first recognised by physical signs, being 
 the stage of engorgement of authors, that seems most strongly to 
 countenance the belief in the serous character of the pulmonary air- 
 cells. This effect consists in an effusion of serum into the cavities 
 of the cells themselves; an effect certainly at variance with the 
 opinion of Eeissessen and others, that the air-cells are merely the 
 blind extremities of as many bronchial tubes, and that, like the latter, 
 they are lined by an ordinary mucous membrane. It is some years 
 ago since I first collected this fluid, and on testing it by heat, found it 
 to be highly coagulable. It is true that there are those who enter- 
 tain a different opinion, and contend that the effusion, though serous, 
 is not poured into the cells, but into an interstitial tissue. This 
 interstitial tissue I have never been able to discover, whereas any 
 one, with a very little care, may satisfy himself that the serous fluid 
 is poured into the cells themselves ; he may do this by forcing, by 
 gentle pressure, the fluid from the cells through the truncated bron- 
 chial tubes of the incised lung, and subjecting it to examination. 
 But as a proof of its not being in the cells, we are told that at this 
 stage of pneumonia expectoration is often absent, or, if present, does 
 not consist of serum ; which it is supposed ought to be the case if 
 it were contained in the cells. It remains to be proved, however, 
 that simple serum, which must necessarily gravitate, can be expec- 
 torated at all under ordinary circumstances ; inasmuch as in order to 
 accomplish expectoration, the matter to be expectorated must admit 
 behind it a sufficient quantity of air to force it into and up the tubes, 
 and we know that in the very worst forms of oedema of the lungs, 
 there is often very little cough, and seldom any expectoration at all, 
 or, if any, not necessarily of a serous character. It is, indeed, con-
 
 AND ITS CONSEQUENCES. 21 
 
 tended that the serous effusion in oedema of the lungs is not poured 
 into the cells, but into the supposed interstitial tissue. The disproof of 
 this, however, is just as easy and as obvious as that of the interstitial 
 deposition of serum in pneumonia ; as I have over and over again 
 satisfied myself ; and I may add that Mr. Hilton and myself col- 
 lected the fluid from the truncated bronchi with great care and with 
 the least possible violence, and found it to be purely serum. In 
 order, also, to prove that it was not lodged in the interlobular tissue 
 we separated an individual lobule, and found that by puncturing it 
 a fluid purely serous was readily collected. Thus, then, as in other 
 serous structures, we find that one of the earliest effects of inflamma- 
 tion of the pulmonary cells is an effusion of serum into them ; and 
 that when there is dropsy of other serous structures, oedema or 
 dropsy also takes place in them ; illustrations of which are perpetu- 
 ally met with in Bright' s disease. 
 
 In this stage of pneumonia, together with a highly red and vascu- 
 lar condition of the cells, we find the cells already more substantial 
 and dense to the feel than natural, although still crepitating and 
 containing air. Sooner or later, however, the turgid parietes of the 
 cells obey the ordinary laws of an inflamed part, they lose their na- 
 tural cohesion, swell, and encroaching on the cavities of the cells, 
 cause the absorption of the serum previously effused, and by thus 
 occupying or filling up these cavities, occasion first a dryness and 
 brittleness, and afterwards the complete consolidation which consti- 
 tutes the red hepatization of authors a consolidation, nevertheless, 
 accompanied, as might be expected, by such loss of cohesion as causes 
 the lung readily to break down under pressure. From the exami- 
 nations I have made of lungs in this state, I am disposed to agree 
 with those who reject the notion of the consolidation being dependent 
 in any degree upon actual effusion of solid albuminous matter into 
 the cells : it seems to result entirely from the great vascularity, soft- 
 ening, and tumefaction of the parietes of the cells themselves, and 
 hence probably the rapidity with which this often takes place in 
 typhoid or cachectic pneumonia, in consequence of that loss of tone 
 which uniformly causes the various tissues speedily to soften under 
 the disorganizing influence of inflammation. Accordingly, if we atten- 
 tively examine a lung in this condition with a moderately magnifying 
 power, we find the granular appearance so much dwelt upon by 
 writers, but without any evidence of actual deposit in the cells. 
 
 In order more clearly to comprehend the subsequent changes
 
 22 OBSERVATIONS ON PNEUMONIA 
 
 which take place in an inflamed lung, it is necessary to bear in mind 
 the disorganizing tendency which uniformly accompanies the morbid 
 process of acute inflammation wherever situated. The changes pro- 
 duced by this morbid process we know to consist not only in a loss 
 of cohesion and more or less tumefaction of the inflamed tissue, but 
 in a remarkable disposition in that tissue to return to a state more 
 or less resembling that which forms the original basis of all tissues, 
 viz., an albuminous material. This re-conversion of a tissue into 
 albumen I would express by the term albuminization. The healthy 
 organizing process converts albumen into the various natural tissues, 
 whereas the disorganizing process of inflammation tends to destroy 
 this organization, and to cause the tissues to return to an albuminous 
 state. We accordingly find that as acute inflammation proceeds, the 
 parietes of the cells become more and more opaque how far from a 
 merely molecular change, and how far from superadded albuminous 
 deposit, it is difficult to determine ; the minute blood-vessels are no 
 longer visible, the parietes of the cells are not only thickened, but 
 become exceedingly softened; and with this extreme loss of cohesion 
 and apparently diminished vascular turgescence, we have undeniable 
 proof that the cells now admit of an albuminous matter being poured 
 into their cavities. This constitutes the grey hepatization of 
 authors. 
 
 When the inflammation occurs in good constitutions this albumi- 
 nous matter may be more or less solid, so as not to allow of its being 
 pressed out; although, by careful washing, it may sometimes be 
 partially removed, so as to restore imperfectly the cellular appear- 
 ance of the lung ; but should the inflammation occur in a bad con- 
 stitution, or take on an atonic form, the albuminous effusion is more 
 fluid, presenting a more or less yellow or even dirty muddy purulent 
 appearance, and may be readily forced out by gently pressing or by 
 pricking the cells which contain it. That this puriform fluid is really 
 contained in the cells themselves, and not in any interstitial tissue, 
 may be further shown by making an incision into the lung, scraping 
 off the matter from the divided surface, and then applying pressure ; 
 when the matter will be seen to issue from separate openings more 
 or less apart from each other, and which are manifestly small bron- 
 chial tubes. These changes may, in any state of constitution, take 
 place in a considerable extent of pulmonary tissue, rendering the 
 whole of an opaque white or grey colour, and obliterating, or rather 
 concealing, the lines of common cellular membrane which naturally
 
 AND ITS CONSEQUENCES. 23 
 
 separate one lobule from another, and which were, during the period 
 of red hepatization, distinctly visible. In other cases, however, and 
 especially in certain atonic forms of acute pneumonia, these changes 
 are confined to individual lobules more or less remote from each 
 other, the common cellular membrane appearing to form a distinct 
 line or boundary to the inflammation ; thus illustrating one of the 
 purposes answered by the lung being divided and subdivided into 
 lobes and lobules, that of preventing, to a certain degree, the 
 extension of disease commencing in one lobule to that immediately 
 adjacent. 
 
 It has long been a matter of remark that acute pneumonia rarely 
 terminates in the formation of abscess ; and it certainly is not a little 
 remarkable that, notwithstanding the great loss of cohesion of the 
 tissues so great that the slightest violence after death causes them 
 to break down into a semifluid amorphous mass a real abscess 
 should be so very rarely met with. In good constitutions, even 
 under the most intense inflammation, such an occurrence is uni- 
 versally acknowledged to be extremely rare; whilst in the more 
 atonic inflammations affecting bad constitutions, although abscesses 
 are by no means so very unfrequent, they are for the most part ex- 
 ceedingly small, and irregularly scattered through the inflamed part. 
 In some cases such is the want of vital power, that acute inflamma- 
 tion rapidly disorganizes the tissue, and either reduces it speedily to 
 a puriform albuminous mass, or entirely robs it of its vital properties, 
 so that it dies or sloughs before the softening and liquefaction are 
 so complete as we find in abscess : in these cases of sloughy abscess 
 the sloughing part sometimes presents a dark dingy aspect, exudes 
 a turbid serous or sanious fluid, and even manifests an offensive or 
 putrid odour. Gangrene, properly so called, is acknowledged to be 
 still more rare ; although, when gangrene of the lung does occur in 
 its diffuse form, I believe it to be closely allied to the sloughing 
 process just alluded to, and to result from a certain degree of inflam- 
 mation occurring in bad constitutions ; all the cases that I have wit- 
 nessed having been in persons who had either been guilty of great 
 intemperance, or had otherwise brought their systems into an 
 extremely cachectic or atonic state. 
 
 I have, in these remarks, specified diffused gangrene in particular ; 
 because another form of gangrene of the lung is spoken of, of a more 
 chronic kind, generally surrounded by condensed lung, and to which 
 the name circumscribed gangrene has been applied. Most, if not all
 
 24 OBSERVATIONS ON PNEUMONIA 
 
 cases of the latter kind, however, I am disposed to suspect, have 
 quite a different origin from the former, and are the result of pre- 
 vious pulmonary apoplexy ; an illustration of which will be found in 
 the accompanying drawings, taken from subjects examined at this 
 hospital. Blood is poured into the aerial cellular tissue : this for a 
 certain time remains in the form of a circumscribed solid red body, 
 imbedded in the lung : it afterwards assumes the appearance of a 
 mass of solid albuminous matter, the red particles or coloured matter 
 having been removed. This albuminous mass may remain perma- 
 nently, and be accidentally discovered when the individual has been 
 cut off by some other disease. It would appear, however, from cases 
 such as these from which the drawings were taken, that these masses 
 occasionally destroy the circulation of the air-cells in which they are 
 imbedded, act as foreign bodies, excite inflammation, and cause albu- 
 minous matter to be poured out around them, by which they become 
 more or less isolated from the surrounding tissues, and consequently 
 die ; or, becoming putrid from their communication with a bronchial 
 tube, give rise to all the ordinary characteristic symptoms of gan- 
 grene of the lung. It is in such cases that a portion of separated 
 and dead lung is occasionally found as a loose nodule in the gan- 
 grenous cavity. 
 
 I have said that the changes produced by acute pneumonia may 
 be limited to separate lobules, more or less remote from each other. 
 This lobular pneumonia, as it has been called, although it may occur 
 in good constitutions as, for example, in pneumonic complications 
 of whooping-cough is, for the most part, observed in bad and 
 cachectic habits of body, and especially towards the termination of 
 various chronic diseases, after surgical operations, and in phlebitis. 
 It is in such cases that the vital properties of the tissue inflamed are 
 rapidly exhausted, so that remarkable softening or small sloughy 
 abscesses speedily result, so rapidly, indeed, that, in the case of 
 phlebitis, it has been somewhat unphilosophically, and certainly very 
 incomprehensibly asserted, that the matter formed in the vein is me- 
 chanically conveyed to and deposited in the lung. The abscess in 
 such cases is, indeed, sometimes of considerable size perhaps that 
 of a large hazle nut very complete, and very rapidly formed ; but 
 that this merely results from the circumstances just pointed out is, 
 I think, sufficiently attested by the fact, that in some instances we 
 can distinctly trace, in different lobules, the progressive changes 
 which usually precede a perfect abscess ; namely, redness, drvness,
 
 AND ITS CONSEQUENCES. 25 
 
 condensation, friability, albuminous opacity, and, lastly, the softening 
 down into a complete abscess. 
 
 There is another form of consolidation of the lung, which has been 
 much dwelt upon by writers on this subject. It was first, I believe, 
 particularly noticed by Laennec, who described it under the name of 
 carnification of the lung, and was regarded by him as the result of 
 pneumonic inflammation, modified by pleuritic effusion. Externally 
 the lung presents a bluish tint, not unlike that of the spleen ; it 
 feels soft and flabby ; and, when cut into, displays no granular, but 
 rather a uniform texture, of a dark or brownish hue, pretty closely 
 resembling raw flesh which has become dark-coloured from long 
 keeping ; it is totally destitute of air, does not crepitate, and instantly 
 sinks in water. This, I repeat, has been considered as a consolida- 
 tion resulting from pneumonia modified by pleuritic effusion; and 
 has even been made the grounds of an argument, that pneumonic de- 
 posits do not take place into the air-cells ; the deposit in the present 
 case being, or supposed to be, seated in the interstitial tissue. I 
 will confess that I never could understand these views, which are 
 altogether at variance with what I understand by inflammation. I 
 never could reconcile it to myself that an inflamed tissue could 
 retain its normal, much less have an increased, tenacity ; for the lung 
 in this state is remarkably tough ; whereas loss of cohesion is one of 
 the most constant and inevitable consequences of inflammation in any 
 tissue. I never could entertain a doubt that the whole of the 
 appearances of such a lung as has been described resulted from pleu- 
 ritic effusion having compressed the lung, forced out the air, and 
 thus brought the sides of the cells into close contact. Accordingly 
 I recently took a portion of lung in this state, and, having ascer- 
 tained that it instantly sank in water, requested my friend Mr. 
 Hilton to try to inflate it : he did so, and the result may be seen in 
 the dried lung which I now present for inspection. In short, the 
 lung is perfectly inflated; and the aerial cellular tissue is in its 
 normal condition, with the exception of a slight redness, indicative 
 of an unusual quantity of blood. That this may occasionally be 
 blended with pneumonic inflammation and its consequences, I do not 
 deny, though I do not know it; but I am strongly inclined to 
 believe that the whole matter is one of those mistakes which, once 
 made, continue to be handed down without correction, in consequence 
 of a neglect to put it to the test of careful experiment. 
 
 I have met with instances of hepatization of the lung, more or
 
 26 OBSERVATIONS ON PNEUMONIA 
 
 less complete, presenting a uniform rather than a granular aspect 
 when cut or torn ; but these were altogether independent of pleuritic 
 effusion. I have seen such cases after whooping-cough, and in 
 hypertrophy of the heart. How much has mere hypertrophy of the 
 aerial cellular tissue to do with such consolidation ? 
 
 There is a peculiar state of lung frequently met with after death, 
 the nature and origin of which are still involved in considerable 
 obscurity. The condition alluded to is met with in the posterior 
 or most depending part of the lower lobes of the lungs ; and the 
 first difficulty is to determine whether it existed before death, or is 
 merely cadaveric, resulting from the position of the dead body. In 
 most instances of this kind, the lung externally is of a dark colour, 
 and when cut into presents an almost uniform soft, flabby, very 
 humid, and readily-lacerable texture, in colour verging from that 
 of red to that of black-currant jelly. If this take place after 
 death, why is it found in one case and not in another? If it 
 take place in any instance before death, what are the pathological 
 conditions which determine the occurrence of this congestive soft- 
 ening, as it might then be called ? Why I mention it in this place 
 is because we very frequently find it mixed up with a certain degree 
 of actual inflammation of the air-cells, as indicated by a marked 
 difference of colour, and by the dryness and brittleness of the in- 
 flamed tissue ; and now and then by an actual albuminous deposit, 
 or purulent infiltration in certain ^points. In such cases did the 
 congestion precede or give rise to the pneumonia, or was the appa- 
 rent congestion purely cadaveric ? In some instances, at least, 
 the signs and symptoms enable us to predict one or both of the 
 morbid appearances just described. 
 
 The remote consequences of pneumonia are scarcely less varied, 
 and are certainly not less interesting than the immediate effects 
 just described. The ordinary progressive changes which take place 
 in a lung recovering from an attack of acute pneumonia are too 
 familiar to require description ; neither will I enter into any spe- 
 culation as to that precise degree of pneumonic inflammation which 
 does, and that which does not admit of perfect resolution such 
 resolution as shall restore permeability to the cells previously in- 
 flamed, without taking into the account any slight opacity or 
 thickening insufficient to prevent their inflation. 
 
 The permanent effects produced in a lung by pneumonia depend, 
 I believe, chiefly upon the state of the patient's constitution, and
 
 AND ITS CONSEQUENCES. 27 
 
 the character of the inflammation, and consequently upon the nature 
 of the albuminous deposits, and the degree of organization of which 
 that albuminous deposit is susceptible. 1 Of these permanent effects 
 I have been led to distinguish three varieties : i. The uniform albu- 
 minous induration. 2. The granular induration. 3. The grey 
 induration. 
 
 When acute pneumonia occurs in good constitutions, the soft- 
 ened tissues appear occasionally to become so blended with or assimi- 
 lated to the permanent albuminous deposit, that the whole is 
 converted ultimately into a uniform homogenous, semi-transparent, 
 or opaque and yellowish material, in which we discover not the 
 slightest trace of either the aerial cellular structure, or of the com- 
 mon interlobular cellular membrane. Passing through this organ- 
 ized mass, we sometimes find vessels of considerable size carrying 
 red blood, which, on making pressure, may be forced out of their 
 truncated extremities ; but as regards any proper vascularity of the 
 new tissue itself, I am not at present in a position to speak with 
 confidence. The material just described may either be diffused 
 through a considerable portion of lung involving several lobules, or 
 even the greater part of an entire lobe, which is sometimes the case ; 
 or, as more rarely happens, it may be limited to one, or a very few 
 lobules only. This, the least frequent of the permanent pneumonic 
 indurations of the lung, I would distinguish by the term, uniform 
 albuminous induration, 
 
 When, on the other hand, the inflammation pours out a less 
 organizable albumen, as often happens ' in strumous habits, the 
 permanent change produced is very different. In such cases the 
 interlobular cellular tissue often, though not necessarily, remains 
 perfectly distinct; and a solid, pale, or yellowish and friable albu- 
 minous matter occupies the lobules ; and this, apparently, without 
 having assimilated the parietes of the cells, as in the former case. 
 The cellular arrangement is still perceptible, both on the exterior 
 and in the interior of the lobule, giving to the former something of 
 the configuration of a raspberry, whilst, on cutting the lobule, we 
 find the friable albuminous matter presenting the granular aspect 
 
 1 Whenever the albuminous products of inflammation become consolidated 
 and contracted, and remain permanently, I, perhaps with little propriety, use 
 the terms " organized " and " organization." The state of the blood-vessels 
 in and around these products may probably form a subject of the future com- 
 munication.
 
 28 OBSERVATIONS ON PNEUMONIA 
 
 produced by the filling up of still separate cells. Whether this 
 change take place in a single lobule, in lobules at a distance from 
 each other, or in a number of lobules as it were heaped together, so 
 little affected is the interlobular cellular membrane in many instances 
 that after keeping the lung a few days to soften it these lobules may 
 be fairly turned out and examined ; as was the case with the lobules 
 from which the accompanying drawing was taken. This constitutes, 
 then, what I would call the granular induration, resulting from a 
 deposit the very character of which seems to indicate a less vigorous 
 constitution, being less capable of organization, and resembling in its 
 appearance ordinary tuberculous matter, from which latter circum- 
 stance it is sometimes called inflammatory tubercle. 
 
 The grey induration is made up of a mixture of dull or yellowish- 
 white and black matter, in variable proportions; the tint being 
 light or dark according to the greater or less quantity of one or the 
 other of these ; the lighter variety occasionally passing insensibly into 
 the uniform albuminous induration, the darker, on the other hand, 
 being of an iron-grey colour, or approaching, in some instances, 
 nearly to black, the former again being in general of moderate den- 
 sity, the latter usually much firmer, and sometimes even as hard as 
 cartilage. In this grey variety of pneumonic induration, the mor- 
 bid change differs from the uniform albuminous induration, in the 
 albuminization of the tissues being much less complete, and from the 
 granular induration, in the albuminous deposit being of a more plas- 
 tic or organizable kind ; in short, the pneumonic inflammation may 
 be said in this case to have terminated in adhesion ; the albuminous 
 effusion having partially undergone organization and contraction, and 
 thereby glueing together and hardening the aerial cellular tissue ; the 
 whole of the appearances being, consequently, the result of perma- 
 nent albuminous deposit, obstructed cells, and black pulmonary mat- 
 ter. I believe the interlobular cellular membrane undergoes a similar 
 change in such cases. That this morbid change may have accom- 
 panied a pneumonia in which the reparatory process was slow, or that 
 it may have been produced by repeated attacks or accessions of acute 
 pneumonia, I am not inclined to dispute ; but I must confess myself 
 unable to understand the proposition, when it is asserted that this 
 grey or black induration of the lung results from chronic pneumonia. 
 In the wet preparation on the table, taken from a woman who lately 
 died in this hospital, of renal dropsy, and in whom I could detect 
 no trace of ordinary tubercle, it will be seen that whilst a portion of
 
 AND ITS CONSEQUENCES. 29 
 
 the pulmonary tissue has nearly taken on the form of the uniform 
 albuminous induration, this character gradually changes as we pro- 
 ceed from the most inflamed part ; the lung merely feels harder, is 
 imperfectly inflatable, is of a darker colour, and is gradually lost in 
 healthy cells. 
 
 As the morbid changes described have been somewhat indiscrimi- 
 nately considered as forms of tubercular infiltration, it may be fairly 
 asked What proof have we of their inflammatory origin ? It is 
 impossible in a necessarily limited communication like the present, 
 to state all the circumstances, which, after several years of careful 
 inquiry, have left no doubt in my own mind. Nevertheless, in reply 
 to such a question, I may observe, in the first place, that we occa- 
 sionally have direct proofs of a previous attack of acute inflamma- 
 tion within the chest. 2ndly. They are pretty uniformly accom- 
 panied by the clearest evidences of former inflammation : viz., old 
 deposit on the pleura immediately above the affected portion of lung ; 
 adhesions between the pleurae in that situation ; considerable pucker- 
 ing of the pleura, with accompanying contraction and diminution of 
 size of the lung itself, sufficient in some instances to cause actual 
 deformity of the thoracic cavity. 3rdly. They are, perhaps, more 
 frequently than otherwise found in the middle and inferior lobes of 
 the lung, and not in the apices, the usual and earliest seat of tuber- 
 cle ; and, lastly, The total absence in many instances of a vestige of 
 tubercle in other parts of the lung. 
 
 I cannot quit this part of my subject without adverting to the very 
 interesting and much-agitated question regarding the relation which 
 exists between pneumonic deposits and tubercle: the question 
 whether tubercle be uniformly and necessarily the result of a process 
 of inflammation ; or, if not, whether it is so in any, and in what in- 
 stances. Without pretending to remove, in any considerable degree, 
 the difficulties and obscurity which at present beset the subject, I 
 think it desirable to place before the society a plain statement of 
 the facts which I have observed, the analogies which have suggested 
 themselves, and the conclusions to which I have been led by my 
 investigations and experiments on the matter. 
 
 Like many others, I have not failed to be exceedingly struck with 
 the general resemblance a resemblance almost amounting to identity 
 observed to exist between the effects of tubercular disease occurring 
 in serous membranes, and those met with in the lungs ; the several 
 forms, changes, and varieties presented by the one being almost
 
 -' '" *-*>v 
 
 30 OBSERVATIONS ON PNEUMONIA 
 
 equally observable in the other. The earliest and simplest form of 
 tubercular disease in a serous membrane consists of a minute, roundish, 
 or oval, grey, semi-transparent projection, usually hard to the touch, 
 and possessed of considerable tenacity, so as to be broken down or 
 disintegrated with some difficulty ; being in a few instances, how- 
 ever, less dense, and more easily broken down by pressure. These 
 small bodies appear to have then- seat chiefly in the deeper and looser 
 tissue of the serous membrane ; sometimes, however, occupying its 
 denser structure, being, apparently, inseparable from it and identical 
 with it, so that an incision presents a surface in which we can dis- 
 tinguish no line of demarcation whatever ; and, still more rarely, it 
 would appear to be but loosely attached to the surface of the mem- 
 brane, and can be separated without much violence. In like manner 
 the earliest and simplest form presented by tubercles in the lungs is 
 that of minute grey semi-transparent and generally hard bodies, in- 
 separably attached to, and apparently incorporated with, the parietes 
 of the air-cells of the lungs, in the same manner as the small tuber- 
 cles are incorporated with the peritoneum. I have carefully examined 
 these tubercles, by means of a considerable magnifying power ; and 
 am satisfied that they are not by any means distinct separate de- 
 posits, but have in reality precisely the same relation to the mem- 
 brane of the air-cells as tubercles have to the cellular tissue which 
 results from inflammation when developed in it, and as tubercles have 
 to the membranes of the peritoneum and pleura. The best mode of 
 showing these appearances is to inject the bronchial tubes and cells 
 of a tuberculated lung with tallow coloured with vermilion ; when 
 not only the interlobular cellular membrane will be rendered appa- 
 rent by remaining pale, but the portion of aerial cellular tissue occu- 
 pied by the minute tubercles will be distinctly seen, and may be 
 examined by means of a microscope with the aid of a reflector ; the 
 rest of the injected lobe presenting a very good example of what is 
 called red hepatization. Should a cluster of such tubercles exist in 
 a single lobule, and in close contact, then we have, as might be ex- 
 pected, a grey semi-transparent and somewhat granular state pre- 
 senting itself. Neither in the case of the peritoneum, nor in that of 
 the lung, do we at this stage discover the slightest trace of inflam- 
 matory action ; no opacity or false membrane in the former ; no 
 puckering nor condensation of adjacent cells in the latter. 
 
 We nevertheless know, from abundant facts, that the peritoneum 
 when once tuberculated, is extremely liable to inflame ; the ordinary
 
 AND ITS CONSEQUENCES. 31 
 
 effects of which are, opacity, thickening, and contraction of the mem- 
 brane, as shown by its dull grey or whitish colour, by the diminished 
 caliber and dense fleshy feel of the intestinal tube, by the shortening 
 of the mesentery, and by the disfigurement of the parenchymatous 
 viscera. These effects manifestly arise from an effusion of coagulable 
 lymph or organizable albumen ; this giving a thin coating to the 
 serous membrane, and, by its contraction during organization, occa- 
 sioning the contraction. I find in the lungs a state scarcely dis- 
 tinguishable from this. In certain lobules, or in a single lobule, we 
 find a cluster of tubercles, the whole presenting now a more dull or 
 opaque appearance : not only do they become dull and opaque, but 
 this change is followed by a decided attempt at contraction or puck- 
 ering of the affected lobule, as I believe, from a cause similar to that 
 in the peritoneum. If we examine several of these clusters of grey 
 tubercles in different parts of a lung, we are led to the conclusion 
 that they begin in a point or cell, and gradually extend to the rest 
 of the cells, either of that or of that and adjacent lobules ; and that 
 contraction first commences in the centre of the cluster or collection : 
 so that whilst the centre has become remarkably dense, and the 
 tubercles, as it were, squeezed up together, the density gradually 
 diminishes, and the tubercular changes become more and more 
 distinct, until at the very circumference we find what are called 
 tubercles occupying a portion of pulmonary tissue still more or less 
 healthy and crepitating. It is not a little singular, too, that as a 
 general rule, in proportion to the degree of contraction and density 
 of these simple tubercles, or rather, perhaps, of the film of inflamma- 
 tory effusion poured out around them, is the quantity of black 
 matter found in the diseased tissue ; so that on cutting through a 
 portion of lung so affected, the gradually diminishing density of the 
 deposit, on the one hand, and the gradually fading black discolora- 
 tion, on the other, give to the cut surface a peculiar radiating or 
 stellated appearance. It is also worthy of remark, that in the tuber- 
 cular state of the peritoneum, a collection of such black matter is by 
 no means uncommonly met with, in small quantity, adherent both 
 to the tubercles themselves and to the false membrane which so 
 usually accompanies them. Admitting my description of the morbid 
 changes to be correct, an objection may be taken to the order of 
 succession which I have adopted. It may be said that inflammatory 
 albuminous deposit takes place first, and that tubercles are subse- 
 quently formed in it, as manifestly often happens in false membranes,
 
 32 OBSERVATIONS ON PNEUMONIA 
 
 both of the peritoneum and pleura. I have very little doubt that 
 this does happen occasionally in the lungs, as well as on the serous 
 membranes alluded to, although it is perhaps more difficult of proof; 
 nevertheless the reasons already given satisfy me that in general the 
 tubercular development is primary, the inflammatory effusion and 
 contraction secondary. On examining advanced cases of tuberculated 
 peritoneum, I have found tuberculated parts becoming opaque, yel- 
 lowish, soft, and almost like cheese : in the lungs I have found pre- 
 cisely similar appearances. The softening and disorganizing process, 
 however, so commonly met with in the lungs, is less manifest in the 
 peritoneum : the difference of the position of the two structures, and 
 the very different degree of excitement and irritation to which they 
 are respectively exposed, will go far to account for this ; whilst it 
 must be acknowledged that we are very far indeed from being with- 
 out examples of even this change. In aggravated cases of strumous 
 peritonitis, and especially when the intestines have been all matted 
 together, with considerable inflammatory deposits between their folds, 
 we not unfrequently find false membranes with every shade of tuber- 
 cular change, from the semitransparent development, through all 
 the various degrees of opacity and softening, to a yellow puriform 
 matter, with ulceration into the intestinal tube, and consequent fsecal 
 abscess. Again, when acute inflammation has supervened upon a 
 tuberculated peritoneum, I have found, after death, a moderately 
 healthy-looking plastic lymph thrown out upon the false membranes 
 and other parts, a great portion of which manifested a strong ten- 
 dency to take on a sort of tubercular form, or rather to arrange 
 itself in separate rounded or oval masses, very closely resembling the 
 opaque yellow soft masses occasionally met with in tuberculated 
 lungs after a casual attack of inflammation. 
 
 As the subject of tubercle is not intended to form any necessary 
 part of the present communication, I have merely alluded to it in- 
 cidentally, in order to trace the close analogy existing between the 
 pathological changes in serous membranes, and those of the aerial 
 cellular tissue of the lungs ; but I may nevertheless be permitted to 
 observe, in reference to this most interesting and important question, 
 that I fail to discover what I had always been taught to consider as 
 essentially tubercle a distinct, separate, or rather separable body, 
 of a particular colour and consistence, imbedded in, and, although 
 adhering to, supplanting a portion of the ordinary tissue of the lung. 
 On the contrary, unless the simple transparent tubercle already
 
 AND ITS CONSEQUENCES. 33 
 
 alluded to can be considered as a separate and distinct body, there 
 is not one of the varied morbid conditions, coming under the de- 
 nomination of tubercle, which has not appeared to me to result from 
 changes in or on the natural tissues, rather than from any separate 
 and well-defined deposit displacing these tissues. These morbid 
 changes have appeared to me to be perfectly identical with those of 
 inflammation. 
 
 Without taking into account a highly injected state of the vessels 
 of the part, or that arrest of secretion said to attend the onset of 
 inflammation in every structure, the ordinary morbid changes imme- 
 diately produced by pneumonia are, i . An effusion into the air-cells 
 of serum more or less highly charged with albumen in solution ; 2. 
 A molecular change in the inflamed tissue, characterised by more or 
 less opacity and loss of cohesion; 3. A deposition of albumen into 
 the cells, either solid and organizable, or fluid and puriform ; 4. Total 
 albuminization of the tissues, either in the form of a material suscep- 
 tible of organization, or of a material unsusceptible of organization, 
 and thence forming an abscess. On the other hand, the salutary or 
 reparatory changes are, I. Absorption of the effused serum; 2. 
 Such a change in the molecular condition of the tissue as restores to 
 it its natural cohesion, and, to a certain extent, its transparency; 3. 
 Organization of the effused albuminous matter, with consequent con- 
 traction and induration of the tissues into which it is effused, or ab- 
 sorption of the albuminous effusion if puriform ; 4. Organization of 
 the albuminized tissue, when susceptible of that change; or the 
 formation of a cyst to circumscribe the abscess, when the conversion 
 is of the puriform kind. The immediate morbid changes produced 
 by ordinary pneumonia and by phthisical disease are the same, with 
 the exception of the albumen, whether effused or resulting from the al- 
 buminization of the tissues, being much more susceptible of organiza- 
 tion, and consequently more likely to become permanent in the former 
 than in the latter ; whereas the reparatory or salutary changes are much 
 less complete and much less permanent in phthisical disease than in 
 ordinary pneumonia. Accordingly, as far as my observation has ex- 
 tended, the uniform albuminous induration can scarcely ever be said to 
 have occurred in strongly-marked phthisical disease; whilst the granu- 
 lar induration may be said to form a connecting link between phthisical 
 disease and ordinary pneumonia. The grey induration in phthisical 
 subjects being chiefly made up of the less organizable or granular 
 deposit and black pulmonary matter, is much less firm, much less 
 
 3
 
 34 OBSERVATIONS ON PNEUMONIA 
 
 permanent, and generally soon softens down into a vomica or abscess ; 
 in short, as we speak of scrofulous peritonitis, so, if called upon to 
 give an expressive name to tubercular phthisis, I should venture to 
 designate the disease scrofulous pneumonia. In both diseases, all 
 the inflammatory changes may take place without either local or gene- 
 ral symptoms sufficient to attract particular attention ; in both, the 
 general and local symptoms may be moderate, with occasional aggra- 
 vations, and in both the general and local symptoms may be those 
 of the most acute inflammation. The scrofulous pneumonia, like 
 scrofulous peritonitis, may or may not be preceded or accompanied 
 by the passive or simple transparent tubercle. 
 
 Some stress, indeed, has been laid upon the scattered and detached 
 form of tubercular disease as contrasted with the more continuous 
 and extended character of pneumonic change. I, however, believe 
 that pneumonia itself, like tubercular change, always commences at 
 a point in separate lobules, the continuity and extent of the changes 
 usually found after death from that disease resulting from the rapid 
 manner in which ordinary acute inflammation spreads ; for in many 
 cases of recent acute pneumonia we can distinctly recognise the 
 separate points or centres : whilst, in not a few, these several centres 
 never coalesce at all, but remain permanently distinct, and constitute 
 what has been called lobular pneumonia. In like manner, scrofulous 
 pneumonia, or inflammatory tubercle, whether it commence around 
 small transparent granulations, or whether it take place in the absence 
 of these bodies, also commences in separate lobules, which either 
 remain permanently separated, or a large number of neighbouring 
 lobules becoming affected at the same time, or in succession, produce 
 a more or less continuous and extensive change, precisely analogous 
 to, if not perfectly identical with, the effects of acknowledged pneu- 
 monia. In both the detached and continuous forms of tubercular 
 disease just named, the hardness, the contraction or puckering, and 
 the concentration of black pulmonary matter, sufficiently attest the 
 attempt at reparation ; although, as we know to our cost, the repara- 
 tory effort rarely proves either complete or permanent, but sooner or 
 later gives way to softening, disorganization, and phthisical destruc- 
 tion of life. 
 
 It has also been made a plausible objection to the inflammatory origin 
 of tubercular disease, that it most frequently takes place in the apices 
 and upper portions of the lungs, whereas the reverse holds true in 
 regard to ordinary pneumonia, Without dwelling upon the many
 
 AND ITS CONSEQUENCES. 35 
 
 exceptions to this rule, and without attempting to account for the 
 greater frequency of ordinary pneumonia in the lower portions of the 
 organs, on the score of these portions being the most dependent, 
 and consequently most favorable to congestion, I may, without dis- 
 puting their accuracy, remark, as a set-off against these statements, 
 that it is quite in keeping with my own experience, in examining the 
 lungs of individuals who have died of disease not affecting the chest 
 at all, to find indications of partial inflammation much more frequently 
 towards the apices than in the lower portions of the lungs. Partial 
 pleuritic adhesion and pneumonic changes, according to my expe- 
 rience, are more frequently met with in the former than in the latter 
 situation. If this observation be correct, will it not go some way to 
 account for the earlier development of tubercular disease in the 
 apices, as a general rule ? 
 
 We know that the several permanent morbid structures or deposits 
 alluded to in this paper, whether of a tubercular or pneumonic origin, 
 maintain what may be called their integrity by a very slender power : 
 that degree of vital influence which holds their molecules in a solid state 
 is so inconsiderable, that it is liable to be impaired or destroyed by 
 very slight disturbing or devitalizing causes. The most common 
 and most powerful of these are, unquestionably, inflammation set up 
 in the surrounding parts, and a cachectic habit of body, 1 but more 
 especially these two causes occurring in the same individual. "We 
 accordingly find that under such circumstances these structures and 
 deposits soften down, and are gradually converted into an albuminous 
 or puriform fluid, and thus give rise to symptoms of phthisis. It is 
 only with the softening of pneumonic deposits that we have to do ; 
 although, for reasons stated, it is almost impossible entirely to lose 
 sight of the changes, which take place in tubercular deposits, and 
 especially so as the latter are often associated with what I have de- 
 signated the granular pneumonic induration. 
 
 In cases of uniform induration, the appearances in the lung pro- 
 duced by its softening necessarily vary with its seat, its extent, its 
 being accumulated in a single well- defined mass, or distributed more or 
 less extensively in more situations than one, and according to the com- 
 pleteness or incompleteness of the softening process, or the entire 
 or partial discharge of the softened matter by the bronchial tubes. 
 We occasionally find one large round or oval cavity, generally but not 
 
 1 See the admirable description given of one form of such cachexy in the 
 valuable work of Sir James Clark.
 
 36 OBSERVATIONS ON PNEUMONIA 
 
 necessarily lined, or rather bounded by an opaque and sometimes 
 moderately thick membrane, probably containing little more than a 
 very small quantity of muco-puriform fluid, not a vestige of either 
 pneumonic or tubercular deposit being discovered in any other part 
 of the lungs, which shall appear to be perfectly healthy. In other 
 instances we find the multilocular cavity or several adjacent cavities, 
 presenting nearly the same characters, but frequently communicating 
 with one another by bronchial tubes, the latter being generally more 
 or less hypertrophied, and partially dilated. These multilocular 
 cavities have, I believe, been regarded as merely dilated bronchial 
 tubes ; but I think that there can be little doubt of their having the 
 origin I have here assigned, inasmuch as we occasionally have an 
 opportunity of examining a lung whilst the changes described are 
 actually in progress, as was found in the case from which the draw- 
 ings were taken. In one there existed several excavations somewhat 
 like a magnified honeycomb, completely evacuated, and lined by an 
 opaque membrane, all appearance of pulmonary tissue being gone, 
 whilst others were imperfectly discharged, one apparently in the first 
 stage of softening, the grey matter being partly converted into a 
 more yellow and more puriform-looking mass. The obscure, lingering, 
 and less distressing form of phthisis resulting from these changes may, 
 I think, in some instances be at least strongly suspected, if not 
 positively declared before death, whilst not a few, I believe, com- 
 pletely recover to die of some other disorder. 
 
 This form of pneumonic phthisis is nevertheless much more rare 
 than that which results from the granular deposit. The latter gene- 
 rally involves a great number of separate lobules, the interlobular 
 cellular membrane remaining more or less distinguishable ; and are 
 either heaped together in a large and extensive mass, or scattered 
 through an entire lobe, or even an entire lung. In these cases the 
 softening process may be proceeding at a great number of points 
 at once, and by no means necessarily commencing in the centre of 
 each lobule ; the irregular cavities thereby produced presenting, in 
 many instances, little or none of the smooth lining membrane found 
 in the cavities previously described, and the parietes, consisting 
 simply of an irregularly ulcerated pulmonary tissue. It is this form 
 of pneumonic induration which is so closely allied to tubercular or 
 scrofulous disease of the lungs ; and which, for the reasons already 
 given, is not in itself distinguishable from it. Phthisis from this 
 species of softening is, I believe, generally fatal ; unless, indeed, it
 
 , AND ITS CONSEQUENCES. 37 
 
 be very circumscribed, as, for example, in one of the apices of the 
 lung. 
 
 Respecting the grey pneumonic induration, I have little to add to 
 what has been already stated. The softening usually takes place 
 very slowly, either in one or in several points : the cavities thence 
 resulting are, I believe, more frequently of moderate than of large 
 size; and unless secondary changes and deposits shall have taken 
 place from accidental attacks of inflammation, the resulting phthisis 
 is proportionably slow. In the few well-marked cases I have seen 
 the disease proved fatal through the supervention of a more or less 
 acute attack of bronchitis or pneumonia. 
 
 In regard to the question respecting the cicatrizing of a vomica in 
 the lung, I may observe that the uniform albuminous, as well as the 
 grey induration, is frequently distributed in a sort of linear form, so 
 as very much to resemble a cicatrix ; and considering the perfect 
 identity of the physical signs of pneumonic consolidation with mucus 
 in the tubes of the consolidated part, and those of pneumonic 
 abscess, on the one hand, and the linear distribution of pneumonic 
 deposit, with consequent puckering of the lung on the other, I 
 cannot resist the belief that many at least, if not all the reputed 
 cases of cicatrized abscess, may have been of this kind ; although I 
 advance the suggestion with all the deference due to the high 
 authority of Laennec, and the scarcely less valuable opinion of 
 Dr. Stokes. 
 
 Having described the ordinary deposits, diffuse and lobular, pro- 
 duced by acute pneumonia ; and having stated what I believe to be 
 the ordinary changes which take place in them in an after period, I 
 may be permitted, in conclusion, to refer to the changes which we 
 so often have an opportunity of seeing in the apex of a single lung, as 
 furnishing a very good illustration and sort of epitome of the whole of 
 this part of our subject. The appearances alluded to are frequently 
 discovered after death, without the least suspicion of their existence 
 having been previously entertained, being merely incidental, and 
 often met with in the bodies of those who have died a violent death, 
 and who might be said to have been previously in perfect health. 
 The total absence of tubercles, or any other disease whatever, in any 
 part of either lung, goes far to negative their tubercular origin : the 
 thickened pleura pulmonalis, the adhesion between the pleura pul- 
 monalis and pleura costalis, together with the irregular puckering 
 of the lung and pleura pulmonalis, sufficiently attest the previous
 
 38 ON PNEUMONIA AND ITS CONSEQUENCES. 
 
 existence of inflammation. On cutting into the part we sometimes 
 find a specimen of the uniform albuminous induration from acute 
 pneumonia ; or, though much more rarely, a well- defined round or 
 'oval cavity, lined by a smooth membrane. In other cases we have a 
 very good example of the granular and yellowish deposit, probably 
 in different stages of change, firm and dry, or softening down in 
 various points, or forming irregular or tortuous sinuses or cavities 
 having an uneven, naked, or ulcerated surface ; or, here and there, 
 portions of dark-grey indurated lung puckered up, and perhaps em- 
 bracing an irregular earthy concretion, thus constituting a mixture 
 of the granular and iron-grey induration. In another case we fiud 
 it to consist entirely of the iron-grey induration, with or without 
 partial softening or earthy change. Lastly, we may find the uniform 
 albuminous, or the grey induration, so arranged, and occasioning 
 such puckering of the pleura and lung, as strongly to suggest the 
 notion of a cicatrix.
 
 PLATE I. 
 
 a. Portion of the superior lobe of the lung in a healthy state. 
 I. An irregular cavity, from softening of light-grey induration. 
 
 c. A large cavity, evidently of long standing, lined by a smooth 
 firm membrane, and communicating with a large bronchial tube, 
 into which a bristle is inserted. 
 
 dd. Sloughy softening of grey induration, bounded by a membrane, 
 as seen at section e. 
 
 f. Uniform albuminous induration in its entire state, its contrac- 
 tion having led to a marked diminution in the size of the lung. 
 
 ff. Septum between the lobes of the luug. 
 
 h. Old albuminous deposit on the pleura, situated above the large 
 excavation.
 
 Plate I 
 
 
 \
 
 PLATE II. 
 
 "Eepresents a section of lung affected with partial iron-grey indu- 
 ration. 
 
 a a. Pleura pulmonalis, thickened, contracted, and corrugated by- 
 old albuminous deposit. 
 
 b. Dark iron-grey induration of the lung, gradually diminishing 
 from a centre, so as at length to disappear in healthy pulmonary 
 tissue ; which is, however, rather more than usually charged with 
 black matter. 
 
 c. Portion of iron-grey induration, softened down into a voinica, 
 and circumscribed by an albuminous deposit, as indicated by the 
 surrounding white line.
 
 Plate II 
 
 W Hiirst del.
 
 PLATE III. 
 
 Fig. I. 
 
 Represents a portion of lung affected with uniform albuminous, and 
 light grey induration, softening down into cavities. 
 
 a. Uniform albuminous induration in progress of softening. 
 
 b. Light grey induration undergoing a similar change. 
 
 c. Cavities remaining after the expectoration of the softened 
 tissues. 
 
 Portion of lung affected with iron-grey induration. 
 
 a. Cavity resulting from softened grey induration. 
 
 b. Bronchial tube and branches extending to masses of calcareous 
 matter, the residue of softened grey induration. 
 
 Represents softening of grey induration, as shown at m m in, com- 
 municating with the bronchial tubes, as shown at n. o. A blood- 
 vessel traversing the softened tissue, its parietes thickened, and its 
 distal extremity closed in a conical form by the contraction of sur- 
 rounding albuminous deposit.
 
 Firf.2. 
 
 "b 
 
 Fig.3.
 
 THE PATHOLOGY OF PHTHISIS. 
 
 Read before tie Guy's Physical Society, Jan. ^th, 1845. 
 
 AT pages 237 and 238 of the ( Elements of the Practice of Medi- 
 cine/ published in 1837, the following passage occurs in relation 
 to changes produced in the lungs by pneumonia : " In some in- 
 stances, however, when the albuminous matter thrown out is of the 
 more plastic or organizable kind, it fails to be entirely absorbed, and 
 part of it permanently remains. Under these circumstances we find 
 it, at an after period, either in small, detached, and more or less 
 rounded masses ; or more extensively and more irregularly diffused 
 through the pulmonary tissue. When distributed in small insulated 
 portions it constitutes one of the forms of albuminous deposit, in- 
 discriminately called tubercles ; whereas, when more extensively and 
 irregularly diffused, it has, in like manner, been regarded as a form 
 of tubercular infiltration. The history, however, of the patient's 
 case, in many instances, as well as the local appearances themselves, 
 lead to the conclusion that they are merely the result of a previous 
 attack of pneumonia. "We often learn, on inquiry, that at some 
 former period, perhaps years before, the patient had had an attack of 
 inflammation within the chest ; whilst if he die of some other disease 
 we almost uniformly discover, on dissection, unequivocal evidence of 
 antecedent inflammation. The evidence consists in thickening and 
 adhesions of the pleurae, especially in the neighbourhood of the 
 appearances in question, together with induration and puckering of 
 the pulmonary tissue immediately surrounding each albuminous 
 deposit; or, when the deposit is irregular and extensive, we often 
 find an actual deformity and puckering of the pleura3 above the in- 
 filtrated parts. This view of the origin of these albuminous deposits 
 will probably serve, in some measure, to explain why they are much 
 less uniformly found in the apices of the lungs than ordinary tuber- 
 cles. It has been observed that these deposits may remain passive 
 for an unlimited period, and without undergoing any very appre-
 
 40 ON THE PATHOLOGY OF PHTHISIS. 
 
 ciable change, except, perhaps, a conversion of some of them into 
 calcareous or chalky masses, especially when deposited in the upper 
 lobe of the lung : it would nevertheless appear that the vital in- 
 fluence by which they are maintained in their integrity is so extremely 
 slender, that if inflammation happen to be set up around them by any 
 accidental cause, and especially if the vital powers of the patient have 
 been greatly impaired, that influence is so far exhausted, that they 
 lose their cohesion and soften, &c." 
 
 In a paper " On the Anatomy of the Lungs/' read before the Eoyal 
 Medical and Chirurgical Society, April 23, 1841, amongst other 
 propositions will be found the following : " Pneumonia and inflam- 
 matory tubercle are identical." " Ordinary tubercles present the 
 same varieties in the lungs as they do in serous membranes." Ever 
 since the above statements were made public, and long before, I have 
 omitted no opportunity of seeking to test them by a constant attend- 
 ance at the inspection of bodies made at this hospital, and by a careful 
 and often repeated examination of morbid parts made at my own 
 private residence. 
 
 The subject, as expressed in the above quotations, suggested for 
 consideration two very important but perfectly distinct questions : 
 i. The pathology of pneumonia. 2. The pathology of phthisical 
 disease; but more especially those forms of it which occur in 
 connection with pulmonary tubercle. 
 
 In venturing to place these two questions more in detail before 
 the profession, I could not but feel that the former, or the pathology 
 of pneumonia, ought, as a matter of course, to take precedence of 
 the latter the pathology of pulmonary tubercle inasmuch as it 
 appeared to me an almost hopeless task to attempt any analysis of 
 the pathological appearances met with in the lungs of persons dying 
 of phthisis, without a previous knowledge of the changes produced 
 in the pulmonary tissue by the mere process of inflammation. 
 Accordingly, in my last communication, my chief object was to trace 
 the morbid changes induced by pneumonia ; and, more especially, to 
 demonstrate the fact that that disease not unfrequently leaves behind 
 it divers forms of induration of the pulmonary tissue, all of which 
 have been somewhat indiscriminately, but, I believe, erroneously, re- 
 garded as modifications of tubercle or of tubercular infiltration. 
 Such indurations of the pulmonary tissue, altogether independent of 
 tubercle, are, I am more and more persuaded, of very common 
 occurrence ; and moreover venture to predict that the time is not far
 
 ON THE PATHOLOGY OF PHTHISIS. 41 
 
 distant when it will be generally acknowledged that they have not 
 by any means commanded the attention they deserve. 
 
 The comparative neglect, hitherto, of these pathological changes 
 is, doubtless, in a great measure, owing to the erroneous impression 
 left by the illustrious Laennec respecting the signs and symptoms of 
 what he was led to regard as the simplest form of ordinary pneu- 
 monia. In a former paper I endeavoured to show that the simple 
 pneumonia of Laennec is in reality a broncho-pneumonia, and that 
 there exists a still more simple form of the disease incident to all 
 ages and constitutions, in which there is but little cough or expec- 
 toration, and in some instances none at all, and that, in consequence, 
 this simpler form is often entirely overlooked. It may be true that 
 this simpler form of pneumonia is most frequently met with in the 
 aged and in cachectic habits, constituting what have been called the 
 latent and typhoid forms of the disorder; but it is nevertheless a 
 very great and very serious error to conclude that it is confined to 
 such persons and constitutions. Nor do I suppose that there is a 
 single experienced physician present who has not had more oppor- 
 tunities than one of satisfying himself that such cases, occurring 
 even in early life and in hale constitutions, are very liable indeed to 
 be either altogether overlooked, or mistaken for, and treated as 
 cases of common continued fever. 
 
 If, then, this simpler form of pneumonia be liable to escape detec- 
 tion, even in early and middle life, and in good constitutions, how 
 much more likely is this to happen when it occurs in the aged and 
 in highly scrofulous or otherwise cachectic habits. It cannot be 
 doubted that simple acute pneumonia occurring in such persons and 
 constitutions must be still more liable to be overlooked or mistaken, 
 inasmuch as neither the constitutional symptoms nor physical signs 
 are in general so unequivocally developed. This is so true that 
 even the crepitating rhonchus, so much and so justly relied upon in 
 the diagnosis of ordinary cases, is often exceedingly transient or 
 imperfect, as if the rapid congestion and consolidation of the pul- 
 monary tissue excluded that degree of serous infiltration which is, 
 apparently, essential to produce crepitation. When we take into 
 consideration these sources of error, against which I know that even 
 the accomplished stethoscopist is not universally or altogether proof ; 
 and when to this we add the fact that a very considerable proportion 
 of the profession still unfortunately continue to disregard ausculta- 
 tion, or are unable to avail themselves of its advantages, we cannot
 
 42 ON THE PATHOLOGY OP PHTHISIS. 
 
 be surprised that morbid changes, the result of a bygone inflammation 
 of the lungs, should frequently fail to be recognised during life. 
 But I venture to carry the argument further, and to submit that 
 acute pneumonia, in its most ordinary forms, and occurring in the 
 best of constitutions, and unequivocally recognised at the time, not 
 unfrequently leads to the permanent indurations I have described, 
 without even the practised stethoscopist being able positively to 
 satisfy himself of the fact. The explanation I believe to be this : 
 in such cases pleurisy lias co-existed with the pneumonia ; the phy- 
 sical signs which might otherwise have proclaimed the presence of 
 consolidation have been masked by the pleuritic effusion ; and the 
 permanent dulness of sound on percussion, absence of respiratory 
 murmur, rough tubular respiration, and modified bronchophony, 
 have been attributed to the presence of the false membranes resulting 
 from organization of the albuminous portion of that effusion. 
 
 Another cause of these permanent indurations of the lung having 
 been so much disregarded or overlooked, is to be found in the very 
 vague and I believe erroneous opinions that have been entertained 
 respecting tubercle, and what has been called tubercular infiltration. 
 In short, I suspect the history of these inflammatory indurations 
 will prove to be very analogous to that of pericarditis. The latter 
 disease was at one time supposed to be extremely rare, and almost 
 uniformly fatal ; whereas we now know that both propositions are 
 equally unfounded : so, in like manner, when acute pneumonia 
 proves immediately fatal, these pneumonic indurations necessarilv 
 cannot exist ; the hepatization which led to them is, for the reasons 
 stated, overlooked ; and hence, when discovered at an after period, 
 they are at once set down to the score of tubercle, or tubercular 
 infiltration, according to the circumscribed or diffused form which 
 they may happen to have assumed ; an error long promoted and 
 apparently confirmed, by the fact of these indurations being, 
 beyond all dispute, most frequently met with in tuberculated 
 lungs. But whether they occur in tuberculated lungs, or in lungs 
 unoccupied by tubercles, they have the same origin : they are the 
 result of pulmonic inflammation: they present the same changes 
 in their progress to permanent induration or repair, and manifest 
 the same tendency to retrograde or disorganize, at various periods of 
 their existence, according to the state of the patient's constitution, 
 or under the influence of certain morbific causes acting more imme- 
 diately upon the lungs themselves : they may soften down or even
 
 ON THE PATHOLOGY OF PHTHISIS. 43 
 
 form sloughs, at a very early period of their development or forma- 
 tion, perhaps a few weeks or months after the occurrence of the 
 inflammation which gave rise to them; the pulmonary tissue, 
 although consolidated, still presenting various degrees of brittleness, 
 or loss of cohesion ; or, they shall proceed to perfect hardness and 
 quiescence, and either remain passive and without creating any in- 
 convenience, or from some cause or other, after an indefinite period, 
 begin to disintegrate and give rise to excavation, with most of the 
 ordinary signs and symptoms of phthisis. 
 
 During the last eight or ten years I have had opportunities of 
 distinctly tracing the progressive changes alluded to in lungs unoc- 
 cupied by a single tubercle; and in cases where the pneumonic 
 inflammation giving rise to them had been satisfactorily recognised 
 during the life of the patient. Such instances, beyond all doubt, 
 occur most frequently, but not exclusively, in persons of a bad or 
 cachectic habit of body ; whilst I very much question whether there 
 ever was a single instance of tubercular disease of the lung proving 
 fatal, in which more or less of this pneumonic change might not have 
 been distinctly recognised, if the prevailing notions respecting tuber- 
 cular infiltration had not obscured the perception of the beholder. 
 
 It is a curious and highly interesting question to the pathologist 
 how far the recent pneumonic change must, in any instance, have 
 proceeded, to have passed beyond the limits of complete restoration 
 of the normal condition of the pulmonary tissue. Undoubtedly this 
 will depend very much upon the condition and constitution of the 
 patient ; permanent albuminous deposits being much less frequently 
 met with in hale and healthy subjects than in persons of a strumous 
 or cachectic constitution. That red hepatization may subside, and 
 ultimately leave the pulmonary tissue little if at all changed, is, I 
 think, hardly to be disputed ; but how far, or to what extent, an 
 albuminous deposit, sufficient to produce grey hepatization, shall 
 have proceeded, to admit of complete restoration, is a question by 
 no means of easy solution. If the opacity produced by inflammatory 
 action in a serous membrane, such as the arachnoid, pleura, or peri- 
 toneum, can be perfectly repaired, and transparency restored, it is 
 easy to conceive that a similar probably merely molecular opacity, 
 giving rise to early grey hepatization, may admit of a similar result : 
 and from my own observation I am led to believe that it is so. But 
 whether the more decided and distinct albuminous material often 
 met with in feeble constitutions can ever be removed, and the trans-
 
 44 ON THE PATHOLOGY OF PHTHISIS. 
 
 parency of the pulmonary tissue restored, I confess that I am not in 
 a condition to speak with any confidence. It may be so, and 
 especially in moderately good constitutions ; but I am in possession 
 of no absolute proof of the fact, nor do I know how any positive 
 proof is to be obtained. When such albuminous effusions have 
 proceeded to actual induration, and consequent obliteration of the 
 cellular structure of the lung, the notion of perfect repair and 
 restoration can hardly, I think, be regarded in any other light than 
 that of a pathological absurdity, although the statements advanced 
 by some modern writers on phthisis would seem to imply that they 
 actually expected the profession to believe in its practicability. 
 
 If I shall succeed in directing more precise attention to this sub- 
 ject, I cannot entertain a doubt that some practical good will result ; 
 and more especially that the knowledge thus acquired will be brought 
 to bear upon the important question of diagnosis in phthisical dis- 
 ease ; a question, the satisfactory solution of which is calculated, 
 above all things, to extinguish the quackery and silence the reckless 
 pretensions which from time to time are brought forward to insult 
 the understanding and shock the better feelings of every upright 
 and really competent member of the profession. 
 
 As it is not my intention to enter upon the subject of diagnosis 
 in my present communication, I shall content myself with observing 
 that the permanent indurations of the pulmonary tissue which I have 
 described, especially when partial, are occasionally accompanied by con- 
 siderable dilatation of the bronchial tube or tubes passing through 
 or near them. These dilatations I believe to be an effect, and not a 
 cause of the indurations, as some have imagined. This state of 
 things induration with dilated tubes may occur in any part of the 
 lungs ; and I shall briefly relate one or two cases in illustration. 
 
 A girl, in Charity Ward, was exceedingly ill, but the details of 
 her illness it is unnecessary to dwell upon ; suffice it to say, that on 
 examining the chest, I observed towards the inferior and anterior part 
 of the right side near the sternum some dulness of sound on percus- 
 sion, to which I should probably have attached little importance if I 
 had not at the same time detected bronchophony and tubular respi- 
 ration. Discovering no physical indications of phthisis elsewhere, I 
 inquired if she had had whooping-cough, and in reply was told that 
 she had had the disease severely some years before. She died and 
 was examined, and, as had been anticipated, she had evidently been 
 the subject of pleuro-pneumonia at some former period. The pleurae
 
 ON THE PATHOLOGY OF PHTHISIS. 45 
 
 were strongly adherent at the spot indicated; the pulmonary tissue 
 beneath was indurated, and the indurated part was traversed by a re- 
 markably dilated bronchial tube. The preparation has been mislaid. 
 
 It is, however, when consolidation occurs at the apex of the lung, 
 even without any considerable bronchial dilatation, that there is the 
 greatest difficulty of diagnosis, and the almost certainty of at least 
 suspecting it to be disorganizing phthisis, especially, if with consoli- 
 dation we happen to have an excess of mucous secretion in the bron- 
 chial tubes. Under such circumstances the physical signs of phthisis 
 are complete. 
 
 A short time ago a case was attended in this hospital conjointly by 
 Dr. Lever and myself. To my indefatigable friend I am indebted 
 for the following history. 
 
 " Rebecca M , a married woman, 29 years of age, presented her- 
 self amongst the out-patients of Guy's Hospital, complaining of 
 hemorrhage from the uterus. She had borne several children, and had 
 miscarried once or twice. The hemorrhage had existed between 
 four and five weeks, and at the time of her visit was profuse. She 
 had placed herself under the care of some chemist, and had taken 
 various medicines, some of which had diminished the flow of blood, 
 but from the time of its commencement it had never entirely ceased. 
 She was pale, exsanguineous, and exceedingly debilitated, her feet 
 and ankles were cedematous, her pulse small, rapid, irregular, and in- 
 termitting. Five years previously she had been laid up for several 
 weeks with ' rheumatic fever/ She stated that for three years she 
 had suffered from a cough, the commencement of such being an 
 attack of inflammation of the lungs ; that she expectorated a little 
 brownish-green matter ; and that she occasionally suffered from great 
 difficulty of breathing ; but that her cough had been less, and her 
 breathing more easy, since the occurrence of the flooding. 
 
 " There was a sensation of weight at the bottom of the back, but 
 there were no lancinating central pains which usually attend malignant 
 organic disease of the uterus. An examination per vaginam was in- 
 stituted. The uterus was found to be flabby, relaxed, and large, but 
 free from organic lesion. The following medicine was prescribed : 
 
 Alurain. gr. xij ; 
 Acid. Sulph. dil. 111.x; ; 
 Tinct. Hyoscy. ir[xx, t. d. 
 Ex. Inf. Rosse. Comp. 
 
 This she took for three weeks with an occasional saline aperient.
 
 46 ON THE PATHOLOGY OF PHTHISIS. 
 
 " I lost sight of her for several weeks, or I may say months, when 
 she again presented herself; complaining of amenorrhcea, cough, 
 pain in the chest, palpitation of the heart, dyspnoea, &c. The 
 amenorrhcea was evidently owing to pregnancy ; and for the relief of 
 her other symptoms I advised her to seek admission into the hospi- 
 tal ; this she did, and on the following Wednesday was placed under 
 your care. 
 
 "Two weeks after she left the hospital she aborted. Her husband 
 being from home, she was alone when this accident occurred, and 
 was for twelve hours unseen and unattended to. A considerable 
 quantity of blood was lost, and for some hours her condition was pre- 
 carious. (She had attained the fifth month of pregnancy.) For three 
 days following abortion there was diarrhoea, accompanied with some 
 pains in the bowels ; tenderness of the abdomen ; her cough was dis- 
 tressing; her dyspnoea urgent; the voice was husky ; the expectoration 
 tough, yellowish- green, and streaked with blood, and occasionally with 
 it was mixed a considerable quantity of rusty-coloured froth ; the 
 pulse was rapid, weak, irregular, and intermitting. Soon after the 
 irritable condition of the bowels was relieved, she suffered from pro- 
 fuse perspiration, occurring three or four times in the twenty-four 
 hours, but most distressing in the night. In the course of a week the 
 perspirations diminished, but in their place supervened the diarrhoea, 
 and so matters continued until the period of her death, three weeks 
 from the time of abortion. At the time of her disease she was sit- 
 ting up in bed in the act of coughing, when a quantity of purulent 
 matter mixed with blood flowed from her mouth, and she fell back 
 and expired." 
 
 Although this patient had organic disease of the heart, and was 
 suffering from uterine disturbance, it was believed at the time that 
 she was also the subject of phthisis. She had cough and expectora- 
 tion, with occasional haemoptysis, and considerable emaciation. There 
 was dulness on percussion at the right apex, with depression of the 
 ribs, bronchial respiration, bronchophony, and mucous gurgling. 
 Nevertheless, the history of the case and some other circumstances 
 taken in connection with it led to the suspicion that the signs and 
 symptoms might be the result of bronchial irritation in a lung 
 damaged by an ancient pleuro-pneumonia. Through the kindness 
 of the Doctor, we obtained permission to examine the body. The 
 pleurae were strongly adherent at the apex, and a portion of the lung
 
 ON THE PATHOLOGY OF PHTHISIS. 47 
 
 beneath was in a state of passive iron-grey induration. There was no 
 destructive disorganization whatever ; nor was there the slightest 
 trace of tubercle to be found in either lung. 
 
 Still more recently a female patient in the hospital died of dropsy. 
 She had been under the care of one of my colleagues. She was sup- 
 posed to be at the same time the subject of phthisis, all the physical 
 signs of that disease being strongly marked at the apex of the lung. 
 On dissection, the pleurae were found adherent, the lung itself 
 beneath the adhesion was in a state of well-marked iron-grey indu- 
 ration, there was no destructive disorganization whatever, nor was 
 a tubercle to be found in any part of either lung. 
 
 Now that morbid state cannot be of rare occurrence of which three 
 well-attested cases come under the observation of a single individual 
 in the short space of a few weeks, nevertheless at the present time 
 it is only vaguely acknowledged, and is still without a name. 
 
 The following is still more curious and interesting. It is certainly 
 upwards of four years ago since Mr. G , the brother of a medical 
 man, first consulted me at the suggestion of my friend Mr. Key. He 
 presented the ordinary signs of phthisical disease at one apex, but with 
 indications of an unusual degree of consolidation. He was exceedingly 
 hoarse, had cough and expectoration, some hectic and considerable 
 emaciation. I saw him from time to time during the last few years of 
 his life, and often had cause to be struck with the quiescent condition 
 of the parts of the lung originally consolidated. The physical signs 
 extended themselves progressively over a very considerable portion 
 of the lung first affected ; and at length presented themselves in the 
 other, in the same order. After dragging on a sad and melancholy 
 existence for four or five years in this way, he was at length assailed 
 by peculiar affliction, and sunk. For the particulars of the inspec- 
 tion made a few months ago I am indebted to Mr. Foaker of Great 
 Baddow, through the courtesy of Dr. Miller of Chelmsford. 
 
 ' ' I now regret that no notes were made of the morbid appearance 
 found in the corpse of poor G ; more especially as some circum- 
 stances were hardly reconcileable with each other, as you will remem- 
 ber. We remarked a lodgment of pus in the lower portion of the 
 trachea, completely obstructing both bronchi, sufficient, I conceived, 
 to have produced suffocation. Nevertheless, there was nothing like 
 excavation in either lung, though cut into every lobe ; and the cut 
 surfaces exuded a gritty half-purulent fluid-like softening tubercle. 
 Both lungs were hard and incompressible, when not adhering to the
 
 48 ON THE PATHOLOGY OF PHTHISIS. 
 
 costal pleurae; their coloured and speckled appearance resembling 
 the surface of granite. There was no ulceration in either the trachea 
 or on the mucous membrane of the small intestines, although some 
 spots on their peritoneal coats led me to open them. 
 
 " I think I did not see him the last three or four weeks of his life, 
 but could not learn that the sputa ever exhibited a purulent charac- 
 ter. I am sensible how incomplete thr. statement is in a patho- 
 logical view, and trust to your own observations and memory to 
 supply what may be more particularly desired by your friend. 
 
 " Yours truly, 
 
 " L. FOAKER." 
 
 Who could have doubted the existence of more or less excavating 
 disorganization in such a case as this ? 
 
 Prom what has been advanced in this and former communications, 
 I hope it may be permitted to arrange the several forms of dis- 
 organization of the lungs resulting from mere inflammation and its 
 consequences, under the head of 
 
 PNEUMONIC PHTHISIS. 
 
 This pneumonic phthisis may be acute ; the deposits and inflamed 
 tissues softening down and disorganizing at once, without any 
 attempt whatever being made at induration or repair ; thereby con- 
 stituting one form of acute or galloping consumption. It may be 
 acuto-cJironic, of which I would distinguish three varieties : 1 . The 
 inflammation, though more or less acute, is slower and more in- 
 sidious in its course, and manifests some attempts at repair, as 
 indicated by various stages and degrees of induration. The indura- 
 tion, nevertheless, is not complete; the pulmonary tissue continues 
 to be friable ; and sooner or later, that is to say, in a few weeks or 
 months, softens down, and gives rise to excavation ; most frequently 
 by a somewhat slow ulcerative process ; more rarely by an actual 
 slough of greater or less portions of the indurated but still friable 
 pulmonary tissue. 2. Inflammation may supervene upon or around 
 ancient induration, leading to disorganization either of the newly- 
 inflamed tissue, of the old induration itself, or of both at the same 
 time. Lastly, pneumonic phthisis may be chronic, of which I would 
 also distinguish two varieties ; first, that in which old indurations 
 undergo a slow process of disintegration, giving rise to vomicfe ; and
 
 ON THE PATHOLOGY OF PHTHISIS. 49 
 
 secondly, that very rare form of the disease, in which an insidious 
 inflammation proceeds very slowly to convert a considerable portion 
 of pulmonary tissue into grey induration, without any necessary 
 excavation whatever, as in the case of Mr. G., before given. 
 
 TUBERCULO-PNEUMONIC PHTHISIS. 
 
 By tuberculo-pneumonic phthisis is meant a very common form 
 of the complaint, in which, although tubercles are present, the really 
 efficient cause of the phthisical mischief is pulmonic inflammation. 
 In this form of the disorder the tubercles sufficiently indicate the 
 strumous or cachectic habit of the individual, and manifestly pre- 
 dispose to the inflammatory change : nevertheless they do not, 
 beyond this, seem to be either primarily or essentially concerned in 
 the serious changes observed to take place in the pulmonary tissue. 
 
 As the time of the Society is valuable, and I have no inclination 
 whatever to write the voluminous details which my subject would 
 admit of, and almost justify, I have, at the risk of being considered 
 dogmatical, resolved to state my opinions in a very brief and some- 
 what unconnected or aphoristical manner. It will at least be favor- 
 able to discussion. 
 
 However analogous and closely allied the abnormal nutrition 
 which produces tubercle may be to that which constitutes inflamma- 
 tion, we cannot, in the present state of our knowledge, admit their 
 identity. 
 
 The great transparency in most instances of simple pulmonary 
 tubercle, for some time after its development, and the total absence of 
 any degree of surrounding opacity, are irreconcilable with the necessity 
 of actual inflammation for its production : nevertheless, pulmonary 
 tubercles, and the ordinary effects of inflammation, have been con- 
 founded with one another. 
 
 Simple pulmonary tubercle is most frequently of a grey colour, 
 vitreous-looking, or semi-transparent, moderately hard, offering 
 considerable resistance to pressure between the finger and thumb, 
 and is apparently homogeneous. It varies in size from that of a 
 mere point, to that of a mustard-seed, and rarely exceeds the 
 latter. 
 
 To these tubercles, by way of distinction, I would apply the term 
 stfienic. They are comparatively little prone to disintegration; a 
 tendency to which is indicated by yellowish opacity and loss of 
 cohesion. 
 
 4
 
 50 ON THE PATHOLOGY OF PHTHISIS. 
 
 Ill other instances simple pulmonary tubercle is, from the first, 
 and however minute, of an opaque white, or boiled-rice colour; 
 sometimes with a faint tinge of yellow ; softer and more friable than 
 the above; and occasionally attains a somewhat larger size. To 
 these I would apply the term astkenic. They are much more prone 
 to disintegration. 
 
 Although no precise line of demarcation can be drawn between 
 these two varieties of simple pulmonary tubercle, the one or the other 
 is observed to preponderate in different cases of phthisis. The sthenic 
 may, by deterioration, assume the character of the asthenic, but not 
 the converse ; the uniform tendency of all tubercles being retro- 
 grade, or towards loss of cohesion and disintegration. 
 
 It is the sthenic variety of tubercle that usually preponderates in 
 the tuberculo-pneumonic phthisis now under consideration. 
 
 Pulmonary tubercle has its seat in the delicate filamentous tissue 
 which forms the slight filmy parietes of the air-cells, and bears 
 the same relation to these parietes that tubercle does to serous 
 membrane. 
 
 The apparent growth and increase of size of simple pulmonary 
 tubercle, beyond that specified, depend upon changes taking place in 
 adjacent cells, either from the development of additional tubercles, 
 or from inflammation. 
 
 The so-called enlarged tubercles, therefore, are, in reality, either 
 aggregations of simple tubercles, or simple tubercles enclosed in the 
 products of inflammation. To the former I would apply the term 
 compound tubercles, which, of course, are made up of two distinct 
 elements, viz., the abnormal product, tubercle, and the tissue of the 
 air-cells in which that tubercle is developed. The latter element of 
 compound tubercle, although little considered, probably plays a by 
 no means unimportant part in some of the most serious changes 
 observed to take place in tuberculated lungs. 
 
 Compound are at all times much more liable to disintegration 
 than simple tubercles. 
 
 The abnormal hypernutrition which leads to tubercle appears to be 
 connected with a scrofulous habit. 
 
 "When tubercles are present, and especially when numerous, in 
 clusters or compounded, but still quiescent, the neighbouring pul- 
 monary cells pretty uniformly afford indication of compensatory or 
 excessive function, the cells being more or less enlarged, as observed 
 in pulmonary emphysema.
 
 ON THE PATHOLOGY OF PHTHISIS. 51 
 
 This compensatory change probably increases the difficulty of 
 recognising simple tubercles in the lungs, it being rarely, if ever, 
 possible to detect them, either by dulness of sound on percussion, 
 or by diminished respiratory murmur as determined by auscultation, 
 unless, perhaps, they exist in great numbers and in groups of con- 
 siderable size. A case which recently occurred at this hospital very 
 well illustrated this position. A little boy was emaciating and gra- 
 dually sinking under a severe attack of what we have now no doubt 
 was infantile remittent fever. From the obscurity of the case, our 
 attention was particularly directed to the lungs, in order to ascertain 
 if any phthisical disease existed; but although he was repeatedly 
 and carefully examined by several gentlemen, with the express 
 view of detecting tubercles, nothing in the least satisfactory resulted. 
 Nevertheless, after death, simple tubercles, in great numbers, existed 
 at the summit of both lungs, as may be seen by inspecting the pre- 
 paration placed upon the table. 
 
 In general, the only physical indication worthy of the smallest 
 confidence at a very early period is a certain degree of inequality in 
 the respiratory murmur, it being a little more loud or puerile at 
 certain points, or in one lung than in the other. 
 
 Having no means of positively ascertaining the presence of simple 
 tubercles, we are unable to determine either their first development, 
 how rapidly they are developed, or how long they may remain in a 
 passive or harmless state. 
 
 When tubercles are present in the pulmonary tissue there exists a 
 great proneness to increased vascular action, congestion, or inflam- 
 mation in the lungs themselves and their appendages, the larynx, 
 trachea, bronchi, bronchial glands, and pleurae. The tendency is, 
 however, most strongly marked in the immediate vicinity of the 
 tubercles. 
 
 Unless subjected to causes calculated to aggravate such tendency 
 to congestion or inflammation, an individual may experience little or 
 no inconvenience from the presence of tubercles a pathological 
 principle applicable to sthenic tubercles generally, whether situated 
 in the lungs, the pleurae, peritoneum, or arachnoid. 
 
 The inflammation which supervenes upon tuberculated lungs is 
 commonly of the low insidious kind observed in scrofulous and 
 cachectic constitutions; and, unless under aggravation, is rarely 
 attended with sufficient serous exhalation to produce perfect pneu- 
 monic crepitation.
 
 52 OX THB PATHOLOGY OF PHTHISIS. 
 
 This inflammatory conditiou of the lung is very commonly accom- 
 panied by a corresponding condition of greater or less portions of 
 the mucous membrane of the air-passages; and especially of the 
 neighbouring bronchi, which, under the circumstances, are usually 
 found somewhat dilated, and have their parietes thicker and softer 
 than natural. 
 
 The commencement of this inflammation, either in the pulmonary 
 tissue itself or in the bronchial tubes, is the ordinary commence- 
 ment of tuberculo-pneumonic phthisis ; and hence it is that most of 
 the symptoms and physical signs of phthisis may manifest them- 
 selves without evidence of a primary change in the tubercles 
 themselves being discoverable after death. 
 
 When the pulmonic inflammation is more considerable than usual 
 the characteristic heat of skin often remains uninterruptedly for days 
 together, whether accompanied by diminished, increased, or varying 
 perspiration. 
 
 The physical signs which become apparent as the disease advances, 
 viz. feebleness or absence of respiratory murmur, bronchophony, 
 tubular respiration, and dulness of sound on percussion, are more 
 the results of this inflammation than of the extension of tubercles ; 
 and may occur from a similar cause, in pneumonic phthisis, without 
 a tubercle ever having existed in the lung at all. 
 
 There is often a well-marked relation to be observed between the 
 degree and permanency of the characteristic pneumonic heat of skin 
 when present, and the rapidity and extent of these local changes, as 
 ascertained by auscultation and percussion. 
 
 The inflammatory changes which take place in tuberculated lungs 
 resemble those resulting from inflammation of the lungs without 
 tubercles. 
 
 Although the red hepatization occurring in tuberculo-pneumonic 
 phthisis very often passes quickly into softening, and the consequent 
 formation of a cavity, nevertheless, when actual albuminous matter 
 is thrown out, it, like that resulting from pulmonic inflammation 
 without tubercle, usually manifests some attempts at repair, as indi- 
 cated by more or less hardening and contraction of the deposit 
 itself, and of the pulmonary tissue, into which it is effused. 
 
 These results of inflammation have been very commonly, but 
 erroneously, regarded as mere varieties of tubercular infiltration. 
 
 It is the contraction of these deposits that chiefly occasions the 
 diminished size of the lung and flattening of the ribs. Pleurisy,
 
 ON THE PATHOLOGY OF PHTHISIS. 53 
 
 doubtless, very often contributes to the same result; but mere 
 excavation of a portion of a lung has no such effect as diminishing 
 its size. In the worst and most excavating forms of emphysema 
 there is no shrinking of the lung. 
 
 The same contraction of albuminous matter on exposed blood- 
 vessels acts as a ligature or roller, helps to obliterate their canals, 
 and so to prevent haemorrhage. Nevertheless, the parietes of an 
 exposed blood-vessel do occasionally soften or ulcerate, and thus 
 give rise to the serious hsemorrhages of advanced phthisis. 
 
 The attempts at repair in the pneumonic deposits which occur in 
 tuberculo-pneumonic phthisis lead most frequently to the iron-grey 
 and granular indurations pointed out in a former paper. In those 
 rare instances where the character of the pneumonic induration ap- 
 proaches that described under the name of uniform albuminous 
 induration, its semi-transparency occasionally imparts to it a gela- 
 tinous or horny aspect. 
 
 When the deposit and subsequent induration are limited to the 
 vicinity of a simple tubercle, or are otherwise very cicrumscribed, we 
 occasionally find, as the result, a small, irregular, hard, and usually 
 dark-coloured body, which is firmly adherent to the more healthy 
 tissue. 
 
 The attempts at repair, or induration of the pneumonic deposits 
 occurring in tuberculo-pneumonic phthisis are commonly very im- 
 perfect, and not durable; so that the deposits, for the most part, 
 sooner or later undergo a second change, by which they soften 
 down, and produce excavation. This softening, however, may take 
 place days, weeks, months, or, I believe, even years after the original 
 deposition. 
 
 When the disease has proceeded to excavation, the natural cure of 
 the ulcer thus produced consists in the formation of a more or less 
 dense and paramount lining membrane the true cicatrix of such 
 ulcers. 
 
 Although this membrane may perhaps now and then remain 
 passive and harmless for years, it most commonly happens that the 
 cicatrization is imperfect and incomplete ; the efforts at repair fail ; 
 the albuminous material, which ought to form the membrane, softens 
 down, and with it successive portions of the pulmonary tissue fur- 
 nishing it ; and thus the ulceration proceeds till, exhausted by un- 
 ceasing irritation and imperfect nutrition, the patient dies. 
 
 In examining the lungs of fatal tuberculo-pneumonic phthisis, we
 
 54 ON THE PATHOLOGY OF PHTHISIS. 
 
 not ^infrequently have an opportunity of observing, along with or 
 without disintegrating tubercles, all the different forms or stages of 
 the pneumonic process : a dull red and congested state of the cells ; 
 diminution of cohesion ; red hepatization ; red hepatization at once 
 softening down, forming cavities containing a dirty puriform fluid ; 
 grey hepatization ; grey hepatization softening down into cavities ; 
 albuminization of portions of the lung ; various stages or degrees of 
 hardening and contraction of the uniform, grey, or granular indura- 
 tion ; secondary softening of one or more of the latter ; together 
 with more or less dilatation, thickening, softening, and opacity of 
 the bronchial tubes passing through the diseased parts; such 
 bronchial tubes very commonly presenting, on being cut across, an 
 appearance which has often been mistaken for tubercle, softening 
 in the centre. It is only, however, in the very worst forms of 
 tuberculo-pneumonic phthisis that we meet with all these appear- 
 ances; cases approaching more nearly to what I shall have to 
 describe, under the name of tubercular phthisis. 
 
 In some instances there seems to be no attempt whatever made at 
 repair in the pneumonic deposits ; instead of which, they, as well as 
 the tissue into which they are effused, soften down at once, pro- 
 ducing one form of what has been called galloping consumption. 
 This result, however, is chiefly met with in the more asthenic disease 
 tubercular phthisis. 
 
 When, on the other hand, diffuse inflammation attacks lungs 
 studded generally with simple tubercles, it gives rise to what I 
 would call suffocative pneumonia ; characterised more particularly 
 by extreme, or at least disproportionate dyspnoea, lividity of lips 
 and countenance, and very commonly by the rapid dissolution of 
 the patient. In this case the inflammation usually proves fatal 
 before albuminous deposits occur at all, and more or less crepitation 
 is heard till the last. 
 
 Although the softening of ancient pneumonic indurations appears 
 to be most frequently brought about by inflammation accidentally 
 set up around them; a cachectic or bad habit of body, however 
 induced, tends to a similar result; not, probably, by actually pre- 
 disposing to inflammation, but rather by lessening the tone of the 
 inflamed or irritated tissue, and so accelerating disorganization or 
 disintegration. 
 
 It is the softening of these indurations, or of the hepa- 
 ti/.ations which precede them, that constitutes the principal
 
 ON THE PATHOLOGY OF PHTHISIS. 5j>. 
 
 source of disorganization and excavation in tuberculo-pneumonic 
 phthisis. 
 
 When the pneumonic deposits have proceeded to that state which 
 constitutes either the uniform albuminous, the iron-grey, or the 
 granular induration, although they may remain in a passive and 
 harmless state for an indefinite period ; it is impossible to imagine 
 that they can ever be removed, and the natural and healthy tissue 
 of the lung restored. 
 
 The amount of expectoration depends upon the extent to which 
 the bronchial tubes happen to be implicated. 
 
 The appearance of the matter expectorated affords, in a large 
 majority of instances, no positive test, either of the existence or of 
 the extent of disorganization. 
 
 Possessing no means of removing tubercles when once developed, 
 our resources are purely preventive ; and are such as are calculated 
 to improve, strengthen, and fortify the general constitution. 
 
 Our next duty is, as far as is consistent with the above principle, 
 to remove all the predisposing, and avoid all the exciting causes of 
 inflammation of the lungs and their appendages. 
 
 Tuberculo-pneumonic phthisis having once fairly commenced, the 
 inflammatory process must be met and combated by moderate 
 general or local bleeding, active and continued counter-irritation, the 
 general use of antiphlogistic measures generally, bland diet, warm 
 clothing, regulated temperature, or, what is infinitely better, a milder 
 and less variable climate. 
 
 When considerable, as indicated by the enduring pungent heat of 
 skin, increased hurry of respiration, sharpness and hardness of the 
 pulse, and by a small mucous or subcrepitant rhonchus, the acces- 
 sions or aggravations of pulmonic inflammation may, to a certain 
 extent, be checked or controlled by the use of mercury in addition 
 to other means ; but when mercury is made to affect the general 
 constitution, it has appeared, in some instances, to hasten disor- 
 ganization, at a subsequent period. 
 
 The disease, by proper treatment and management, may often be 
 arrested for a time, and not very unfrequently for years, the pneu- 
 monic changes already produced remaining in a passive state, as 
 determined by auscultation and percussion. 
 
 It is but just, and of some importance to admit, that although 
 the general tendency to repair or induration in pneumonic deposits, 
 and the absence of it in tubercle, are strongly marked, and suffi-
 
 56 ON THE PATHOLOGY OE PHTHISIS. 
 
 ciently distinguishable, it is sometimes difficult or impossible to pro- 
 nounce with certainty whether the change in the pulmonary tissue 
 be the result of tubercles or of a bygone inflammation ; neither is it 
 at ah 1 times easy to decide whether the inflammatory changes, when 
 sufficiently evident, have or have not been preceded by tubercle. 
 It is not improbable, however, that injection of the blood-vessels, 
 organic chemistry, and the use of the microscope, singly or com- 
 bined, may one day enable us to meet and overcome these occasional 
 difficulties. The proper course, nevertheless, appears to be to deter- 
 mine what, in strict propriety, we ought to really regard as tubercle 
 before we proceed to subject it to examination of any kiud. Whether 
 what I have advanced will promote this desirable end I do not pre- 
 sume to determine, but would willingly entertain the hope that it 
 may do so. 
 
 From the animal chemist, probably, little is to be expected towards 
 the solution of such a question, inasmuch as the albuminous material 
 of tubercle probably differs, chemically, but very little from ordinary 
 albuminous tissues : the modification being, in all probability, rather 
 molecular than atomic; rather a new vital arrangement than a 
 chemical change. The microscope holds out a better prospect of 
 success, and is more likely to recognise and discriminate a peculiar 
 abnormal admixture with natural tissue than any other means or 
 appliances at present at our command. 
 
 My friend, Mr. Dalrymple, has kindly undertaken to assist me in 
 this very interesting part of the inquiry ; and his great skill and 
 experience in the use of the instrument, and his unimpeachable good 
 faith, afford me grounds to hope that I may ere long be in a con- 
 dition to lay before the Society results of some interest in regard to 
 minute differences and distinctions, only to be obtained in this way. 
 
 TUBERCULAR PHTHISIS. 
 
 It may be fairly doubted whether, in perfect strictness of language, 
 the term tubercular, taken in an exclusive sense, can with propriety 
 be applied to any form of phthisis ; for, however strange and para- 
 doxical it may appear, I venture to submit that, at the present 
 moment, we are not in possession of any conclusive evidence that 
 either tubercle or its disintegration ever constitutes the primary 
 and essential cause of the disorganization which characterises fatal 
 phthisis. We have phthisical disorganization without tubercle, and 
 we have phthisical disorganization with tubercle. In that form of
 
 ON THE PATHOLOGY OF PHTHISIS. 57 
 
 the disease which I have described under the name of tuberculo- 
 pneumonic, tubercles are present; but the tubercles being usually 
 of the sthenic kind, and little compounded, remain, with few excep- 
 tions, quiescent, until disturbed by inflammation setting up around 
 them; this inflammation, moreover, proving the chief source of 
 destruction, first of the pulmonary tissue itself, and, consecutively, 
 of the tubercles. Nevertheless, as compounds are, in every instance, 
 more prone to disintegration than simple tubercles, we cannot be 
 surprised that occasionally the most sthenic form of tubercles should, 
 when compounded, undergo primary disintegration ; that is to say, 
 disintegration independently of that pulmonic inflammation which 
 constitutes so essential a part of ordinary tuberculo-pneumonic 
 phthisis. It has also been admitted that no precise line of demarca- 
 tion can be drawn between what, for the sake of distinction, I have 
 called sthenic and asthenic tubercles, the one or the other merely pre- 
 ponderating in different cases. The sthenic, as already observed, pre- 
 ponderate, in the tuberculo-pneumonic phthisis previously described ; 
 and if the single term of " tubercular " may be retained at all, to 
 express any particular form of phthisis, I should feel inclined to 
 appropriate it to that sad and fatal form of the disease in which 
 asthenic tubercles prevail, and in which they manifest a strong ten- 
 dency to assume the compounded character, although it would pro- 
 bably be more correct to employ the term " tubercular " in a specific 
 sense, and regard the two forms of phthisis associated with tubercle 
 as mere varieties : the one, the tuberculo-pneumonic, as the sthenic ; 
 and the other, now under consideration, as the asthenic. 
 
 This form of phthisis, then, is characterised by a preponderance of 
 asthenic compound tubercles. These often exist in great numbers, 
 either separately, or, more rarely, aggregated together, so as to 
 occupy several adjacent lobules, or even a considerable portion of an 
 entire lobe of a lung. It is not to be understood from this that 
 compound tubercles alone are to be found in this form of phthisis, 
 to the entire exclusion of tubercle in its simple, or even sthenic 
 form : all that is meant is, the great preponderance of compound 
 tubercles. These masses of compound tubercles present various 
 appearances, not only as regards their size, figure, and diffusion, 
 but also according to the stage of development or degeneration in 
 which they happen to be at the period of examination. It would 
 appear, from careful inspection of numerous specimens, that the 
 simple tubercles of which they are made up are sometimes like simple
 
 58 ON THE PATHOLOGY OF PHTHISIS. 
 
 sthenic tubercles, at first extremely minute and of a semi-transparent 
 grey colour, presently, however, assuming more or less of the asthenic 
 character; at other times they are observed to be of an opaque, 
 white, pale-straw or boiled-rice colour, from their very first develop- 
 ment, and when of the smallest size. As their size increases, they 
 crowd upon each other, and variously disfigure, as it were, the indivi- 
 dual mass or group ; whilst some few seem to take the lead, surpassing 
 others in magnitude and rapidity of development, and present greater 
 opacity and more decided loss of cohesion than the rest. These 
 larger, more opaque, and softer tubercles, which project from the 
 surface of the compound mass, on being cut into occasionally, 
 display a manifest central softening ; but this is by no means con- 
 stant : nevertheless, this, and a similar change, now and then ob- 
 servable in the accompanying simple asthenic tubercles, constitute 
 almost the only examples of central softening of tubercle that I have 
 been able to make out. 
 
 We thus have the simple tubercles constituting the compound 
 mass, presenting different degrees of advancement ; and as the whole 
 proceed to the dull-white, pale-straw, or boiled-rice opacity, thereby 
 increasing contrast of colour, we commonly perceive black stains or 
 streaks variously distributed over them. These have been ascribed 
 to the presence of black pulmonary matter; but although such 
 black pulmonary matter probably exists, it is not difficult to ascer- 
 tain most distinctly that these black streaks are nothing more than 
 small pulmonic veins containing black blood, a sufficiently distin- 
 guishable branch of which may be readily laid hold of by a pair of 
 forceps, and seems to fork or divide, and penetrate the compound 
 mass : so that, however true it may be that simple tubercle is non- 
 vascular, the pulmonic element of compound tubercle continues, at 
 least for a time, to receive blood-vessels. 
 
 At a still more advanced period actual softening takes place; 
 sometimes at one point, sometimes at another, and sometimes at 
 several simultaneously or in rapid succession. It is an interesting 
 pathological question, "Whence arises this softening ? Is it to be 
 regarded as one of the attributes of asthenic tubercle ? Does that 
 original deterioration of the albuminous material which unfitted it 
 for organization necessarily lead to the changes which constitute soft- 
 ening, or are we to look for some secondary cause ? And, if so, 
 does the secondary cause consist in a process taking place in the 
 pulmonary element of tubercle analogous to inflammation ; or is the
 
 OX THE PATHOLOGY OF PHTHISIS. 59 
 
 secondary cause purely mechanical, the crowding together of non- 
 vascular tubercles mechanically arresting circulation, and thus pro- 
 ducing softening of all the tissues and materials of the part analogous 
 to what we see taking place in particular portions of brain, from 
 arrest of circulation through the vessels immediately supplying them 
 with blood ? A preparation on the table would rather favour the 
 former of these speculations. It is a portion of the lung of a person 
 who died of phthisis, and whose lungs throughout were thickly beset 
 with tubercles : both the lung itself and the pleura had undergone 
 much inflammation, and it will be seen that to a considerable extent 
 the pleura has been completely dissected from the surface of the 
 lung by the entire destruction of the uniting areolar tissue ; whilst 
 simple tubercles remain in great abundance, partly resting on the 
 naked surface of the lung, and partly on the internal, or naturally- 
 attached surface of the pleura. The appearance, too, of the soften- 
 ing mass itself would almost lead to an inference that at all events 
 the softening first takes place in the pulmonary element of compound 
 tubercle; for on attentively examining the softening mass, especially 
 in the most asthenic form of the disease, we can often distinctly per- 
 ceive the small opaque, whitish or straw-coloured tubercles, as it 
 were, suspended in or supported by a delicate sort of tissue, more or 
 less copiously soaked or infiltrated with a sero-purulent fluid. I may 
 also venture to express it as my belief that the pulmonary element 
 of sthenic compound tubercle not only presents, in many instances, 
 indications of a primary inflammatory process, but even attempts at 
 repair, as shown by hardness, contraction, and blackening of the 
 more central parts. It is, however, of no profit to speculate further 
 on this part of the subject; and whether the softening be the 
 result of a physiological or of a mechanical secondary cause, the 
 fact remains the same ; the compound, and occasionally the simple 
 asthenic tubercles do admit of, or take on, softening, independently 
 of any evidence of inflammation of the pulmonary tissue beyond 
 their respective boundaries. 
 
 But although, contrary to the general rule observed in sthenic 
 tubercles, the asthenic variety may, nay, often does, soften, without 
 evidence of either preceding or accompanying inflammation around ; it 
 is not thence to be inferred that such primary softening of asthenic 
 tubercle, whether compound or simple, constitutes the sole, or even 
 the principal source of the disorganization of the lung met with in 
 the form of phthisis now under consideration. So far is this from
 
 60 ON THE PATHOLOGY OF PHTHISIS. 
 
 being true, that there, perhaps, never was a single instance of the 
 disease proving fatal, without more or less of this complication. By 
 this complication is not to be understood the inflammation which I 
 suppose to take place in the pulmonary element of tubercle ; nor the 
 mere inflammatory state almost necessarily present in the pulmonary 
 tissue, in immediate contact with the softening mass. The inflam- 
 mation to which I allude is often very considerable : it may extend 
 from the vicinity of the tubercles to one, two, three, or more inches 
 beyond ; or it may arise at a distance from the tubercles, having 
 apparently healthy pulmonary tissue interposed; and is moreover 
 very often accompanied by inflammation of the pleura situated 
 immediately above it. 
 
 This inflammation usually manifests the same asthenic character 
 observed in the tubercles themselves ; a feeble red hepatization pass- 
 ing at once into disorganization ; a grey flabby hepatization under- 
 going a similar change ; complete albuminization of a greater or less 
 portion of pulmonary tissue, presenting the albuminous material in 
 the form of either concrete or fluid pus ; and occasionally such rapid 
 exhaustion of the vital properties of the tissue, as to occasion its 
 death, or, in other words, a slough. 
 
 As ulceration proceeds in such cases, the albuminous material fur- 
 nished by the ulcerating tissue, instead of manifesting attempts at 
 repair, by contraction and the formation of a lining membrane or 
 cicatrix, as now and then observed in the more sthenic forms of 
 phthisis, entirely fails to do so, and the destruction proceeds for the 
 most part uninterruptedly till the mischief completely overpowers 
 the constitution and the patient dies. From all this, it may, I think, 
 be legitimately inferred as a general law that contraction is, as far as 
 it goes, a favorable sign in every form of phthisis, it indicates a cer- 
 tain degree of constitutional power and attempt at repair. This 
 contraction,, however, must not be confounded with mere hardness, 
 the latter may be occasioned by the mere quantity of tubercular or 
 inflammatory deposit, and it is equally observable in ordinary pneu- 
 monic hepatization ; but when with hardness we have contraction 
 it may at ah 1 times be regarded as favorable. 
 
 Accordingly, this contraction is often very inconsiderable in the 
 most asthenic forms of tubercular phthisis, and it is on this account 
 that unless tubercles or inflammatory deposits are very abundant 
 indeed, the physical signs are often much less strongly marked, how- 
 ever extensive the excavation, than in the more sthenic varieties of
 
 ON THE PATHOLOGY OF PHTHISIS. 61 
 
 the complaint, in which, although the excavation may be very limited, 
 the inflammatory contraction and consequent induration of the pul- 
 monary tissue are usually much more extensive as well as more com- 
 plete. The asthenic character, equally apparent in the tubercles and 
 in the accompanying inflammation, whilst it establishes the influence 
 of constitutional peculiarity goes far to deprive us of all reasonable 
 hope of ever being able successfully to combat this variety of 
 phthisis when once developed, for without repudiating those rare 
 exceptions to be met with in the history of the most fatal disorders, 
 pathology alone would lead me, however reluctantly, to subscribe to 
 the opinion of those who pronounce this form of phthisis at least to 
 be at once incurable and hopeless. Prevention I believe to be the 
 golden rule in every form of phthisis, and especially in the tuberculo- 
 pneumonic and tubercular varieties, but I think I may venture to 
 predict that if a remedy, either of prevention or of cure, be in store 
 as a mercy and a blessing for future generations, that remedy will 
 prove to be very different indeed from the enervating expedients so 
 indiscriminately employed at the present day. 
 
 I may, in concluding this part of my subject, be permitted to add 
 that the bronchial tubes of the diseased lung very commonly present 
 corresponding indications of want of tone, being thickened, softened, 
 and opaque ; and, making allowance for a little exaggeration, may not 
 unaptly, in some instances be compared to a boiled pipe of maccaroni. 
 In my former as well as in my present communication, I have 
 endeavoured to point out several morbid changes of pulmonary tissue, 
 the result either of recent or of ancient inflammations, which have 
 as I am led to conclude been mistaken for tubercle or tubercular 
 infiltration. I have, at the same time, freely admitted the occasional 
 difficulty of determining positively whether certain changes are attri- 
 butable to tubercle or to a bygone inflammation, or to a combination 
 of the two. There are, however, some pathological appearances by 
 no means unfrequently met with in phthisical lungs, which, although 
 very commonly regarded as tubercular, are most unequivocally 
 not so. 
 
 When a lung has been for some time the seat of irritation of 
 almost any kind, the small bronchial tubes are liable to become 
 hypertrophied to have their parietes thickened and indurated. On 
 incising such a lung, the truncated extremities of the more minute 
 tubes have very often been mistaken for simple tubercles, in conse-
 
 62- ON THE PATHOLOGY OF PHTHISIS. 
 
 quence of their canals having been so encroached upon as to escape 
 observation. 
 
 The membranous bronchial tubes passing through or near a por- 
 tion of indurated lung, are very often found considerably and irre- 
 gularly dilated, so that on examining the lung, the cut surface 
 presents an appearance of several small cavities containing pus, and 
 lined by a pyogenic membrane. These apparent cavities, when of 
 some size and of irregular form, have been regarded as disorganiza- 
 tions, or when smaller and still circular as tubercles softening in the 
 centre. They may, however, by careful examination, be shown to 
 be mere tubes, and a bristle or fine probe may be made to pass be- 
 yond the supposed cavity or suppurating tubercle, as well as into the 
 continuation of the canal, found on the corresponding point of the 
 opposite side of the incision. 
 
 But perhaps the most frequent source of fallacy in regard to tu- 
 bercles is to be found in the bronchial tubes which pervade a portion 
 of lung affected with the pneumonic hepatization attendant upon phthi- 
 sical disease. In this case the parietes of the tube are apt to become 
 considerably thickened, softened, and variously dilated. Such tubes, 
 when they contain puriform mucus, as they generally do, are perpe- 
 tually being mistaken for tubercles softening in the centre : they may 
 be shown to be tubes by the means already noticed. 
 
 An inflammatory albuminous deposit, of some consistency, occa- 
 sionally takes place in the smaller bronchial tubes, somewhat analo- 
 gous to what is observed in croup, and in a few cases of bronchitis. 
 This, when the lung is incised, has been mistaken for tubercle. 
 
 Neither diagnosis nor treatment forms any necessary part of this 
 communication, nevertheless, at a time when so much is said respect- 
 ing the facility of recognising and curing consumption, it may not, 
 perhaps, be without its use to append a brief recital of the several 
 forms of thoracic disease which, within my own knowledge and ex- 
 perience, have been pronounced to be phthisis. 
 
 1. Recent pneumonic hepatization, especially when situated at 
 the apex of a lung. 
 
 2. Recent pneumonic hepatization supervening upon ancient or 
 recent bronchitis. 
 
 3. The various forms of pulmonic induration. 
 
 4. Pulmonic induration with bronchial irritation. 
 
 5. Suppurative, sloughing, or gangrenous pneumonia.
 
 ON THE PATHOLOGY 01' PHTHISIS. 63 
 
 6. Simple bronchitis, especially when confined to the apex, or 
 otherwise circumscribed. 
 
 7. Dilatation of the bronchial tubes with or without induration. 
 
 8. General but recent pleuritic effusion. 1 
 
 o. Partial or circumscribed, but recent pleuritic effusion. 
 
 10. The flattening of the rib, and compression of the lung, occa- 
 sioned by ancient pleuritic disease, especially when associated with 
 bronchial irritation. 
 
 IT. Emphysematous crepitation, especially when coupled with 
 dilated bronchi. 
 
 13. Pulmonary apoplexy. 
 
 13. Aneurism of the aorta. 
 
 14. Malignant disease of the lung or neighbouring parts. 
 
 It is well known to many members present that for some years 
 past I have taught it as my conviction that both ancient and recent 
 pleuritic adhesions occasionally give rise, during the respiratory act, 
 to divers modifications of crepitation, varying from that of the 
 smallest subcrepitant to the largest mucous or even gurgling rhon- 
 chus. To this opinion, I have made few converts, and for the 
 very obvious reason that the question scarcely admits of direct proof 
 or demonstration. The patient probably continues to live, and if he 
 die, I am unable to obviate the objections urged, that the sounds 
 heard may have resulted either from a mechanical change in the 
 condition or position of the lung, or from some sort of obstruction 
 in the bronchial tubes. Nevertheless, I entertain no doubt what- 
 ever about the matter, and, moreover, have much reason to believe 
 
 1 Whether the following ought to be regarded as a case of this kind, I do 
 not presume to determine. In the interval between the reading and discussion 
 of this paper, I was requested to visit a young man about twenty-five years of 
 age, whose father told me that he had, the day immediately preceding my visit, 
 taken his son to a gentleman who has excited some attention by the facility 
 with which he professes to recognise and cure consumption. The doctor told 
 him that the case had gone too far ; that he must make up his mind to lose 
 his son shortly : that the patient himself needed not to repeat his visit j but 
 that he, the father, might return, and report progress. He was ordered to take 
 a small dose of rectified naphtha twice a day. I found the young man labouring 
 under a good deal of constitutional disturbance, his left chest was full of fluid, 
 and the heart was beating below the right nipple. 
 
 My friend, Mr. Cock, at my request, drew off about three pints and a half 
 of fluid, and subsequently about a pint. The patient is doing well.
 
 64 ON THK PATHOLOGY OF PHTHISIS. 
 
 that the sounds in question have been repeatedly mistaken for phthi- 
 sical disorganization. 
 
 Should this very imperfect communication have the effect of 
 awakening in the breasts of practitioners and students a desire more 
 zealously and carefully to investigate the pathology of phthisis, its 
 principal object will have been accomplished, whether such investiga- 
 tion tend to confirm or to refute the proposition, that inflammation 
 constitutes the great instrument of destruction in every form of 
 phthisis.
 
 PLATE IV. 
 
 Fig. I. 
 
 Sections of a portion of lung, representing one form of gangrenous or slough- 
 ing pneumonia. 
 
 a. Pulmonary tissue consolidated by acute pneumonia, undergoing repair, 
 and in transition to permanent grey induration. 
 
 b. Portion of lung apparently more in advance towards permanent grey 
 induration. 
 
 c. A. cavity occupied by sloughing pulmonary tissue. 
 
 In this instance the acute pulmonic inflammation proved more severe and 
 extensive than the powers of the constitution could bear. The apices of both 
 lungs had already been excavated by tuberculo-pneumonic phthisis ; and hence 
 the inflammation, instead of passing on to contraction and induration, sloughed 
 early, and destroyed life. In this instance there was no foetor of the breath, 
 which I ascribe to hepatization being complete previous to the slough taking 
 place. In order to have foetor of the breath, I believe the slough must com- 
 municate with a pervious bronchial tube. In this and similar cases the hepati- 
 zation appears to prevent it. 
 
 I have more recently seen a case in which acute pulmonic inflammation 
 supervened upon tuberculated lungs, and in whicli most extensive sloughing 
 took place early, attended with the most horribly foetid breath and expectora- 
 tion. The patient speedily sunk. It was found on inspection, that notwith- 
 standing the extent of the gangrenous disorganization, the inflammation had 
 not in reality passed into perfect hepatization ; the pulmonary tissue generally, 
 giving out, on pressure, a considerable quantity of air and serum. Both liver 
 and kidneys were unsound ; the two great sources of that cachectic state, so 
 unfavorable alike to the progress and to the results of inflammation ; two 
 organs, a diseased condition of which, proves the most insidious and relentless 
 foe both of the physician and the surgeon. 
 
 This Plate represents a portion of lung affected with recent pneumonia 
 supervening upon simple stheuic tubercles, partial grey induration, and excava- 
 tion. There is also false membrane on the pleura. 
 
 It will be observed that the red hepatization is hardly complete ; and i?, 
 moreover, of a remarkably livid hue, the usual result of diffuse inflammation in 
 lungs thickly set with tubercles. At the apex we find a very good illustration 
 of the ordinary changes which take place in one form of tuberculo-pneumonic 
 phthisis. The pulmonary tissue in the vicinity of the tubercles has, at some 
 former period, been inflamed ; the inflammation has led to iron-grey induration ; 
 and portions of this iron-grey induration are now undergoing disintegration, 
 and forming cavities. The ancient pleuritic false membrane, immediately above 
 the indurated parts, sufficiently attests the antecedent inflammation. 
 
 a a. The lung beset with simple sthenic tubercles, and passing into a state 
 of red hepatization from acute pneumonia. 
 b. Pleura thickened by adventitious deposit. 
 
 cc. Iron-grey induration from previous pulmonic inflammation around 
 tubercles. 
 
 dd. Cavities in the lung, occasioned by disintegration of the old pneumonic 
 deposit, and pulmonary tissue containing it. 
 
 fi. Bronchial glands enlarged.
 
 Fig 1.
 
 PLATE V. 
 
 Fig. I. 
 
 A. portion of lung affected with red hepatizatipu, and presenting appear- 
 ances very commonly mistaken for tubercles softening in the centre. 
 
 a a. Bronchial tubes thickened, softened, dilated, and containing a muco- 
 purulent fluid. Bristles are introduced into their truncated extremities. 
 
 Portion of lung divided, to show the opposite sections of an old inflammatory 
 albuminous deposit. 
 
 a a. Bronchial tubes thickened and congested. 
 b b. Apparently healthy pulmonary tissue. 
 
 c c. Opake yellow or granular induration, partially surrounded by a portion 
 of lung in a state of iron-grey induration. 
 
 d. Portions of yellow granular induration, disintegrated, and occupying a 
 bronchial tube. 
 
 <?. A bronchial tube closed by the contraction of iron-grey induration. 
 
 The little boy from whose lung the drawing was taken, was admitted for 
 recent pneumonia, occurring in connection with the most extensive disease of 
 the dorsal vertebra I ever saw a connection by no means of very unfrequent 
 occurrence. After death, besides evidence of recent inflammation," the mass of 
 yellow granular induration represented, was found ; which, with other appear- 
 ances, left no doubt as to its having been the result of long antecedent in- 
 flammation. There was no appearance of tubercle. 
 
 I have more recently seen a very good illustration of this form of pneumonic 
 induration, occurring in an adult female. She had evidently long before, been 
 the subject of pleuro-pneumonia, chiefly attacking the base of the lung. The 
 pleurae were strongly adherent, both over the ribs and diaphragm ; whilst old 
 induration, chiefly of the kind described, was found in detached portions of 
 considerable size at the base of the lung, mixed up, however, with small points 
 of iron-grey, and somewhat more diffused streaks of uniform albuminous in- 
 durations, the latter almost resembling merely dense cellular membrane. There 
 were no tubercles. 
 
 Fig. 3. 
 
 Section of a portion of lung showing red hepatization, partial disorganization, 
 and the truncated extremities of numerous bronchial tubes, with bristles intro- 
 duced into them. 
 
 a a a. Pulmonary tissue in a state of red hepalization. 
 
 b bb. Sections of bronchial tubes thickened, softened, and containing a 
 muco-puriform matter. 
 
 cc. Cavities from partial disorganization. 
 
 Both of the above illustrations were taken from tuberculated lungs ; and it 
 may be observed that, unless the surface be naked and uneven, which is not 
 often the case, it is not at all times easy to determine whether the apparent 
 disorganization is not itself, in many instances, a mere bronchial dilatation of 
 unusual size.
 
 PIP. 2. 
 
 a 
 
 PI ate V. 
 
 Fig.l.

 
 PLATE VI. 
 
 A section of lung, representing tubercles surrounded by the 
 effects of old and recent pulmonic inflammation. 
 
 a a. Tubercles surrounded by iron-grey induration from ancient 
 pulmonic inflammation. 
 
 I b. Bed hepatization from recent pulmonic inflammation. 
 
 The apex of the lung had been extensively disorganized by tuber- 
 culo-pneumonic phthisis ; a form of phthisis in which the disorgani- 
 zation results partly from the softening of recent hepatization, and 
 partly from the disintegration of pneumonic indurations more or less 
 ancient. 
 
 Although rude and incorrect, some sort of analogy may be drawn 
 between sthenic tubercles in the lungs and acne on the face. The 
 follicles in the latter, although enlarged and distended, may remain 
 perfectly quiescent, and without producing the least inconvenience ; 
 so may tubercle in the pulmonary tissue. Inflammation may be set 
 up in the distended follicle ; so may it be, in the pulmonary nidus 
 of tubercle. The inflammation of the follicle may not proceed to 
 suppuration, but terminate in an earlier adhesive process ; the same 
 may take place in the pulmonary nidus of tubercle ; leading, as it 
 commonly does, to iron-grey induration immediately around. The 
 follicle may suppurate ; so may the nidus of tubercle. The inflam- 
 mation may extend considerably beyond the boundary of the follicle ; 
 the same happens with tubercle : nay, in some forms of acne, the 
 intervening skin occasionally inflames primarily ; thus, still bearing 
 some analogy to the inflammatory complication, so constantly ob- 
 served in phthisis.
 
 PLATE VII. 
 
 The drawing was taken from the lung of a person who died of 
 phthisis, whilst labouring under diabetes mellitus. 
 
 The apices of both lungs were more extensively disorganized than 
 I almost ever saw in any form of phthisis: nevertheless, not a 
 vestige of tubercle could be detected in either lung. 
 
 It was a case of purely pneumonic phthisis. The case appears to 
 me to be at once curious, and highly interesting, as occurring in 
 connection with the cachectic state observed in advanced diabetes 
 mellitus. 
 
 a a. Vast excavations in the apex of the lung. 
 
 b b. Smaller excavations in various parts. 
 
 c c. Pulmonary tissue in a state of red hepatization. 
 
 dd. Pulmonary tissue in a state of grey hepatization.

 
 THE DimCULTIES AND FALLACIES ATTENDING 
 PHYSICAL DIAGNOSIS 
 
 DISEASES OF THE CHEST. 
 
 (Head before the Guy's Physical Society, February 28^, 1816.) 
 
 WERE I to affirm that Laeimec contributed more towards the 
 advancement of the medical art than any other single individual, 
 either of ancient or of modern times, I should probably be ad' 
 vancing a proposition which, in the estimation of many, is neither 
 extravagant nor unjust. His work, ' De 1* Auscultation Mediate/ will 
 ever remain a monument of genius, industry, modesty, and truth. 
 It is a work, in perusing which, every succeeding page only tends to 
 increase our admiration of the man, to captivate our attention, and 
 to command our confidence. We are never permitted for a moment 
 to imagine tha.t we are reviewing, for the first time, the mere pro- 
 fessions of an ingenious speculator or plausible theorist : we are led 
 insensibly to the bedside of his patients; we are startled by the 
 originality of his system ; we can hardly persuade ourselves that any 
 means so simple can accomplish so much, can overcome and reduce 
 to order the chaotic confusion of thoracic pathology ; and hesitate 
 not, in the end, to acknowledge our unqualified wonder at the 
 triumphant confirmation of all he professed to accomplish. If to 
 any one this should appear the language rather of exaggeration and 
 enthusiasm than of sober judgment, let him, as a matter of justice 
 to Laennec, endeavour to ascertain the actual state of our knowledge 
 on the subject previous to the time of that distinguished man ; let 
 him consult the work of Cullen, the standard work of that day ; let 
 him divest himself for the moment, if he can, of all that he has 
 learned directly or indirectly from the labours of Laennec ; let him 
 
 5
 
 66 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 lay aside what he may now regard as the mere alphabet of thoracic 
 disease. I say, let him do this, and he will, I doubt not, be amazed 
 to find that of this very alphabet Laennec was the original and 
 undisputed author. 
 
 Great though his merits, incalculable his services to the profession, 
 and indisputable the efficiency of his system of diagnosis, Laennec 
 furnishes no exception to the common lot of all original discoverers : 
 for he, like the rest, had to encounter his full share of doubt and denial, 
 of misrepresentation and ridicule. It cannot, however, be otherwise 
 than gratifying to his admirers and to all lovers of justice to know 
 that he survived his labours and his publication sufficiently long to 
 reap an honourable reward in the respect, the acknowledgments, and 
 cordial congratulations of the most eminent in his profession, and 
 indeed of all who, having had the industry and perseverance fairly 
 to test his merits, possessed a heart capable of rendering honour 
 where honour was due. It is nevertheless scarcely to be doubted, 
 and very much to be lamented, that the cause of Laennec has sus- 
 tained more real and serious injury from indiscreet and indiscriminate 
 advocacy than from the most determined and open hostility. Cre- 
 dulity may be less unamiable than scepticism : we may be disposed to 
 regard the former as an infirmity untainted by selfishness, whilst we 
 look upon the latter as too often blended with envy, hatred, or malice ; 
 still are they alike opposed to the advancement of truth. In the 
 present instance, indeed, the man of science may be permitted to 
 dissent from the moralist ; since scepticism, whatever shape it may 
 assume, or from whatever motives it may proceed, serves but to 
 provoke discussion, to encourage inquiry, and to subject all novel 
 pretensions to the searching test of repeated and careful experiment ; 
 whereas the tendency of an easy belief is just as certainly to create 
 and strengthen prejudice, to engender misguided enthusiasm, and to 
 pervert or suspend the exercise of that calmer judgment so essential 
 to the honest and impartial investigation of facts. 
 
 Books and essays without number, and of great value, have been 
 written for the purpose of adding favourable testimony to the merits 
 of the stethoscope ; to increase its utility, and extend its application ; 
 whereas, so far as I know, not a single individual has deemed 
 it right or desirable to pursue the opposite course, of expressly 
 publishing to the world the manifold difficulties and fallacies 
 attending its use. The publications alluded to, by the semblance of 
 a too exclusive advocacy, have, according to my humble belief,
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 67 
 
 placed the stethoscope and its pretensions in a false position ; they 
 have awakened in the minds of many a vague notion of infallibility ; 
 they have led the profession and the public to expect too much, 
 and by suppressing or concealing the real imperfections of a favorite 
 expedient, have put it in the power of hostile parties to inculpate 
 the stethoscope for the errors of the stethoscopist. But if the 
 works of even able and experienced writers have thus done injury to 
 the cause of physical diagnosis, and have furnished weapons of 
 attack to its opponents ; what shall we say of that very numerous 
 class of persons who, with the most slender experience, mistake zeal 
 for proficiency, and are perpetually falling into grievous and palpable 
 error ? The enthusiasm, the rashness, the bigotry and conceit of 
 the exclusive stethoscopist have indeed, most seriously retarded the 
 adoption, and vitiated the claims of physical diagnosis ; and have 
 done more to discourage the student, to shake the confidence of the 
 profession, and to throw ridicule upon the stethoscope itself than the 
 most inveterate hostility could ever have accomplished. They seem 
 to look upon the instrument as all-sufficient ; they rush at once to 
 auscultation and percussion ; they neglect or disdain to make those 
 careful and minute inquiries which no sound and sensible physician 
 ever fails to do, and thereby convert an invaluable auxiliary into 
 what, in their hands at least, proves but an imperfect and treacherous 
 substitute. Unfortunately, in the medical profession, all truly 
 valuable and practicable knowledge is only to be attained by a pro- 
 portionate sacrifice of time and labour, and as a general rule the one 
 may very fairly be measured by the other. Physical diagnosis is 
 signally obedient to this law ; a perfect mastery over it would indeed 
 be an inestimable acquisition ; but its accomplishment can scarcely be 
 numbered with the possible. The truth is, even moderate proficiency 
 in the use of the stethoscope is much more rarely achieved than 
 many are willing to admit ; and I venture to affirm that the student 
 who shall attempt to acquire such proficiency from a perusal of 
 books, and by an attendance upon patients in the wards of even 
 this large hospital, will, if he rely solely upon his own individual 
 efforts, unaided by an experienced guide, most certainly and most 
 miserably fail in his object. His attempts will prove but a profitless 
 expenditure of valuable time ; he will only be storing his mind with 
 false knowledge, and in the end will assuredly reap for his reward 
 disappointment, mortification, and loss of professional fame. The 
 very language of physical diagnosis must prove, in a great measure,
 
 68 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 unintelligible to him ; and it would be almost as unreasonable to 
 expect that a man born blind should, on receiving his sight, be able 
 at once to recognise and accurately distinguish the ever-varying 
 tints of a landscape, as to suppose that a novice in the art of phy- 
 sical diagnosis could, without the aid of an interpreter, uniformly 
 attach a correct idea to every term employed to express the ever- 
 varying phenomena elicited by auscultation and percussion. It 
 may indeed be alleged that the example of Laennec himself presents 
 us with unquestionable proof how much may be accomplished by 
 the unaided exertions of an individual. This is undoubtedly true ; 
 but the fine genius, the indefatigable industry and vast oppor- 
 tunities of Laennec do not fall to the lot of many, and his case can 
 only be regarded as a very rare exception to a very general rule. 
 Laennec net only gave assistance, but a language to the art. 
 Scarcely more hopeful is the case of the practitioner who, having 
 unfortunately neglected the cultivation of physical diagnosis during 
 his pupilage, has already entered upon the duties of his profession. 
 Driven by necessity or pride to rely upon his own resources, he will, 
 even with all the advantages of a large hospital, seldom be suc- 
 cessful ; and if without the benefit of such opportunities as a large 
 hospital affords, he would probably be exercising a sound discretion 
 were he to repudiate the practice altogether, or, at most, make 
 it entirely subservient to other means of diagnosis. 
 
 Such sentiments, proceeding from a hospital physician, may by 
 some be pronounced to be vain and presumptuous. Nevertheless, 
 my conscience tells me that in the present instance, plain speak- 
 ing, if not the most prudent, is certainly the most honest policy. 
 To strip the stethoscope of the extravagant and meretricious pre- 
 tensions thrust upon it by injudicious friends; to make a candid 
 acknowledgment of the manifold difficulties and fallacies to be en- 
 countered in its employment; to state fairly what it will not, as well 
 as what it will do, is surely calculated to render it some service : for 
 by so doing we disarm hostility and establish on a solid foundation 
 its legitimate claims to the respect and confidence of the profession. 
 If, notwithstanding this explanation, my sentiments shall be deemed 
 an offence, it is to be hoped that the confessions, which are to follow 
 will go some way towards its excuse : neither will it be taxing 
 generosity too much to claim an acquittal from all empirical motives, 
 _f I venture to declare, what is well known to many members of the 
 Society, that these confessions are made by one who has zealously
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 69 
 
 cultivated the practice of auscultation and percussion at this large 
 hospital and elsewhere for a quarter of a century. 
 
 Desirous on the present, as on all other occasions, of economizing 
 the time of the Society, and promoting discussion, I have arranged 
 my subject in the form of separate propositions, and have attached a 
 number to each. By such an arrangement, any single proposition 
 can readily be singled out and commented upon by those gentlemen 
 whose intention it is to favour us by joining in the discussion. 
 
 PROP. 1. It is well known that many persons whilst under exami- 
 nation entirely fail to perform tlie respiratory act efficiently, either from 
 mere nervousness or from a mistake in regard to the mode of accom- 
 plishing it; they merely heave the chest up and down instead of freely 
 and forcibly inhaling and expelling the air. This may lead to an 
 erroneous belief that the respiratory murmur is deficient, even whilst 
 the lungs are perfectly healthy. 
 
 This source of fallacy is best corrected by desiring the patient to 
 cough, and instantly afterwards to inspire forcibly in order to cough 
 a second time. ^Yhen to this expedient is added a comparison of 
 the two sides of the chest, the actual condition of either lung may, 
 in general, be determined with considerable precision. 
 
 2. Whatever lessens the freedom, mobility, or elasticity of ihe ribs, 
 renders the sound, on percussion, more dull. Hence it is that in 
 rickety persons, where deformity of the chest has taken place sub- 
 sequent to birth, the signs furnished by percussion are often extremely 
 unsatisfactory; and, indeed, under such circumstances, neither per- 
 cussion, nor, in many instances, auscultation, can be much relied 
 upon. 
 
 3. Some persons, without actual deformity, have naturally sitch 
 fixedness of the ribs, that they at all times manifest very imperfect 
 resonance, as well as considerable feebleness of the respiratory murmur. 
 
 4. The rigidity of the cartilages of the ribs in advanced life has a 
 similar effect, and, moreover, often tends to throw obscurity over 
 hypertrophy of the heart, by preventing the usual heaving of the ribs 
 at each systole of the hypotrophied organ. 
 
 " The dulness of the sound elicited by percussing the chests of
 
 70 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 aged and deformed persons arises probably from the fixity of the 
 ribs at their extremities. In aged persons this arises from ossifica- 
 tion of the cartilages and rigidity of the tissues; and in deformity 
 from a permanently unnatural elevation or depression of the ribs. 
 In such conditions the force of a sudden blow upon a rib is trans- 
 mitted to the parts at its extremity, and this occurs the more readily 
 from the convexity of the parietes. Whereas, in the condition of 
 health, such a force applied to a rib would be in a great measure 
 limited to it, the yielding attachments of either end allowing of its 
 vibrating. Looseness of connection or fixation of the extremities 
 will produce much greater difference in the cone of a curved rod, 
 the force being applied to the convexity, than when the rod is 
 straight. In the former, the force coming upon the keystone of the 
 arch is transmitted on either side to the extremities of the curve ; 
 whereas, in a straight rod, the force applied curves it from the force, 
 and tends to loosen the connection at the extremities, its own elas- 
 ticity causing it to return to its previous condition, and so to vibrate, 
 although the ends be fixed." 1 
 
 5. When exploring the chest in a case of recent disease, we may le 
 misled ly the permanent effect of an ancient pleurisy r . 
 
 Such a sequel to pleurisy may, though rarely, involve both sides of 
 the chest, and may be so considerable as to resemble externally the 
 deformity which usually results from rickets. More commonly we 
 find the deformity of old pleuritic contraction at the inferior part of 
 the chest only, either anteriorly or posteriorly, or both. 
 
 This deformity, from pleuritic contraction is sometimes obvious to 
 the sight, but even when not so apparent, the difference of the two 
 sides, when one only is affected, may in general be recognised by 
 simply grasping from before to behind the ribs of one side with the 
 right, and the ribs of the other with the left hand, and comparing 
 the respective rotundity or flattening of the two. The physical signs 
 also of ancient pleuritic contraction, although often obscured by the 
 more recent disease, are in general pretty decisive ; these are dull- 
 ness of sound on percussion, feebleness or absence of respiratory 
 murmur, constrained movement of the ribs, the dry crepitations or 
 cracklings, especially during inspiration, the harsh dry croaking sound 
 or rale swore during inspiration, to which may be added, the incom- 
 
 1 Dr. Gull.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 71 
 
 patibility of a few, or of many of these with the recent history of the 
 case, and with other physical signs present. In such a case I con- 
 sider the employment of the naked ear much superior to that of the 
 stethoscope. When ancient pleuritic mischief exists at the upper 
 part of the chest, and especially in front, it occasionally proves a 
 source of very serious mistakes, to be noticed hereafter. 
 
 6. When, as usually happens, rickety deformity consists in lateral 
 fattening of the ribs, with projection of the sternum, the action of the 
 heart is liable from slight causes to beat with such violence, and to 
 have its sound and impulse so extensively diffused, as not unfre- 
 quently to have led to an unfounded apprehension of serious organic 
 disease of that organ. 
 
 I had an opportunity of witnessing a good illustration of this some 
 time ago, with my friend Dr. Eidge. The ready disturbance of the 
 heart's action, and the great extent of its sound and impulse had led 
 to a belief that it was organically diseased, yet inspection after deatli 
 displayed a healthy organ. 
 
 7. When acute disease of the lungs occurs in persons with rickety 
 deformity, the violence of the symptoms is often quite disproportionate 
 to the extent and severity of the pulmonary disease, and may thereby 
 suggest unnecessarily active treatment. 
 
 8. When the abdomen is greatly distended with fluid, the encroach- 
 ment of the diaphragm upon the chest and its imperfect descent during 
 inspiration, often give rise to such dulness on percussion, and feeble- 
 ness of respiratory murmur at the inferior part of the chest, as may 
 be mistaken for effusion into the latter cavity. On the right side en- 
 largement of the liver, and on the left enlargement of the spleen, may 
 to a certain extent, have a corresponding effect. 
 
 9. Of all the sources of fallacy to be encountered in the physical 
 diagnosis of diseases of the lungs, bronchitis is by far the most prolific 
 of mistakes and oversights. It may greatly obscure phthisis , pneu- 
 monia, and pleurisy ; as well as divers forms of chronic disease of 
 the organs. 
 
 10. When the bronchitic complication in phthisis is considerable, 
 we often fail to detect some, or all, of the ordinary physical signs of
 
 72 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 the latter dulness on percussion, tubular respiration, and even 
 Ironchophony 'and pectoriloquy. This is more especially the case, 
 however, in the earlier stages of phthisis ; the difficulty being then 
 increased by the absence of any flattening, or even immobility, of t lie 
 ribs 0* the side affected. 
 
 It is under such circumstances that the too exclusive stethoscopist 
 is liable to be beaten in diagnosis by those who reject physical ex- 
 amination altogether, for the latter inquiries carefully into the his- 
 tory of the patient and of his family, he observes attentively the 
 patient's general aspect, and the character and order of the gene- 
 ral symptoms ; all of which are wont to be too much disregarded 
 by the stethoscopist. Nevertheless, if the stethoscopist do his duty, 
 he has greatly the advantage, he will institute an equally careful 
 inquiry : added to which, he will observe whether the bronchial ob- 
 struction is limited to the apex of the lung, he will repeatedly and 
 for some minutes at a time, apply the stethoscope, or what I prefer, 
 the naked ear, to the upper part of the chest, he will desire the pa- 
 tient to breathe freely, to cough, and if possible to expectorate. He 
 will, by so doing, often succeed in removing the obstructing mucus, 
 and thereby develope, however slightly, some degree of bronchial 
 respiration, or bronchophony, or both, signs strongly confirmatory of 
 phthisical disease in doubtful cases. According to my own experi- 
 ence the individual symptom which, without being decisive, above all 
 others increases the apprehension of phthisical disease, is occasional 
 slight hemoptysis just sufficient to tinge or streak the sputa. Little 
 reliance can, I fear, be placed upon any other appearances of the 
 sputa, as distinctive of the two diseases. The more limited the bron- 
 chitis, especially if situated at the apex, the greater the probability of 
 its being associated with phthisis; the more general the bronchitis, 
 especially if it affect both lungs, the greater the hope of an exemp- 
 tion from phthisis. The more abrupt the transition from bronchial 
 obstruction to natural or puerile respiratory murmur in the affected 
 part of the lung, the greater the likelihood of phthisis. 
 
 Moreover, when there are no indications of bronchitis of the small 
 tubes, and its almost constant associate, vesicular emphysema ; con- 
 stituting a very common form of what is vulgarly called asthma, a 
 puerile or blowing murmur, wherever situated, ought at all times to 
 create a suspicion of phthisical or other form of consolidation in the 
 adjacent pulmonary tissue ; although neither auscultation nor per-
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 73 
 
 cussion may detect its presence at the time. On the other hand, in 
 the form of bronchitis alluded to, such puerile or blowing murmurs 
 are so very common, that whenever the long, laboured, wheezing ex- 
 piratory murmur, or paroxysmal character of the dyspnoea indicates 
 the former, we may at all times expect to find more or less of the 
 latter. 
 
 The general tendency of bronchitis is to enlarge, that of phthisis 
 to contract the chest. 
 
 11. When with bronchitic rales the stethoscoplst detects some dull- 
 ness of sound on percussion, tubular respiration, bronchophony , pec- 
 torlloquy, and gurgling ; It still is not conclusive evidence of phthisis, 
 as the whole of these signs may result from the permanent changes 
 produced from a former pleurisy, pleuro-pneumonla, or whooping~ 
 congh, or even a recent pleurisy or pneumonia, when these several 
 conditions happen to be associated with considerable bronchitis. 
 
 There is a case in Lazarus Ward, under the care of Dr. Barlow, 
 somewhat illustrative of this proposition. We have the history of 
 ancient pleurisy, there is universal dulness over the right side, with 
 contraction of the ribs, vibration is not extinct, the patient expecto- 
 rates puriform matter, and there are all the signs of excavation in the 
 lung. The case is, in every respect so strongly marked that no one 
 can doubt its original character, although before death I hold it to be 
 impossible to pronounce with certainty the existence or absence of a 
 cavity. 
 
 The case of Robert B , aged 28, admitted into our Clinical 
 Ward, resembled the above, in several particulars. He had been in 
 the hospital four years before with the sequelae of pleurisy general 
 dulness over the whole of the right side of the chest, contraction of 
 the ribs, heart drawn over to the right side, all the ordinary signs of 
 an excavated lung, and copious puriform expectoration. When he 
 reappeared in our Clinical Ward, with the exception of greater ema- 
 ciation, his general condition and the state of the right chest were 
 little altered. 
 
 Acute disease set up in the opposite lung destroyed life, and dis- 
 section proved the correctness of the opinion that had been formed 
 as to the pleuritic origin of the disease in the right side. The re- 
 markable displacement of the heart excited some surprise, neverthe- 
 less, I am disposed to conclude, from what I have seen in practice, 
 that great contraction of the right chest after pleurisy almost as cer-
 
 74 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 tainly draws the heart towards the same, as extensive effusion into 
 the left chest forces it towards the opposite side. 
 
 AYhen the changes just described are more limited in extent ; and 
 more especially when they occur at the upper part of the apex of the 
 lung, a correct diagnosis becomes much more difficult. The com- 
 pressed or condensed lung, the dilated tubes, and copious bronchial 
 secretion give rise to signs perfectly identical with those of disorgan- 
 ising phthisis, and although the former may prove fatal, either by 
 gradual emaciation and exhaustion, or by setting up actual ulceration 
 in the pulmonary tissue, still our prognosis would be very different 
 in the two cases the one holding out a fair and reasonable hope 
 of recovery, whilst the other would be regarded as nearly or alto- 
 gether hopeless. 
 
 The history and progress of the case, together with a careful con- 
 sideration of the symptoms present and past, will afford us the best 
 grounds on which to found our diagnosis. 
 
 12. When, in phthisis, the larynx becomes so involved as to 
 impede the entrance of air, and thereby give rise to a permanent 
 rale sonore in that organ, the reverberation of the rale through the 
 entire chest, at each inspiration, greatly obscures the stethoscopic 
 signs, and often leads to a mistaken belief that the obstruction and 
 imperfect respiratory murmur are attributable to the lungs themselves, 
 when the latter, though perhaps unhealthy, are in a condition totally 
 different from that suspected. 
 
 This source of fallacy is detected by applying the stethoscope to 
 the larynx itself, and by exploring both sides of the chest, when it 
 will be found that the rale sonore is audible everywhere. 
 
 13. When, with partial obstmction in the larynx, there is com- 
 plete loss of voice, the results of mere auscultation are often of very 
 little avail in diagnosis. 
 
 14. When the bronchi opening into a phthisical cavity are tem- 
 porarily obstructed by secretion, auscultation may fail to detect that 
 cavity, especially if the patient breathe but moderately, and should the 
 cavity be large and superficial, the fallacy may be rendered more 
 complete by a certain degree of resonance being elicited by percussion. 
 
 In every case of suspected phthisis, therefore, we ought to cause 
 the patient to breathe and cough with some violence, and repeat the
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 75 
 
 experiment from time to time, whilst the ear continues to be applied 
 to the chest. I have known large cavities overlooked from a neglect 
 of these precautions : the puerile respiration, which so often sur- 
 rounds phthisical obstruction, tending not a little to promote the 
 fallacy. 
 
 15. A person may have a violent tearing cough, lasting for iceeJcs 
 or months, attended with slight mucous expectoration, occasionally 
 even streaked with blood, and causing pain to le felt through the 
 whole chest, as well as an appearance of general constitutional dis- 
 tress, whilst neither auscultation nor percussion can detect any morbid 
 change within the chest. 
 
 All this often results from a relaxed uvula, in either sex ; or, if 
 the patient be a female, it may depend upon hysterical irritation. 
 More rarely I believe it to occur in connection with miliary tuber- 
 cles antecedent to phthisical disorganization. 
 
 16. When any form of chronic induration of the pulmonary tissue 
 exists, and especially if a/fended with dilated bronchial tubes, neither 
 auscultation nor percussion enables us to distinguish such a condition 
 of lung from phthisical disease. If bronchitis be present, and the 
 induration be situated at the apex, the signs are perfectly identical 
 with those of phthisical disorganization. 
 
 Our diagnostic resources are to be found in the history and pro- 
 gress of the case, the absence of some of the more ordinary symp- 
 toms of phthisis, and some incongruity observable between the 
 local signs and the general aspect and condition of the patient. 
 Illustrations of this proposition are of repeated occurrence. 
 
 17. Auscultation and percussion alone are Insufficient to distin- 
 guish malignant disease, hydatids, or a tumour from more ordinary 
 diseases of the chest. 
 
 Nevertheless, by disclosing something unusual, or apparently 
 incompatible with ordinary diseases of the chest, physical examination 
 will often excite a suspicion which by a careful consideration of 
 the history and progress of the case by the wooden dulness of sound 
 on percussion, by the peculiar expectoration, by the effects of me- 
 chanical obstruction on the veins of the neck or external chest, or
 
 76 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 even by exploration with a fine needle or trochar may occasionally 
 be converted into certainty. 
 
 A very remarkable fallacy of the opposite kind came recently under 
 my own observation. A lady whom I had attended professionally for 
 several years had occasion to travel whilst in a very delicate state of 
 health. After much suffering from increasing illness, she at length, 
 in returning, reached Paris, and there consulted one of the highest 
 medical authorities. Finding extreme dulness in the upper part of 
 the chest, and some resonance remaining below and behind, the signs 
 and suffering were pronounced to arise from some solid growth. As 
 I had examined the chest a short time before her departure, as I 
 knew that she had diseased heart after rheumatism, and that a 
 former attack of pleuro-pneumonia in all probability had left adhe- 
 sions, I could not but conclude that fluid effusion was the cause of 
 her distress. I discharged several pints. 
 
 18. If acute pneumonia have already proceeded, to complete hepa- 
 tization when we first examine the patient, the physical signs are not 
 unfregiiently insufficient to distinguish the morbid change from 
 phthisical disease, or from ancient pultnonic induration, with or 
 without dilated bronchial tubes. This is more especially the case 
 when acute pneumonia assails the apex of a lung, which is by no 
 means very uncommon. 
 
 I have on several occasions known hepatization of the apex from 
 acute pneumonia, pronounced to be phthisis by stethoscopists ; they 
 have not sufficiently appreciated the difficulty, they have neglected 
 to inquire carefully into the history and progress of the case, and 
 have mistaken the pungent heat of skin of ordinary pneumonia for 
 that which occurs in phthisis, and which I believe, nevertheless, has 
 often the same origin. 
 
 "MaryB , aged 19, admitted, under Dr. Addison. She had 
 always been delicate; and after the whooping-cough and measles, 
 which she had had eight years before, had been subject to attacks of 
 cough and cold, in which she had frequently expectorated blood. 
 
 " When admitted, she had a troublesome cough, with scanty sputa, 
 slightly tinged with blood. There was dulness on percussion below 
 the left clavicle, with tubular breathing and gurgling, the last ex- 
 tending down nearly to the margin of the ribs, where it became 
 more dry and crepitating. Posteriorly there was dulness on the left
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 77 
 
 side, extending from the apex nearly as low as the angle of the 
 scapula; and tubular breathing and bronchophony to the same 
 extent; slight tubular breathing and brouchophony at the right 
 apex, with large crepitation. 
 
 " Under the impression that phthisis was present, she was ordered, 
 
 Empl. Canth. infra claviculas singulas applicetur. 
 Pil. Papav. c. Ipecac, bis die sumat. 
 Mist. Mucilag. ter die sumat. 
 
 Under this treatment the cough became worse ; sputa more copious, 
 fawn coloured, and uniform, except that it contained puriform 
 streaks ; the head painful ; pulse 120, compressible ; cheeks flushed ; 
 skin hot and pungent ; while the signs afforded by auscultation and 
 percussion continued unaltered. She was then bled twice to eight 
 ounces ; and calomel, antimony, and opium were administered. Her 
 mouth was kept sore by the calomel for a few days, when it was 
 discontinued, and nothing given but julep ammon. acet. Under 
 these remedies, the dulness, tubular breathing, bronchophony, and 
 gurgling at the left apex, gradually diminished, and at length 
 entirely disappeared. The tubular breathing and bronchophony at 
 the right persisted longer, and caused some alarm ; but these also 
 ceased : the expectoration became white and frothy, and then, with 
 the cough, subsided. 
 
 19. When pneumonia occurs in its simplest form that is, with 
 little or no bronchial complication there is sometimes no cough, and 
 consequently no expectoration ; the whole case so closely resembling 
 common continued fever, that loth the stethoscopist and the non- 
 stethoscopist are apt to be thrown off their guard. 
 
 In such a case the stethoscopist has greatly the advantage ; for if 
 he do his duty he will pretty certainly detect the pneumonia by 
 physical examination ; whereas the non-stethoscopist is very likely 
 to remain in ignorance of its existence, to the serious detriment or 
 destruction of the patient. 
 
 Although there are many exceptions, this, the simplest form of 
 pneumonia, most frequently occurs in the aged and cachectic ; and 
 in such subjects I have met with a few cases in which even an 
 ordinary physical examination of the chest might have failed to 
 detect the disease. A case of the kind occurred some time since in 
 Billet Ward, and to which I remember having directed the attention
 
 78 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 of Dr. Gull. On desiring the patient to breathe, neither crepitation 
 nor tubular respiration could be heard; but on urging him to 
 inspire violently and to cough, both signs became sufficiently deve- 
 loped to declare the presence of the disorder. It would appear as if 
 the muscular strength were so much impaired, that, unless by an 
 unusual effort, a sufficient expansion of lung does not take place to 
 admit the necessary impulse being given by the air to the tubes and 
 cells of the organ. 
 
 It is in such cases that the very characteristic pungent heat 
 of skin so often and so fortunately directs attention to the chest. 
 This pungent heat, though not necessarily present, is very rarely ab- 
 sent so long as any portion of lung continues to be in the first or 
 crepitating stage of pneumonia. 
 
 20. Physical examination of the chest does not enable us to distin- 
 guish an advanced stage of pneumonia with considerable bronchitis 
 from pneumonia with breaking up of the lung, a difficulty the more 
 embarrassing inasmuch as the former may pass into the latter. 
 
 Here we must be guided chiefly by the history and general symp- 
 toms. The phthisical aspect, the cachectic or exhausted condition, 
 or the intemperate habits of the individual will afford us some help 
 in arriving at a correct diagnosis. 
 
 21. When the anterior and inferior portion of the left lung is 
 consolidated by pneumonia, percussion may produce good resonance, 
 in consequence of the proximity of the flatulent stomach, and 
 thereby throw us off our guard. When pneumonic consolidation takes 
 place anteriorly and inferiorly, and even posteriorly , on the right side, 
 a remarkable degree of resonance is occasionally elicited in a highly 
 tympanitic condition of the intestines. Under precisely similar cir- 
 cumstances auscultation may detect a well-marked modification of 
 amphoric respiration, and metallic tinkling, to a considerable height 
 in the chest, thereby leading to the erroneous conclusion that pneumo- 
 thorax is present. 
 
 The respiration acquires its amphoric character by reverberating 
 through the solid parts of the inflated bowels, the metallic tinkling 
 developed below the diaphragm acquires its intensity by reverberating 
 in the opposite direction,
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 79 
 
 The following case presents a very remarkable modification of this 
 source of fallacy : 
 
 " Charlotte C , aged 19, was admitted into our Summer Clinical 
 Wards, complaining chiefly of some pain and tenderness over the 
 whole of the abdomen, but especially on the right side, and the 
 bowels appeared to be greatly distended with flatus. These complaints 
 were of a month's standing, but about three months prior to admis- 
 sion she had had an attack of inflammation within the chest, and was 
 still harassed by a short dry cough. 
 
 " On the right side of the chest, anteriorly, there was increase of 
 resonance as high as the third rib, and even the apex, the resonance 
 was greater than normal, dulness at the base of the same lung 
 posteriorly. 
 
 " Respiration was puerile in the apices of both lungs anteriorly, 
 mixed with sibilant rales in the right. On the right side, as high 
 as the third rib, slight and distant crepitation, with a metallic state 
 of the breathing, and when she spoke or coughed similar ampho- 
 ric sounds were to be heard. Accompanying these amphoric sounds 
 we had the tintemint metalligue" 
 
 On inspection after death, the pleurae on both sides of the chest 
 were adherent ; but the diaphragm had been raised up high within 
 the chest, partly by the inflated bowels, and partly on the right side, 
 by old adhesions between it and the base of the lung. A vast fsecal 
 abscess extended from the pelvis to the under surface of the diaphragm 
 on the right side. From this inflated abscess, or from the distended 
 intestines, or from both, had originated the great resonance, the 
 amphoric sound, and tintement metallique. 
 
 22. Physical examination cannot determine whether pneumonia, in 
 any of its forms have or have not supervened upon tubercles, although 
 the prognosis in the two cases would be very different. 
 
 23. / very much doubt whether physical examination can in any 
 instance determine with certainty the existence of simple tubercles in 
 the lungs. 
 
 In a former paper I communicated a case which very well illus- 
 trated this, and the following is to the same effect : 
 
 "Adah H , aged 17, admitted under Dr, Addison, She was
 
 80 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 admitted with what appeared to be symptoms of fever. The 
 chest was resonant on percussion, and the respiration puerile. It 
 was supposed that the breathing was somewhat harsher at the left 
 apex than at the right. There was no cough or expectoration. On 
 the following day, the case proved to be one of hydrocephalus, and 
 on the next day she died. At the post-mortem examination, nume- 
 rous miliary tubercles were found scattered throughout the lungs : 
 they were more numerous in the upper and middle lobes than in the 
 inferior ; and in the right lung, than in the left, the latter being 
 the lung in which the respiration was considered harsher. The pul- 
 monary tissue surrounding the tubercles was perfectly healthy. 
 
 24. We may be catted to a case of pleurisy before a single physical 
 sign has been developed. 
 
 In such a case it may be doubtful whether the pain arises from 
 pleurisy, rheumatism, neuralgia, or the approach of shingles. 
 
 A very good example of the latter source of fallacy presented itself 
 in the case of Sarah !F , aged 18, admitted into the Summer Clini- 
 cal Wards. It will be found accurately described in the clinical 
 book by my clerk, Mr. Greenwood. 1 
 
 25. When pleurisy occurs low down in the angle between the ribs 
 and diaphragm, and especially when situated anteriorly, a considera- 
 ble period, perhaps several days, may elapse before auscultation can 
 detect either pleuritic rubbing, agopkmy, &ronchopho/iy, or tubular 
 respiration, whilst percussion proves fallacious, in consequence of the 
 presence of the liver on the right, and of the inflated stomach on the 
 left side. 
 
 Doubtless this source of error is connected with the relative posi- 
 tions of the effusion, the lung and the parietes of the chest, but 
 without attempting any elaborate explanation, I content myself by 
 simply vouching for the fact, in my own experience. I have known 
 such cases mistaken for spasms, for neuralgia, for hepatitis, for sple- 
 nitis, for peritonitis, and, in consequence of pressure of the abdomen 
 causing a descent of the false ribs, for enteritis. A knowledge of 
 
 i The Summer Clinical Wards were committed to my charge, and were appro- 
 priated exclusively to diseases of the chest. Dr. Novelli, Mr. Greenwood, 
 
 r. M alter Johnson, and Mr. Howard Johnson, were my clinical clerks; and 
 better I could not have had.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 81 
 
 the fact alone will go far to preserve us from error, and when the 
 suspicion exists a long-continued application of the naked ear to the 
 chest will often succeed in detecting a little transient graze, or pleu- 
 ritic crepitation, sufficient to greatly strengthen that suspicion. The 
 lapse of one, two, or three days will in general place the matter 
 beyond dispute. 
 
 " Jeremiah , aged 23, ill two weeks ; was admitted into Job 
 Ward under Dr. Addison. He complained of acute pain beneath 
 the right nipple when a deep inspiration was taken, of headache, 
 pains in the limbs, and extreme prostration. There was a frequent, 
 harassing cough, copious expectoration of a frothy mucus, tinged 
 with blood, the skin was ptingently hot, and the tongue was loaded 
 with a moist white fur. 
 
 " Physical examination of the chest. It was deep and well 
 formed. The movement of the right side was instinctively checked 
 during respiration. Vocal fremitus good in all parts. From a 
 peculiarity in the configuration of the thoracic parietes, not very un- 
 frequently met with, percussion elicited in all parts very imperfect 
 resonance. Dulness, it is true, was more strongly marked beneath the 
 right mamma, and below the scapula of the same side, than in the 
 corresponding parts of the left lung, but the presence of the liver 
 renders this sign fallacious, and but imperfectly diagnostic. The 
 signs afforded by stethoscopic observation were, if possible, still 
 more unsatisfactory. Where the sounds of respiration could be fully 
 heard, with the exception of occasional bronchitic whines, they were 
 normal. At the lower parts of both lungs the patient will not 
 permit the air fully to enter the cells, and even after coughing, nc- 
 thing, save a slight roughening of the respiratory sounds before, and 
 a tendency to tubularity behind in the right lung could be detected. 
 The voice was triflingly modified at the base of the right lung : it 
 was bronchophonic in character. 
 
 " The case was diagnosed to be phlegmasial fever, with broncho- 
 pleuro-pneumonic complication, and Dr. Addison ventured to pro- 
 phesy that in a few days, all the stethoscopic signs diagnostic of such 
 pulmonic disease would present themselves. 
 
 " The treatment consisted in moderate depletion, local and gene- 
 ral, with small doses of antimony, opium, and calomel combined in 
 form of pill. 
 
 " On the second and third days no change took place in the phy- 
 
 6
 
 82 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 sical signs, save that on the latter, after long listening, a soft rubbing 
 sound attendant on respiration was occasionally heard in the angle 
 below the right mamma. 
 
 " On the fourth day, a distinct to and fro sound, accompanied by 
 moist crepitation, had become audible in the right submammary 
 region. The friction sound was most marked to the right of and on 
 a level with the nipple. It diminished in intensity as the angle was 
 approached, where it was replaced by fine crepitation. At the base 
 of the lung behind, some minute crepitation had arisen, and imme- 
 diately below the scapula a soft brushing to and fro sound could 
 occasionally be heard. This examination was made at n a.m. In 
 the evening of the same day the patient was re-examined. 
 
 " In front, little change had taken place excepting an increase in 
 degree of the previous signs. The friction sound was more harsh, 
 and the crepitation had become larger. Behind, harsh grating to 
 and fro sounds with which was mingled crepitation in various de- 
 grees, large and small, extending from the base of the lung over the 
 lower half of the scapula and round to the axilla had become audi- 
 ble. Diffused rhonchi were to be heard in various parts. All the 
 signs, in short, that are recognised as diagnostic of bronchitis and 
 pleuro-pneumonia had manifested themselves." 
 
 The further progress of the case is detailed in the clinical 
 books. 
 
 "Emma H , aged 19, a tolerably healthy-looking girl, was ad- 
 mitted into the Clinical Ward, under the care of Dr. Addison, Nov. 
 26, 1845. She had been labouring for several months under some 
 obscure affection about the pelvis, which, after careful examination, 
 appeared to be probably nothing more than hysterical. Three weeks 
 after her admission she was attacked with a severe rigour, followed 
 by great heat and dryness of skin ; these symptoms were succeeded 
 on the following day by an acute pain in the right side of the chest, 
 below the mamma, increased by inspiration, and attended with a short 
 hacking cough and all the ordinary symptoms of pyrexia. The 
 chest was attentively examined by Dr. Addison, myself, and others, 
 but none whatever of the physical signs of pleurisy could be 
 detected. 
 
 The next day she had great anxiety of countenance, distress of 
 breathing, and, in short, an aggravation of all the symptoms. On
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 83 
 
 listening for some time towards the base of the right lung posteriorly 
 I thought that a pleuritic rub or friction sound was occasionally 
 audible at the end of a forced inspiration, but Dr. Addison after a 
 protracted examination said he could not hear it. 
 
 "The following day, viz., the third from the attack, there was no 
 doubt as to its existence, it having become constant, although heard 
 over a limited space, and unaccompanied by the signs of serous 
 effusion." 
 
 Some time ago I attended a very instructive case of this kind, with 
 Mr. Busk and Mr. Bell. It occurred in the person of a foreigner. 
 He was supposed to be suffering from acute hepatitis. The chest 
 had been carefully examined, and no physical signs of disease within 
 that cavity could be detected, the dulness present on percussion being 
 attributed to the liver. I repeated the examination, but although 
 persuaded that it was a case of pleurisy affecting the angle, and from 
 the pungent heat of the skin that the pleurisy was associated with 
 pneumonia, I could detect no sign whatever, except some dulness on 
 percussion, and there was neither cough nor expectoration. A few 
 days removed all doubt about the matter. 
 
 I may observe, in concluding my remarks on this proposition, 
 that when pleurisy has its seat in the parts alluded to above, it con- 
 stitutes by far the most painful and perhaps the most dangerous 
 form of the acute and sthenic disease. It is the paraphrenitis of the 
 ancients, a disease which, according to them, consisted simply of in- 
 flammation of the diaphragm. This, however, is not correct, for the 
 pleura covering the diaphragm is often inflamed without giving rise 
 to the dreadful suffering observed in paraphrenitis, whereas, when 
 acute and sthenic inflammation attacks the pleura, where it is reflected 
 from the diaphragm of the ribs at the base of the chest, and thus 
 involves both the diaphragmatic and costal pleurae at the same time ; 
 then it is that we have such intense suffering and such an expression 
 of agony in the countenance, as forcibly to remind us of the rims 
 sardonicus of the older writers. 
 
 26. When the effusion into the chest is of the purely serous kind, 
 or when the proportion of albuminous material is very inconsiderable, 
 the J!n.id gravitates to thejloor of the cavity, and may, unless very 
 abundant, entirely escape detection, either by auscultation or percus* 
 sion.
 
 81 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 The luncr rests, as it were, on the surface of the fluid ; it still ad- 
 
 O ' ' 
 
 mits air, and consequently general expansion ; it still continues to 
 apply itself more extensively to the parietes, and consequently neither 
 segophony, bronchophony, nor tubular respiration is necessarily pre- 
 sent in a marked degree, whilst any slight dulness of sound on per- 
 cussion is rendered equivocal by the liver on the right and by the 
 flatulent stomach on the left side. Neither does vocal vibration 
 necessarily cease under such circumstances. The correctness of this 
 proposition is not, I am aware, generally admitted, any unexpected 
 serous effusion being under such circumstances supposed to have 
 taken place immediately before dissolution, or to be purely cadaveric. 
 Experience, however, leaves me no room for doubt about the matter. 
 In such cases we must found our opinion, or rather our suspicion, upon 
 the history and general condition of the patient. We know that 
 effusions of the character described are most likely to take place in 
 diseases of the heart, in cachectic and dropsical persons, in those 
 suffering under Bright' s disease, or the sequelae of scarlet fever. I 
 may, nevertheless, be permitted to observe that when there has been 
 a suspicion of the presence of serous fluid without any well-marked 
 segophony, bronchophony, tubular respiration, or unequivocal dulness 
 of sound on percussion, by placing the patient in a sitting position, 
 and placing the ear for a considerable time to the posterior and in- 
 ferior part of the chest, and in the mean time moving the patient's 
 body several times to nearly the horizontal position and back again, 
 and directing him to cough forcibly, I have succeeded in eliciting a 
 distant tubular respiration, sufficient to indicate partial compression 
 of the lung. 
 
 In the case of John B , aged 49, affected with Bright's disease, 
 the signs of effusion into the right chest were very unsatisfactory, 
 although on a post-mortem examination shortly afterwards, it was 
 found to contain a large quantity of serum. 
 
 Frederick S , aged 24, laboured under disease of the heart of 
 long standing, but greatly aggravated by bronchial complication. 
 Bronchial rales were loud throughout the chest, the right side was 
 generally dull on percussion, there were some bronchophony and 
 very imperfect respiratory murmur, the whole of these signs being 
 most strongly marked posteriorly and inferiorly. Vibration was 
 nearly perfect. 
 
 A difference of opinion arose whether the signs depended upon old 
 pleuritic adhesions or upon serous effusion and great congestion.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 85 
 
 Being myself of the latter opinion, I had a fine exploring trochar in- 
 troduced between the eighth and ninth ribs. A little fluid trickled 
 out of the minute canula, immediately followed by the entrance of 
 air into the chest ; the body was then inclined to the right side, 
 when about a drachm more escaped, upon which I immediately had 
 the canula removed. The question of adhesion or effusion was thus 
 decided, but how much serum remained and had gravitated towards 
 the diaphragm can only be surmised. 
 
 27. When serous effusion is very considerable, giving rise to 
 unequivocal Ironchophony , tubular respiration, and want of resonance, 
 and vocal vibration, physical examination has repeatedly led to a 
 mistaken belief that these signs resulted from pneumonic or other 
 consolidation of the lung. 
 
 A few years ago a little girl was admitted into the hospital, under 
 my care, labouring under great oppression of the chest. Amongst 
 other signs and symptoms, I found great dulness on percussion of 
 the right side, tubular respiration, and so clear and powerful a bron- 
 chophony that I did not hesitate to pronounce the case one of pneu- 
 monic consolidation. She shortly died, and I found the affected side 
 of the chest full of fluid. More attention to the history and progress 
 of the case would have saved me from this error. 
 
 Some time ago a middle aged woman was under my care in the 
 hospital, who had diseased heart and, as I believed, effusion into the 
 right chest. She was seen by another physician, a zealous stetho- 
 scopist, who without hesitation and with considerable confidence, 
 declared the case to be one of pneumonic consolidation. I intro- 
 duced a trocar, and proved beyond all dispute that the pleural cavity 
 contained a large quantity of fluid. 
 
 " In reference to the apparent paradox that, in certain conditions 
 of the chest, the vibrations of its parietes, ordinarily produced when 
 the patient speaks, can no longer be felt, whilst, under the same 
 circumstances, loud bronchophony is audible ; we must bear in mind 
 that there is no necessary connection between the two results. 
 Sound is transmitted through bodies by a successive motion of its 
 molecules, the whole mass not necessarily undergoing any change of 
 place, whilst the movement appreciable by the hand is the change of 
 place which an entire body undergoes. As a familiar illustration : 
 suppose the end of a deal rod is in contact with the ear, and let a.
 
 86 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 trembling motion be communicated to it, the movement is readily 
 felt by the means of common sensation; but no sound is heard 
 except that of friction, produced by the end of the rod on the ear : 
 here we have motion without sound. Let the rod come to rest, and 
 be firmly applied to the ear, and apply a vibrating tuning-fork to 
 the other end ; the sound yielded by it is transmitted by the rod, 
 yet without any appreciable movement of the rod. Not only does 
 the immobility of the rod not prevent the transmission of the acoustic 
 vibrations ; but the more firmly the rod is held, the more distinct is 
 the sound. It is true that deep sounds, having also great intensity, 
 do produce a visible vibration of the mass which transmits them ; 
 but this arises from the gravity and molecular cohesion of the 
 masses so affected being less, equal to, or only slightly greater 
 than, the acoustic force. If from any cause the body transmitting 
 acoustic vibrations be fixed, there may be no perceptible movement 
 of its mass : such is the condition of the chest, when full of fluid, 
 or affected by pleuritic adhesions ; the bronchophony in such cases 
 may be remarkably loud, and yet the hand feel no vibration/' * 
 
 28. Even in ordinary acuie pleurisy , when the albuminous material 
 thrown out is more abundant ; when, in consequence, the lung is held 
 more in contact with the ribs ; and when, instead of the whole of the 
 fluid gravitating to the base of the chest, it is more or less confined 
 within the meshes of the solid deposit ; it not unfrequently havens 
 that auscultation and percussion fail to determine with certainty 
 whether the physical signs present result from that disease, or from 
 pneumonia advanced to hepatization, or from a combination of the tico, 
 
 An instance of this kind has recently been witnessed by some 
 members of the Society in a patient under the care of Dr. Babington. 
 
 Were I addressing gentlemen altogether unacquainted with the 
 use of the stethoscope, it might be excusable to point out in detail 
 the means by which we may in general arrive at a correct diagnosis ; 
 but, as that is not the case, I shall content myself with offering a 
 caution not to mistake the crepitations so often attendant upon 
 recent pleuritic effusion for the crepitating and mucous rales of 
 broncho-pneumonia; nor to imagine that the physical condition of 
 the chest and physical signs are the same, when the effusion consists 
 
 *Dr. Gull.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 87 
 
 of pure serum, and when it is made up of the ordinary mixture of 
 serum and solid albumen, usually met with in acute pleurisy occur- 
 ring in persons of good constitution; the physical signs of the 
 former being, for the reasons stated, much more equivocal and 
 inconclusive than those of the latter. 
 
 Although I have just alluded to certain crepitations detected by 
 auscultation, not only in cases of acute, but of ancient pleurisy also 
 and although I believe that little doubt is now entertained as to 
 their occurrence in both of these morbid states I do not think it 
 is by any means satisfactorily established whether these crepitations 
 result from the mere movements of the adhesions themselves, or 
 from some mechanical change or impediment in the adjacent lung. 
 
 The following communication from my friend Dr. Barlow bears 
 somewhat upon this question : 
 
 " UNION STREET, SOUTHWAEK, June 26, 1846. 
 "MY DEAR DOCTOR, 
 
 " I much regret that there has not been a complete report of 
 the case of the man who died at No. 3 Lazarus Ward, last Monday, 
 and was inspected on the following day. I trust, however, that the 
 following particulars may serve your purpose. 
 
 "This patient was admitted under my care with hemoptysis, 
 about the end of February last : there were also strong reasons for 
 believing him to be phthisical, although the auscultatory signs were 
 not unequivocal. Soon after his admission he was transferred to 
 the care of Dr. Bird (whilst I had charge of the Clinical Wards) till 
 the end of April, when he again became my patient ; and when there 
 were undoubted signs, both topical and general, of advanced tuber- 
 cular phthisis. Some time before his death, his position, respiration, 
 and the seat of pain, led to the diagnosis of diaphragmatic pleuritis ; 
 but there was, moreover, a defined pain and tenderness over a space 
 nearly half-way between the ensiform cartilage and umbilicus, about 
 the size of a crown piece. Here a crepitus could be distinctly felt 
 by the hand ; and, upon applying a stethoscope to the part, a cre- 
 pitation could be plainly heard with each inspiration and expiration. 
 Upon one occasion, a few days before the death of the patient, this 
 crepitation so closely resembled that produced by bronchitis of the 
 smaller tubes, that I made the remark " there is a mucous rattle in 
 the peritoneum/' And this resemblance was also noticed by Dr.
 
 88 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 Bevan, who was present, and by ray reporters, Messrs. King and 
 Rump. Upon inspection, in addition to the disease diagnosed in 
 the chest, there was found a layer of fibrinous effusion on the surface 
 of the parietal peritoneum, corresponding to the situation in which 
 the stethoscopic phenomena had been noticed, and a similar layer 
 on the apposed surface of the liver. 
 
 " I am yours, very truly, 
 
 "G. H. BARLOW/-' 
 Dr. Addison. 
 
 29. When a patient presents himself, with a febrile disorder of 
 any kind, we may, on examination, detect dulness of sound on per- 
 cussion, tubular respiration, bronchophony, and a rale not distin- 
 guishable from that form of mucous or sub-mucous crepitation so 
 commonly observed in the hepatization of acute pneumonia ; and yet 
 physical examination shall not enable MS to determine whether the 
 chest affection be recent or of ancient date. When a portion of lung 
 has been compressed by pleuritic effusion, and has been prevented 
 from expanding again by surrounding pleuritic adhesions, the phy- 
 sical signs may remain permanently , and be found to resemble pre- 
 cisely those ivhich result from recent ftleuro-pneumonia. 
 
 This actually happened in the case of Charlotte C , already 
 
 mentioned. There was considerable obscurity about the case alto- 
 gether; but as she was feverish, and had a frequent hacking cough, 
 and furnished the physical signs just enumerated at the lower and 
 posterior part of the right chest, I scarcely hesitated to conclude 
 that she had pleuro -pneumonia affecting that part. On inspection 
 after death, we found the morbid changes above described of ancient 
 date, and without any trace whatever of recent inflammation in any 
 of the structures involved. 
 
 In a case of this kind the stethoscopist is much more likely to 
 err than the man who repudiates the instrument altogether; since 
 the former would be very apt indeed to conclude that recent pleuro- 
 pneumonia existed; whilst the latter, utterly ignorant of the 
 treacherous physical signs, would never entertain the least suspicion 
 of anything of the kind. 
 
 30. Experience leads me to the conclusion that physical examina- 
 tion cannot, in every instance, distinguish the rub and crepitation of
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 89 
 
 pleurisy situated at the lowest part of the chest on either side, but 
 especially the right, from similar sounds resulting from recent adhe- 
 sions between the liver and diaphragm ; or between the liver and 
 abdominal parietes : neither can auscultation and percussion at all 
 times distinguish some of the croaking sounds developed in the bronchi 
 from a pleuritic rub ; the sounds often closely resembling each other, 
 and both occasionally communicating a manifest vibration to the hand 
 applied to the parietes of the chest. 
 
 I met with a case of the abdominal friction sound alluded to above, 
 in a gentleman who died of malignant disease of the liver; and, 
 more recently observed the same thing in a patient whom I attended 
 with Mr. Tidier of Peckham. One of the best illustrations, how- 
 ever, occurred in a patient, Eliza "W , aged 22. This poor 
 
 creature laboured under a sad complication of disease. She had 
 phthisical disorganisation of both apices of the Inngs, an enlarged 
 liver, and the morbid kidneys of Bright's disease. In the progress 
 of her case she was attacked with acute pain and great tenderness 
 over the region of the liver, extending up beneath the margin of the 
 ribs, first of the right, and afterwards of the left side. The crepi- 
 tation of palpation could scarcely be felt ; but a strongly-marked 
 friction sound was heard during the acts of inspiration and expira- 
 tion, perfectly identical with a pleuritic friction sound. Indeed, it 
 extended so high into the chest on the right side, that it was doubt- 
 ful whether pleuritis, as well as peritonitis, was not present. Inspec- 
 tion after death proved that there was no recent pleurisy ; but " the 
 abdomen contained about a pint of pale straw-coloured serum. The 
 liver weighed six pounds three ounces, extended as high as the third 
 rib, as low as the umbilicus, and across to the left hypochondrium ; 
 its upper surface, especially of the right lobe, was coated with a 
 layer of recent lymph ; there were also recent adhesions between it 
 and the diaphragm, and the anterior parietes of the abdomen. In- 
 testines slightly reddened, connected together by very soft adhesions, 
 slightly coated with lymph : all these were more apparent on the 
 right side than on the left. Kidneys slightly enlarged, together 
 weighed ten ounces; tunic adherent at some parts, surface irre- 
 gularly contracted; cortical substance, composed of fatty-looking 
 matter, in which all striated appearance was nearly lost; tubular 
 portion pale; pelvis normal; no fat obtained by heat. Bladder 
 healthy."
 
 90 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 a I. As simple pericarditis is rarefy attended with pain, and as 
 the other symptoms of 1hat disease are either unsteady or equivocal, 
 the physical signs are chief y to oe relied upon informing a diagnosis. 
 Nevertheless, when effusion has taken place to a certain amount, the 
 friction sound commonly disappears, and auscultation then fails to 
 recognise the disease. 
 
 The rheumatic ailment of the patient, the more or less distant 
 sound of the heart, the dulness of sound, especially towards the apex 
 of the left lung, and the usually soft and compressible, but slightly 
 jerking, pulse, may perhaps lead to a strong suspicion ; but auscul- 
 tation cannot, in such a case, positively confirm it. Of course, the 
 more considerable and more rapid the effusion, the sooner and more 
 completely does the friction sound disappear ; whence the greater 
 difficulty of diagnosis in cachectic and dropsical than in otherwise 
 healthy subjects. I may observe that when, from the quantity of 
 fluid effusion, the ordinary friction sound is no longer heard, by 
 applying my ear to the chest, and retaining it there for some time, 
 I have occasionally been able to detect, once or oftener, a single 
 slight and transient pericardial rub, or rather brush, quite as de- 
 cisive, in a diagnostic point of view, as the most perfect double 
 pericardial rub. 
 
 A curious case of this kind occurred in the person of M , 
 
 late porter to the hospital. When requested to see him by Mr. 
 Stocker, he was labouring under severe pleurisy, which was obvious 
 enough ; but on applying my ear over the region of the heart, I 
 imagined I heard once such a transient single rub or brush as I have 
 just alluded to. Believing that I had made an important discovery, 
 I carefully repeated my exploration; but although I continued to 
 listen a considerable time, I could never hear it again. He presently 
 died ; and on examination we found universal and intense pericarditis, 
 with unusually copious sero-albuminous effusion. 
 
 32. Enormous accumulations of fluid, in the pericardium cannot 
 ly physical signs le distinguished at all limes from effusion into the 
 cavity of the pleura, 
 
 33. When the pericardial friction sound is single, auscultation 
 may fail to distinguish it from a valvular murmur ; and especially 
 so when the single friction sound is heard most distinctly over the 
 situation of the valves.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 91 
 
 34. So far as auscultation is concerned, the double friction Bound 
 of pericarditis, if heard toward the base of the heart, might be mis- 
 taken for the see-saw murmur of imperfect aortic valves, or vice versd. 
 
 The character of the pulse alone would be almost sufficient to 
 decide the question. 
 
 35. Auscultation does not at all times enable us to distinguish a 
 friction sound produced within from a friction sound produced with- 
 out, the pericardium ; i. e. friction between the pericardial surfaces 
 
 from friction between the loose pericardium and lung or parietes of 
 the chest. 
 
 I have had more illustrations than one of this difficulty ; and the 
 following case, admitted into our Clinical Ward, I am disposed to 
 think furnishes another. 
 
 " SAMUEL P , aged 21, was admitted on Sunday night, the 
 
 yth of June, in a state of partial collapse. He had been seized about 
 two hours after his meal with excruciating pain in the lower part 
 of the abdomen: there were frequent, but ineffectual, efforts to 
 vomit. The pain extended so as to involve all parts of the abdo- 
 men, which was exquisitely tender on pressure. He gradually sank 
 into a semi- comatose state ; the extremities became cold ; respiration 
 was hurried, and effected with great apparent pain ; the pupils were 
 contracted ; consciousness of surrounding objects was imperfect. 
 
 " Diagnosis Perforation of the stomach. 
 
 " The chest being examined, gave the following stethoscopic 
 signs : Over the aortic valves was heard a soft brushing to and fro 
 sound, accompanying each systole and diastole of the heart. The 
 sounds of respiration anteriorly were normal. Behind, at the base 
 of the right lung, a harsh grating rub met the ear, synchronous with 
 inspiration and expiration : elsewhere, breathing was normal. 
 
 " The patient sank rapidly, and died the following day at twelve 
 o'clock. 
 
 " SectiO'Cadaveris. A perforating ulcer in the lesser curvature of 
 the stomach. Universal peritonitis. 
 
 " Lungs and heart perfectly healthy. Between the right pleura 
 and pericardium there existed a band of old adhesions, which had in 
 all probability given rise to the anomalous bruit heard with the heart's 
 action. Both lungs overlapped the heart.
 
 92 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 " The peritoneal coverings of the liver and diaphragm were coated 
 with recently-effused albuminous deposit. The ascent and descent 
 of the diaphragm during the respiratory act, bringing these two 
 surfaces into contact, had caused the rubbing to and fro sound heard 
 at the base of the right lung." 
 
 36. A sound closely resembling a valvular murmur appears not 
 unfrequently to be produced by the stroke of the heart against a 
 portion of lung } interposed between it and the parietes of the chest. 
 Under such circumstances, auscultation may lead, and I believe often 
 has led, to the erroneous conclusion, that the heart is diseased, when 
 it is perfectly normal in every respect. 
 
 This sound is most frequently heard at some point in the direction 
 of the edge of the left lung, where it overlaps the heart, to the left 
 of the sternum, from about the second or third to about the fifth 
 rib, and especially somewhere between the second rib and the neigh- 
 bourhood of the left nipple. Its tone somewhat resembles that of a 
 bruit de rape ; but, at the same time, it communicates a sense of 
 dryness and crumpling, different from the rigid squeezing or grating 
 observed in the ordinary bruit de rape. It is also more variable, 
 both in its development and its extent. We find it different at 
 different moments, and during the different movements of the chest ; 
 and it may occasionally be made to disappear altogether, by a deep 
 and forcible inspiration, so long as that inspiration is maintained by 
 the individual. On the other hand, its extent or prolongation varies 
 in different cases ; or even at different times in the same case ; 
 apparently according to the extent or size of the portion of lung 
 which happens to be struck by the heart at each systole of the organ. 
 In a few instances I have found the sound, to a certain extent, 
 double; the second, or that attending the diastole of the heart, 
 being in general, perhaps, more limited and indistinct than the first. 
 I believe this sound, which I have long observed, and now attempt 
 to describe, to be that recently pointed out by my colleague, Dr. 
 Barlow. It may possibly be that also noticed also by Dr. Latham as 
 frequently present in phthisis. 
 
 I have met with it occasionally under the clavicles, resulting 
 probably from the impulse of the aorta or large arteries ; although 
 at first, I was led to entertain serious apprehensions of the existence 
 of aneurism.
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 93 
 
 Instances of extrinsic cardiac murmurs are, in truth, exceedingly 
 common, and ought to be carefully borne in mind in exploring the 
 chest. The following case is probably one of this kind. 
 
 "JOSEPH C , aged 24, was admitted into our Clinical "Ward 
 
 on the 8th of July. He complained of dyspnoea, and a painful 
 feeling of weight at the bases of both lungs when a deep inspiration 
 was taken. The history was that of recent supervening upon old 
 pleurisy. The stethoscopic signs indicated phthisical disease at the 
 apex of the right lung, pleuritic adhesions below the left mamma, 
 and consolidated lung with pleurisy and dilated bronchial tubes at 
 the left base posteriorly. The heart's position in the chest, its 
 impulse, and rhythm, were perfectly normal ; no bruit accompanied 
 either sound. 
 
 " But little change, save that of a gradual extension of the pleurisy, 
 took place in the general or physical signs, until the 24th. On this 
 day, the ear being placed over the aortic valves, a rubbing sound 
 was heard accompanying the heart's action. Inasmuch as there was 
 no symptom whatever of any affection of the pericardium, the nature 
 and cause of the bruit underwent a rigorous investigation. It was 
 found not to be persistent, but to vary as the act of respiration 
 varied. The patient was ordered to take a full inspiration and hold 
 his breath. The heart's sounds were then heard, somewhat feeble 
 and distant, but perfectly normal. The lungs were then allowed to 
 collapse partially, and the breath was again held. A distinct double 
 bruit became audible, accompanying the systole and diastole of the 
 heart ; a loud, harsh bruit de rape with the systole ; a soft brushing 
 sound with the diastole. The act of expiration being fully effected 
 and the breath once more held, the heart was heard to beat loudly 
 and distinctly, and nothing abnormal could be detected in its sounds. 
 The patient is still in the hospital, and the phenomenon persists 
 unchanged/' 
 
 "For the particulars of the next case, I am indebted to my friend 
 Dr. Gull. 
 
 " W. H , aged 27, admitted, under Dr. Barlow, April 22, 
 
 1846: engineer by employment; single; very muscular; habits 
 irregular. The first symptoms of his present disorder came on about 
 three days previous to his admission ; his legs at that time beginning
 
 94 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 to swell. For a few days after his admission, he went on as usual 
 with cases of renal anasarca ; the urine being loaded with albumen, 
 but not tinged with blood. From some imprudent exposure he 
 became feverish ; great dyspnoea supervened ; his urine was scanty, 
 and seemed little else than pure blood. 
 
 " There were signs of universal bronchitis, with imperfect respira- 
 tion, and indistinct tubular breathing at the base of the right lung. 
 The next day, his dyspnosa continued very urgent : great pain across 
 the prsecordia, extending into the left side : impulse of heart in- 
 distinct, with excessive dulness ; sounds indistinct. On passing the 
 stethoscope up to the space between the second and third costal 
 cartilages, a well marked to and fro sound was audible, continuing 
 during the suspension of respiration. He was too ill to examine the 
 chest generally. 
 
 " Added to the above stethoscopic indications, regarded as indi- 
 cative of fluid into the pericardium, was his waking from sleep in a 
 sudden fright, his constant erect position in bed, the great feeling of 
 oppression about the heart (to use his own words) ' as if a cupping- 
 glass were pressing over the spot/ 
 
 " The reasoning on the case was something in this manner : He 
 has renal disease, of an acute character ; nearly entire suppression : 
 we have the usual renal catarrh of the bronchial tubes, pleuritic 
 effusion of right side, acute pleurisy of left side, and pericarditis. 
 In these renal cases we have a considerable quantity of fluid with the 
 plastic matter : from his erect position, the more fluid parts would 
 gravitate, leaving the surfaces of the pericardium in apposition above, 
 where there is audible a distinct to and fro sound : now this may be 
 pleuritic, but it continues unaltered when the patient holds his- 
 breath. Thus again the indistinctness of the sounds and imperfect 
 impulse would coincide with fluid in the pericardium. .. There seemed 
 but one sign opposed to such a view, and that was the large volume 
 and firm character of the pulse, -which peculiarity seemed explicable 
 on the well-known concomitance between hypertrophy of the left 
 ventricle and renal disease. 
 
 " Sectio.cadaveris. General oedema of the body; the results of 
 acute inflammation in the left side, the pleura containing a consider- 
 able quantity of serum, turbid from flakes of fibrin. The pleura was 
 covered with a layer of plastic lymph ; and between the second and 
 third ribs the fibrin was so situated on the pleura pulmonalis, as to
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 95 
 
 be influenced by the movements of the heart, and thus produced the 
 to and fro sound, which could be artificially produced at the post- 
 mortem examination by traction of the pericardium. The pulmonary 
 tissue of the left lung was in the first stage of pneumonia (oedema) . 
 On the right side, the upper lobes of the lung were emphysematous ; 
 the lower lobes were devoid of air, from compression of the clear 
 serous fluid in the pleural cavity ; no signs of recent inflammation. 
 The bronchial tubes, on both sides, contained a large quantity of 
 viscid mucus. 
 
 " Heart. Eight side very much distended and pushing the left 
 side backwards : (did not this render the impulse so indistinct, and 
 cause the increased dulness ?) : left side hypertrophic : weight of 
 heart, fourteen ounces and a half. Several ounces of clear serum 
 into pericardium. 
 
 " Liver enlarged and congested ; weight, six pounds one ounce. 
 
 " Spleen. Weight, fifteen ounces ; granules indistinct. 
 
 " Kidneys very large ; weight, twenty-five ounces and a half ; dark 
 chocolate ; tissue soft." 
 
 A very curious modification of extrinsic cardiac murmur occurred 
 in Miriam Ward a few years ago. A young female, with diseased 
 lungs, furnished, on auscultation, a double murmur of the character 
 described. The sound was very strikingly developed, both in the 
 systole and diastole of the heart ; but mixed up with a remarkable 
 moist sucking sound, somewhat resembling what would be produced 
 by the application and up-and-down movement of the leathern play- 
 thing called a " sucker/' The diagnosis formed was vomica, with 
 adhesion to the pericardium ; and this was found to be correct on 
 inspection after death. 
 
 The only doubt remaining in my own mind in this matter is, 
 whether the extrinsic cardiac murmurs, which I have been in the 
 habit of calling pulmonic, may not in every instance be associated 
 with some slight or circumscribed adhesion, or albuminous deposit. 
 
 37. Auscultation fails to distinguish an aortic murmur depending 
 upon organic change from that which results from other causes. 
 
 The murmur from diseased valves cannot always be distinguished 
 from the murmur so often attendant on chlorosis, diseased spleen, or 
 other form of anaemia. The general history, coupled with the character 
 of the murmur, will very commonly decide the question.
 
 96 ON THE DIFFICULTIES AND FALLACIES ATTENDING 
 
 38. Auscultation alone cannot determine whether what has been 
 called a mitral murmur result from organic or functional change. 
 
 Auscultation cannot distinguish the mitral murmur of endo-car- 
 ditic disease from the temporary mitral murmur occasionally met with 
 in chorea. 
 
 39. No physical examination will enable us, in many instances, 
 correctly to analyse the morbid condition of a heart, whilst that organ 
 continues to be greatly overcharged with blood. 
 
 Hence the prudent rule, always to wait a certain time before 
 giving a positive opinion. This precaution applies more especially 
 to cases in which severe bronchitis complicates the cardiac affection. 
 
 40. In certain diseases of the heart, especially when the organ is 
 enlarged, it is difficult, or impossible, accurately to localize the 
 murmurs, however distinct and obvious these murmurs may be. 
 
 The two following cases have recently come under our observa- 
 tion; and although, perhaps, not very strongly marked, are, never- 
 theless, instructive. 
 
 " JAMES T , aged 56, a tanner by trade, residing in Ber- 
 
 mondsey. A year and a half ago, after exposure to bad weather, he 
 became affected with cough, attended with expectoration and hoarse- 
 ness of voice. These symptoms continued, sometimes aggravated 
 and sometimes remitting in severity, till thirteen weeks ago, when he 
 became much worse, suffering from occasional attacks of dyspnoea 
 and oedema of the extremities. 
 
 " On admission, the positive physical signs of thoracic disease 
 were as follows : Dulness, extending from the left nipple to the 
 margin of the ribs ; bounded by the sternum to the right, and pos- 
 terior line of the left lateral region, to the left. Absence of vesi- 
 cular murmur over the same space. Large mucous crepitation 
 heard irregularly over various parts of the lungs. Action of heart 
 very irregular ; frequently intermittent ; contraction feeble. Every 
 now and then a stronger beat is made ; and at such times a loud 
 bruit is heard with the first sound. This bruit, perhaps loudest over 
 the aortic valves, may be traced almost as far down as the margin of
 
 PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. 97 
 
 the ribs, and along the great vessels up to the clavicles. It is diffi- 
 cult to say in which direction it is heard more distinctly. Pulse 100. 
 " The condition of the heart, on post-mortem examination, was the 
 following : Great hypertrophy of both sides ; weight, twenty-four 
 ounces : right and left auriculo-ventricular orifices large : pulmonary 
 artery thickened, having very much the appearance of the aorta ; its 
 valves healthy : mitral cords stretched ; curtain thickened somewhat; 
 aortic valves rigid from a large deposit of bony matter, extended and 
 leaving a mere slit for the passage of the blood. The pulmonic signs 
 discovered by auscultation, which had led to a suspicion of effusion 
 into the left chest, were all due to the great hypertrophy of the 
 heart." 
 
 " JAMES A , aged 24, ill four years : a sailor, unmarried, 
 
 living at Woolwich. He had never had any serious illness until 
 four years before admission, when he fell into the water, and had an 
 attack of rheumatism, which lasted two months. After this, on 
 making any exertion, he felt palpitation, dyspnoea, sensation of 
 weight in the chest, with pain and tenderness at the epigastrium. 
 
 "When admitted under Dr. Addison, February 4, 1846, his 
 aspect was tolerably healthy ; he had a slight cough, with white, 
 scanty sputa. With the exception of an- occasional intermission, the 
 pulse was regular. Impulse of heart and prsecordial dulness in- 
 creased ; mucous rales in various parts of the chest ; bruit on first 
 sound of heart below mamma, second sound scarcely audible : there 
 was severe pain in the loins, and pain and tenderness at the epigas- 
 trium. It was at first supposed that the symptoms were produced 
 by simple hypertrophy and dilatation ; but shortly afterwards it was 
 discovered that the bruit was loudest at the epigastrium, where a 
 tolerably well-defined pulsating tumour was felt. The bruit could 
 not be heard posteriorly, and was constant in all positions of the 
 patient. The case was now supposed, by Dr. Addison, to be either 
 aneurism of the abdominal aorta ; or adhesion between the cardiac and 
 diaphragmatic pericardia. The symptoms which ensued, seemed to 
 confirm the former opinion. The cough became loud, frequent, and 
 violent ; the patient declaring that he was trying to cough up some- 
 thing which he felt in his throat. The food appeared to stop at the 
 epigastrium before it passed into the stomach ; and on two or three 
 occasions it regurgitated soon after it had passed down the gullet. 
 The voice became thicker ; he felt choked when he lay on his back ; 
 
 7
 
 98 ON THE DIFFICULTIES AND FALLACIES, ETC. 
 
 pain and oppression at the epigastrium increased. During this 
 period the bruit and pulsation remained unaltered. On the 4th of 
 July he began to cough up blood, which gradually increased in 
 quantity : and on the i8th of July he died. 
 
 " Sectio-cadaveris. Apoplexy at the base and apex of the right 
 lung posteriorly, and, to a less extent, at the posterior part of the left 
 lung : pericardium connected to the heart by old adhesions ; right 
 auricle dilated ; right ventricle hypertrophied and dilated ; tricuspid 
 valve opaque, thick, pliable, with small granulations in its auricular 
 surface ; pulmonary crescents healthy ; left auricle large ; some small 
 bony projections on auricular surface of mitral ; orifice of mitral 
 greatly contracted; left ventricle dilated, its walls of usual thickness; 
 mitral valve rigid and opaque, its cords contracted, thick, and firm. 
 The thick, hard mitral formed a projection into the ventricle, which 
 pressed against that smooth track of lining membrane which leads 
 up to the aorta, the membrane at the point of contact being 
 thickened and hard. Small granular excrescences on the ventri- 
 cular surface of the aortic valves : slight atheromatous deposit in 
 the descending aorta, and also in the pulmonary arteries, which were 
 thickened and enlarged. The circumference of the aorta, just above 
 the valves, was 2*63 inches. No aneurism, nor any abdominal 
 tumour, pressing on the aorta." 
 
 41. Auscultation cannot distinguish the murmur of an aneurismai 
 or otherwise diseased artery , from, the murmur occasioned by some 
 source of pressure upon the same vessel. 
 
 42. Physical examination does not enable us to distinguish con- 
 genital malformation from disease of the heart or large vessels. 
 
 There are, however, many exceptions to this proposition. 
 
 To have treated fully the many important questions comprised in 
 this communication would have rendered it totally incompatible with 
 the means and object of the Society. This must plead my excuse 
 for having preferred the greatest possible brevity to more elaborate 
 detail. My object has been to acknowledge, and point out, the 
 many difficulties and fallacies which I have myself had to encounter 
 in the practice of physical diagnosis, without presuming, for an 
 instant, to suppose that they would have proved equally embarrassing 
 to other stethoscopists.
 
 OBSERVATIONS 
 
 FATTY DEGENERATION OF THE LIVER. 
 
 THIS morbid condition of the liver has hitherto attracted but 
 little attention in this country ; the extremely imperfect infor- 
 mation which we at present possess concerning it having been ob- 
 tained from the French physicians ; whilst even amongst them, if 
 we accept its imputed connection with phthisical disease, it must be 
 confessed that no advance whatever has been made towards a know- 
 ledge of either its causes or its consequences. This want of infor- 
 mation is probably, in a great measure, attributable to our inability 
 to recognise the disease during the life of the patient ; for as we 
 then entertain no suspicion of its existence, we fail to make the 
 minute and connected observation of facts so necessary to the eluci- 
 dation of every internal affection. 
 
 We find the utter barrenness of diagnosis upon this matter 
 well illustrated in the candid avowal of the accomplished and expe- 
 rienced M. Louis, who, in his admirable work on Phthisis, observes : 
 " Nous manquons de signes capables de la faire reconnaitre & une 
 epoque quelconque de sa duree. En vain nous avons ete au-devant 
 des symptomes qui pourraient lui appartenir, nous n'en avons 
 recueilli aucun/' 
 
 To supply this defect ought, then, to be the endeavour, as it 
 unquestionably is the duty, of every one enjoying the advantages of 
 a large hospital, and it is in this spirit that I submit to the profes- 
 sion the scanty materials of this communication. 
 
 When the liver has undergone the extraordinary change in ques- 
 tion, it exhibits, when the abdomen is laid open, a pretty uniform 
 and highly characteristic appearance. It is observed to be of a 
 cream or pale-yellow colour, figured irregularly with brownish or 
 deep -orange spots. It is usually, though not always, more or less 
 enlarged, and sometimes very considerably so.
 
 100 OBSERVATIONS ON 
 
 When cut into, its interior is found to present an appearance 
 somewhat corresponding to that of the exterior, excepting that the 
 brown and pale-yellow tissues are much more uniformly distributed 
 throughout the organ than they are upon its surface. It is some- 
 times softer, and more readily crushed between the fingers than is 
 the healthy liver ; sometimes, however, it is firmer than natural, and 
 occasionally even a scirrhous or almost horny hardness. It will often 
 very perceptibly grease the scalpel, or impart an unctuous feel to 
 the fingers ; and on being exposed to the flame of a candle, will 
 yield a considerable quantity of fat. Although its absolute weight, 
 when enlarged, may exceed that of the healthy liver, I am disposed 
 to think that its specific gravity will, in perhaps the majority of 
 instances, be found to be less : thus a liver apparently healthy was 
 of the specific gravity ro625; whilst the specific gravity of two 
 fatty livers, examined at the same time, was only 1*0275. I nave > 
 moreover, recently met with a case in which the liver was not only 
 much enlarged, but exceedingly dense and hard, and consequently, 
 as I suppose, of great specific gravity. 
 
 The following analysis of the liver, bile, and urine of a patient 
 whose liver presented, after death, the morbid condition under con- 
 sideration, was furnished me by my friend, Mr. Golding Bird. 
 
 " The bile differed from the healthy form of the secretion in its 
 colour, which was of a dirty brown, scarcely partaking anything of 
 a green tint ; it contained in diffusion, numerous black grains, which 
 were insoluble in water, alcohol, and alkalies ; burnt without flame ; 
 detonated when thrown on fused nitre, causing the formation of car- 
 bonate of potass : hence these granules consisted of carbon nearly pure, 
 which substance has been, I find, detected floating in the bile of a 
 maniacal patient by Prof. Lavini of Turin (' Atti del? Academia de 
 Turino/ 1834). Numerous globules of oil appeared after repose, 
 on the surface of the bile ; but their quantity could not be readily 
 determined : in other respects the secretion presented the same 
 chemical characters as ordinary specimens of bile. Its composition 
 was as follows 
 
 Biliary matter, with an appreciable quantity of very soft fat . 6'o 
 
 Earthy salts (phosphates of lime and magnesia) . . o - 2 
 
 Osmazome, lactate of soda and common salt . . . ro 
 
 Water p 2 . 8 
 
 IOO'
 
 FATTY DEGENERATION OP THE LIVER. 101 
 
 The most remarkable deviation from the healthy state apparent in 
 this specimen of bile was the peculiar odour it evolved after the 
 addition of an acid, even of acetic. This odour was the most dis- 
 gusting and least tolerable I ever met with evolved from any kind 
 of animal product, it was quite sui generis, and very permanent. 
 
 The liver was next examined for the purpose of ascertaining the 
 quantity of fat present. One thousand grains were cut into very 
 small pieces, and boiled in repeated portions of alcohol, the solutions 
 being filtered, whilst nearly boiling hot, through muslin. By this 
 process a solution of fat and osmazome, with saline matter, was 
 obtained : the fluid was evaporated over a vapour bath, to dryness, 
 and the residue digested in boiling water, to remove the salt and 
 osmazome. The insoluble portion consisted of a soft brownish fat, 
 very fusible, and possessing a peculiar and unpleasant odour : the 
 quantity yielded by the one thousand grains was 47^6 grains, equal 
 to 333 '2 grains in each pound of liver. 
 
 The urine of the same patient was examined on June ist : it was 
 remarkable for its extremely low specific gravity, being but 1*007 : 
 it was quite neutral ; contained in suspension dense mucous flocculi, 
 and yielded a precipitate by protracted ebullition, which was insolu- 
 ble in nitric acid ; it however differed from albumen, in not being 
 precipitated by nitric acid. It contained but very minute traces of 
 the earthy phosphates. When evaporated to dryness, it left a resi- 
 due, soluble partly in alcohol, and remarkable for its peculiar bitter 
 taste, which I had never previously met with in any specimen of 
 urine. That this bitterness is not owing to the presence of bile, was 
 evident from its being scarcely coloured, and not yielding any change 
 of colour, on the addition of nitric acid." 
 
 Having, in the course of my experience, been often struck with 
 a remarkable appearance of the face in certain patients an appear- 
 ance dependent not so much on the expression of the countenance as 
 the texture and aspect of the integuments and having observed 
 the exact resemblance of the appearance in each case, I endeavoured 
 to connect it with some corresponding uniformity in the accompany- 
 ing disease ; and at length arrived at the conclusion, that, when 
 strongly marked, it is indicative, if not pathognomonic, of fatty de- 
 generation of the liver. It is purely integumental, as it is not con- 
 fined to the face, but may pervade the whole surface of the body ; 
 although I am not disposed to think that it is earliest observable, as 
 well as most conspicuous, in the integuments of the face and backs
 
 102 OBSERVATIONS ON 
 
 of the hands. To the eye the skin presents a bloodless, almost semi- 
 transparent and waxy appearance ; when this is associated with mere 
 pallor, it is not very unlike fine polished ivory ; but when combined 
 with a more sallow tinge, as is now and then the case, it more re- 
 sembles a common wax model. To the touch, the general inte- 
 guments, for the most part, feel smooth, loose, and often flabby ; 
 whilst in some well-marked cases, all its natural asperities would 
 appear to be obliterated, and it becomes so exquisitely smooth and 
 soft as to convey a sensation resembling that experienced on handling 
 a piece of the softest satin. Whether this condition of the integu- 
 ments precede or follow that of the liver, and whether the two are 
 necessarily associated in every instance, I am by no means prepared 
 to offer a decided opinion, but having on several occasions confidently 
 and correctly predicted finding the fatty liver, from having observed 
 the particular condition of the integuments just described, I have 
 ventured to make the crude fact known to the profession, in the 
 hope, that, attention being once directed to such a starting point, 
 something more interesting, and of greater practical utility, may 
 result from its further investigation. 
 
 M. Louis, in the elaborate work to which I have already alluded, 
 dwells upon the frequent occurrence of this degeneration of the liver, 
 in connection with tubercular disease of the lungs. He even esti- 
 mates that it occurs in one third of the whole number of phthisical 
 patients in France ; as in 1 20 cases, he met with 44 instances of 
 the complication ; and he even goes so far as to regard it as a mere 
 part or consequence of such tubercular disease. He appears to 
 have been led to this conclusion, by observing, that in almost every 
 case of fatty liver there existed more or less indication of tubercular 
 disease in the lungs ; and that in the development of the fatty dege- 
 neration of the liver it is not materially influenced either by the age, 
 sex, or constitution of the patient ; except, inasmuch as these cir- 
 cumstances affect the phthisical disease, upon which he considers it 
 to depend. 
 
 But although this condition of the liver is most frequently found 
 associated wtth tubercles in the lungs, this is far from being uni- 
 formly the case, in this country at least : and it is not a little re- 
 markable, that within the short period of the last two months I have 
 myself met with no less than three instances, in which not the 
 slightest vestige of tubercular disease was discovered, either in the 
 lungs or in any other part of the body : and it is further worthy of
 
 FATTY DEGENERATION OF THE LIVER. 103 
 
 notice that in two of them (Elizabeth Castline, aged 32, and Samuel 
 Minx, aged 57) no suspicion had, to my knowledge, been enter- 
 tained of disease existing, either in the lungs or liver ; both indivi- 
 duals having remained plump and fat up to the period when death 
 took place. Elizabeth Castline died of organic disease of the brain, 
 and the following is the account of the appearances found on dissec- 
 tion, furnished by Mr. King, who examined the body : 
 
 " There was a nsevus in the pia mater, near the vertex ; and the 
 ventricles of the brain were distended, with two ounces of pretty 
 clear fluid. 
 
 " The contents of the chest were tolerably healthy, and the blood 
 in the heart was coagulated and fibrinous. 
 
 " The liver was of a large size, rather pale, coarse, and close, and 
 yielded much oil when baked in paper. Bile pretty copious, and 
 dark yellow, nearly to blackness. The spleen was of good size, 
 and coarsely granular. Uterine system in a healthy condition/' 
 
 S M died of pericarditis, succeeding to an attempt to commit 
 suicide by cutting his throat. 
 
 His body when examined was much distended by the gaseous 
 products of decomposition : the lungs were watery, and the pericar- 
 dium lined with honeycomb fibrin : the spleen unhealthy ; and the 
 liver fatty, and presenting the usual characters of that state. 
 
 AYhether any symptoms or indications attended this condition of 
 the liver in these two individuals, or what they were, I had no 
 opportunity of ascertaining; but what has been stated renders it 
 sufficiently apparent that fatty liver is not necessarily associated 
 with tubercular disease of the lungs ; and that such a state of liver 
 is not, for a time at least, incompatible with a certain degree of 
 bodily vigour. 
 
 The following case, which was furnished me by Mr. Barnes of 
 Chelsea, presents an instance of an asthenic or atrophic state 
 connected with this change of the liver ; which I am inclined to 
 believe is of by no means unfrequent occurrence, and tends to show 
 not only that fatty degeneration of the liver may exist, uncon- 
 nected with the tubercular disease of the lungs, but that its existence 
 may occasionally be pretty confidently diagnosticated during the life 
 of the patient. 
 
 "In January, 1835, I first saw Mrs. T , who was then suffering 
 from a very troublesome cough, which she said was usual at that
 
 104 OBSERVATIONS ON 
 
 period of the year ; her countenance was anxious ; great emaciation, 
 and a total loss of appetite, had taken place ; her pulse was very 
 feeble, and under 70 : tongue clean : bowels generally regular ; and 
 evacuations healthy. There was no expectoration, and no perspira- 
 tion. From her general appearance, I thought she was phthisical 
 auscultation, however, afforded no signs of disorganization ; nor 
 was her pulse such as would lead one to infer that tubercles 
 existed. This cough continued more or less till May, when it left 
 her. During my visits, from January to May, she occasionally suf- 
 fered from sickness, which was always relieved by prussic acid ; she 
 had rarely occasion for purgative medicine. From this period till 
 March, 1 835, I heard nothing of her, and concluded she must have 
 been under the care of some other person. Such was not the fact ; 
 she had occasionally suffered from cough, but not to any extent : 
 her emaciation continued, and her appetite had not increased. To 
 all appearances, no change had taken place, her spirits were greatly 
 depressed, having lost a sister a few weeks before. 
 
 " At this time, auscultation elicited nothing satisfactory. 
 
 " The medicines which afforded relief before were now taken with- 
 out any good results ; and I requested permission to call in Dr. 
 Addison. 
 
 " At that time she was able to move about, complained of great 
 weakness, but no pain; indeed, she said she had never felt pain. 
 Her hands at this time began to swell, towards evening ; and there 
 was also some puffing of the face. Her urine had always been plen- 
 tiful, and did not appear changed : it contained no albumen. 
 
 "Dr. Addison examined the chest with great care, but could not 
 make up his mind if disease existed there ; as the stethoscopic signs 
 led to the belief that there was no change of structure going on, 
 whilst the general symptoms seemed to favour a contrary opinion. 
 
 1 ' Three weeks after this, oedematous swelling of the feet com- 
 menced : and finding that it had disappeared in the morning, she 
 could not be prevailed upon to get up, for fear it should return. It 
 may be observed that she never experienced any difficulty in breath- 
 ing; had no occasion to have the head or chest raised; and could 
 lie on either side. Dr. Addison saw her again in a short time ; he 
 could perceive no change, excepting her increasing debility, which 
 was occasioned by her refusing all food ; her only supporting a 
 little weak wine or brandy and water. She slept tolerably well. 
 The treatment during this consisted of small doses of blue pill", com-
 
 FATTY DEGENERATION OF THE LIVER. 105 
 
 bined with extract of henbane and a grain of quinine night and 
 morning, and a drop or two of prussic acid with a few grains of 
 magnesia in camphor mixture : she went on thus till the end of May, 
 when she died. 
 
 " Having obtained permission to examine the body, I requested 
 the attendance of Dr. Addison, who had always said that this patient 
 liad a fat liver, but had been unwilling to venture a decided opinion 
 respecting disease in the chest, the impression, however, on his mind 
 had been that little, if any, existed. 
 
 " Having opened the chest, we found extensive firm, old adhesions 
 of the pleura, but we could not discover a vestige of tubercular dis- 
 ease in the lungs, even upon the most careful examination ; they 
 were, indeed, to all appearance, quite healthy ; excepting that, like 
 other parts of the body, they were easily broken down. 
 
 " The heart was sound. 
 
 " When the abdomen was laid open, the liver was seen somewhat 
 enlarged, presenting a straw colour in appearance, and rather firm. 
 We cut a thin slice from it ; and having exposed to the flame of a 
 candle, it did not curl as is usual with healthy liver ; but it gave out 
 a considerable quantity of fat, which was allowed to drop on paper ; 
 the stomach was, to ah 1 appearance, healthy, excepting the mucous 
 covering being rather hard in the follicles, and somewhat of a horny 
 aspect. The kidneys, uterus, and bladder were examined and had 
 a healthy appearance." 
 
 In this instance I was led to form the diagnosis regarding the state 
 of the liver entirely from the aspect and feel of the integuments espe- 
 cially on the face and backs of the hands, for during the life of the 
 patient she had exhibited no decided symptoms of disease of that 
 viscus ; and, indeed, the character and situation of the anasarca under 
 which she had laboured led me to suspect some morbid change in the 
 kidneys, but on examining the urine no trace of albumen could be 
 detected. I think it not improbable, therefore, that this degenera- 
 tion of the liver may, like mottled kidney, occasionally prove a cause 
 of anasarca ; a supposition somewhat strengthened by finding, on 
 visiting her shortly before death, a great degree of anasarcous infil- 
 tration of the back, loins, and sides, exactly such as I have often 
 found in renal diseases, although with much less swelling of the legs 
 and thighs than usually accompanies the latter. In one case it 
 scarcely existed at all, or at least in a very slight degree. Could 
 this anasarca be a mere consequence of inanition ; the appetite being
 
 106 OBSERVATIONS ON 
 
 as it were completely obliterated ? Certain it is that there was not 
 only remarkable flabbiness of the soft solids during life, but, as I 
 have observed in more cases than one, an extraordinary lacerability 
 and want of tenacity of the tissues generally, and of the lungs in 
 particular, after death. As bearing upon this question, however, I 
 may add, that I have recently seen a case in which anasarca had 
 occurred, and again disappeared, long prior to the death of the pa- 
 tient. This person was a female of the name of Gowan, aged 30, 
 under the care of Dr. Bright, in Lydia's Ward. On passing through 
 the ward some time before her death, my attention was attracted by 
 the peculiar aspect of the integuments already described ; and on 
 examination of the chest, I found that she was sinking from phthisi- 
 cal disorganization of the lungs. Convinced that she had a fat liver, 
 notwithstanding her stools presented a natural appearance, I inter- 
 rogated her very narrowly, and ascertained that several mouths be- 
 fore, she had had anasarca, which disappeared under medical treat- 
 ment. Upon dissection the lungs were found studded with niiliaiy 
 tubercles, and there was a vomical cavity. The liver was fatty. 
 
 With respect to the causes of this fatty degeneration of the liver, 
 very little, or alsolutely nothing is known. In most of the cases 
 which I have met with, there has been either positive or strong pre- 
 sumptive evidence that the individuals had indulged in spirit- drinking, 
 and indeed the most exquisite case I ever saw in a young subject, 
 occurred in a female who had for some time subsisted almost exclu- 
 sively on ardent spirits. On the other hand the extreme frequency 
 of the degeneration in Trance, where the people are but little given 
 to such indulgences, throws considerable doubt upon such an origin 
 of the complaint, whilst its great frequency there in conjunction with 
 phthisis, would almost lead to a belief that it has some connection 
 with a scrofulous tendency, a belief which, I confess, I am strongly 
 disposed to entertain. 
 
 Connected with scrofula or not, it remains to be ascertained 
 whether it be in reality an original disease of the liver ; or whether 
 it may not, in every instance, be merely secondary to some other or 
 remote disorder, is not yet determined. Future experience, also, 
 must discover what are its immediate, and what are its remote con- 
 sequences, whether feebleness of the powers generally, and of the 
 digestive organs in particular, be sooner or later induced by it, 
 in every instance where the patients escape other mortal diseases ; 
 whether, by impairing the powers of the constitution, it may not,
 
 FATTY DEGENERATION OF THE LIVER. 107 
 
 iu some instances, prove rather a cause than a consequence of 
 phthisis ; whether anasarca or any other form of dropsy be peculiar 
 to certain stages or degrees of it; and, lastly, what influence it 
 exerts upon the brain and nervous system generally, and consequently 
 upon the feelings and disposition of the individual.
 
 ON THE 
 
 DISORDERS OF FEMALES CONNECTED 
 WITH UTERINE IRRITATION. 
 
 PREFACE. 
 
 HAVING been honoured with a share of the Clinical 
 duties in the Medical School of Guy's Hospital, I 
 availed myself of a few Cases admitted into the Female 
 ward, to illustrate, to the best of my ability, a very 
 prevalent and very important class of diseases which 
 had long engaged my attention, a class of diseases most 
 seriously affecting the health and comforts of Female 
 life, and consequently fraught with the deepest interest 
 to the Profession. It was after the delivery of a 
 general Lecture on the subject that I was recommended 
 by a few friends, upon whose candour I thought I 
 could rely, to publish my opinions. To this, I can 
 truly affirm, I felt considerable reluctance. I was too 
 much occupied in the performance of laborious public 
 duties to compose such a work as might be deemed 
 worthy the acceptance of the Profession, whilst I had 
 little inclination to intrude upon their notice so slender 
 a production as a Clinical Lecture. It is of very little 
 consequence how or why I overcame such scruples :
 
 ii PREFACE TO DISORDERS OF FEMALES. 
 
 suffice it to say, that the opinions advanced were 
 adopted with caution, and have stood the test of 
 several years of the veriest professional drudgery. 
 If the merit of these opinions be small, it is the more 
 commensurate with my pretensions ; if I fail to 
 multiply the means of relief, let me at least indulge 
 the hope that I may have diminished the sources of 
 error. To the experienced practitioner the contents 
 of this little pamphlet may appear as trifling as its 
 form and style are unattractive and homely; but, 
 should it contribute in any degree to preserve the 
 Junior Members of the Profession from those errors 
 into which I myself have fallen, I shall not regret 
 having permitted its publication. 
 
 T. A. 
 
 24, NEW STREET, SPRING GARDENS, 
 March 13, 1830.
 
 ON THE 
 
 DISORDERS OF FEMALES CONNECTED 
 WITH UTERINE IRRITATION. 
 
 THE object of this lecture is to make you acquainted with the 
 morbid effects produced upon the general constitution, and upon 
 particular parts of the body, by continued Uterine Irritation. In 
 making the attempt, some apology is probably due to my excellent 
 friend and colleague, Dr. Blundell, for thus encroaching upon his 
 particular province. But, gentlemen, if I am correct in attaching 
 an unusual degree of importance to the subject, and can succeed in 
 imparting any really useful and practical knowledge to you, I am 
 too sensible of the zeal, intelligence, and liberality of my friend, to 
 entertain the least apprehension of giving him offence. 
 
 There are few circumstances more powerfully calculated to excite 
 serious reflection in the breast of one acquainted with the history of 
 our profession, than a knowledge of the various opinions that have 
 at various times prevailed respecting the nature of disease in general ; 
 opinions which, like disease itself, have been observed to have their 
 rise, height, and decline ; opinions which have for the most part 
 held sway, or been revived, rather in deference to the authority of a 
 great name, than to the results of legitimate and dispassionate in- 
 vestigation. When the Egyptians attributed disease to the influence 
 of demons of the air, they, perhaps, did a very foolish thing ; but 
 before we consign them to ridicule and contempt, we ought, in 
 justice, to award to them the merit of having been just as intelligible, 
 and quite as reasonable, as many of the reputed lights of after-ages. 
 Hippocrates had his nature, his humours, and his concoction ; Ascle- 
 piades had his pores and corpuscles ; Themisou, his stricture and 
 relaxation ; the Galenites added their own absurdities to those of 
 Hippocrates, and kept possession of the medical schools for 1500
 
 110 ON THE DISORDERS OF FEMALES 
 
 years, whilst in more modern times, fancy has equally run riot, and 
 furnished ample material for the strife of opinions. 
 
 It may indeed be alleged in reply, that such evils, such imperfec- 
 tions, were not absolutely inseparable from physic, but resulted rather 
 from the deplorable ignorance of those who professed it. Now, 
 gentlemen, this may be true, yet with all the advantages we at 
 present possess, with all the improvements of our own times, we still 
 have to deplore the very imperfect state of medical science. The 
 functions of the human body are so numerous and complicated, they 
 are so intimately connected with, and dependent upon each other, 
 and their derangements are so diversified according to age, constitu- 
 tion, and other circumstances that, amid the obscurity attendant 
 upon all vital phenomena, it would be little short of a miracle were 
 all observers precisely to agree in the various relations of cause and 
 effect. Hence the diversity of opinion prevailing even at the present 
 day, in diseases, too, of repeated and daily occurrence, and amongst 
 men equally meritorious, and equally deserving our respect. 
 
 The distinctions of general and local diseases, at one time undis- 
 puted and apparently well, or at least boldly denned, have in our 
 days, undergone such an ordeal as to leave us in doubt of their very 
 existence; whilst we have seen arising from the ashes of former 
 opinions another " loop to hang a doubt upon ;" we have seen one 
 party contending for the constitutional origin of local diseases, 
 another party, with equal plausibility, contending for the local 
 origin of disorders formerly believed to be general ; whilst a very 
 numerous class of important diseases constitute at the present day a 
 sort of neutral ground, concerning which there appears to exist a 
 truce amongst all parties ; a truce, however, only to be observed 
 until the decision of present contests shall afford time and opportu- 
 nity to break it. Thus, fevers were from time immemorial regarded 
 as general diseases, but are now traced, or are attempted to be 
 traced, to originally local disorder, the champions of the cause being 
 Clu.tterbuck, in this country, and Broussais in France. On the other 
 hand, various diseases, formerly regarded and treated as purely local, 
 have been traced to a constitutional origin ; the great champion of 
 the cause being our distinguished countryman, Mr. Abernethy ; 
 whilst the pUegmasia, as they are called, form the neutral ground 
 of which I have spoken a neutral ground, which, like Poland of 
 old, remains in reserve, as a prize to the victors ; for, although tacit, 
 but reluctant assent refers them to the class of local disorders^ doubts
 
 CONNECTED WITH UTERINE IRRITATION. Ill 
 
 and disputes have ever and anon crept in to disturb the creed. 
 Individuals have observed, or have imagined they have observed, 
 that in many of these phlegmasise, in many of these reputed local 
 inflammations, the general or febrile symptoms often anticipate the 
 local inflammation, and consequently cannot be truly said to be 
 secondary or symptomatic of that local inflammation ; neither are 
 the general symptoms at all times in proportion to the degree of 
 the local inflammation, which ought to be the case, were the general 
 symptoms purely symptomatic, as may be repeatedly witnessed both 
 in catarrh and in rheumatism. 
 
 Now, all this abundantly attests the many difficulties which oppose 
 themselves to the attainment of truth ; it teaches us humility in the 
 pursuit ; it furnishes an apology for the many errors we all of us 
 commit in the exercise of a profession, founded upon general and 
 ever varying principles principles the result rather of multiplied 
 observation and experience, than deducible from any distinct know- 
 ledge of the vital endowments of the human frame. But, gentlemen, 
 this diversity of opinion in regard to the constitutional or local 
 origin of disease, teaches us, at the same time, a most impressive 
 lesson as to the intricate and intimate connexions existing between 
 the different systems and organs of the living body ; it proclaims, 
 in language which cannot be misunderstood, the danger, the folly of 
 reasoning upon the functions of the living body, as if it were a mere 
 piece of mechanism ; and confirms the important truth, that, whether 
 we call a disease general or local in its origin, the sympathetic or 
 secondary effects which arise during its progress, will vary and 
 require correction widely different from what we observe in any 
 derangement, however complicated, of wheels and levers. If a mere 
 piece of mechanism go wrong, from some defect in one of its parts, 
 although it may derange the movements of the whole, so long as the 
 partial defect is allowed to remain, yet it will generally be found, 
 that it is only necessary to correct that original defect to restore the 
 whole to regular order; not so with the living body, for the 
 secondary effects, as well as the primary disorder, must be com- 
 bated, in order to restore the entire machine to a healthy condition : 
 nay, so true is this, especially in what we call idiopat/iic fever, that 
 the secondary or sympathetic affections often demand our special and 
 almost exclusive attention, whilst they constitute the chief sources 
 of danger and alarm. Again, let us reverse the position, and let us 
 suppose a person to receive a severe local injury from external
 
 112 ON THE DISORDERS OF FEMALES 
 
 violence, we shall presently have the whole system participating in 
 the disturbance, and perhaps to such an extent, as to constitute by 
 far the most important and most prominent feature of the case. 
 
 Now, in the instances quoted, the sympathetic or secondary 
 disorders are so manifest, and are so uniformly present, that so far 
 from questioning the connection, we look for them as a matter of 
 course, and, in short, are apt to regard the combination as merely 
 constituting one entire disease. But, suppose the general disorder 
 of the frame to be tardy and insidious in its approach ; suppose it, 
 from the nature of the offending cause, to steal almost insensibly 
 upon the patient, its presence not being indicated by any signs or 
 symptoms, very oppressive to the individual, or very obvious to an 
 ordinary observer, I say, suppose such a case, and then it is, that 
 the connexion between the general disturbance and divers local 
 disorders is liable to be overlooked. It was, in pointing out this 
 almost latent connexion ; it was in demonstrating this important but 
 neglected truth, that raised, and justly raised Mr. Abernethy to the 
 highest eminence in his profession. His acuteness and penetration 
 enabled him to trace the insidious march of diseased action from the 
 imperfect digestion, and assimilation to the general contamination of 
 the constitution, and thence to divers forms of local disorder in the 
 different tissues and structures of the body; a principle of vast 
 application in the practice both of physic and surgery a principle, 
 the elucidation of which will ever rank Mr. Abernethy amongst the 
 most gifted and most successful cultivators of medical science. But, 
 gentlemen, whilst I freely pay the tribute of my respect and admi- 
 ration to this distinguished individual, I fear we must admit that 
 this, like other human benefits, has not been without its alloy. The 
 whole history of physic is a history of extremes, to which, indeed, there 
 appears to be at all times and in all matters, a remarkable proneness 
 in the human mind. Not only are we liable to be captivated by a 
 newly discovered truth, not only are we liable to fall into excess in 
 its application, but we are moreover extremely apt to doubt, neglect, 
 or even reject our previous knowledge, merely because it happens to 
 form a part of the creed of those who lived before us, and whom 
 we are too much given to regard with complacent contempt. Mr. 
 Abernethy's work on the Constitutional Origin of Local Diseases, I 
 need not repeat, sheds a new light upon numerous diseases, previously 
 ill understood ; but, gentlemen, I cannot persuade myself, that it did 
 not at the same time have the effect of diverting attention too much
 
 CONNECTED WITH UTERINE IRRITATION. 113 
 
 from the opposite of his position, from the consequences of insidious 
 local irritation upon the general constitution. Proceeding with 
 something little short of enthusiasm upon the newly established 
 principle, men began to discover a purely constitutional origin for 
 all local disorders ; they forgot, or at least slighted the secondary 
 effects produced upon the general system, by the continuance of 
 local irritation, and regulated their practice accordingly. Of course 
 I now speak of that form or species of local irritation, which proves 
 injurious rather from its continuance than from its immediate severity ; 
 and it is the form of local irritation to which I am anxious in this 
 lecture to solicit your earnest attention an irritation often so slow 
 and gradual in its approach, as to pass unheeded by the sufferer, and 
 overlooked by the practitioner ; an irritation nevertheless, which, 
 whatever may have been its origin, shall by its continuance insi- 
 diously undermine the general constitution, and give rise to remote 
 consequences subversive of almost every personal comfort I mean 
 then, gentlemen, Uterine Irritation. 
 
 I will not occupy your time and attention by any elaborate 
 attempt to define the term irritation, a term in common use, to 
 signify a disturbance in the endowments or functions of a part 
 independent of either actual inflammation or organic lesion. It is 
 not denied that either the one or the other of these states may 
 occasionally attend or result from such irritation ; all that is meant 
 by the term is, as I have said, a disturbance in the endowments or 
 functions of a part without either inflammation or organic lesion 
 being necessarily present. In thus characterising uterine irritation 
 therefore I do not deny that it may be coexistent with, or even give 
 rise to inflammation or organic lesion; but speaking generally, I 
 would say that it is found to exist altogether independently of either 
 of these states. 
 
 The first question then is, how are we to ascertain its presence ? 
 ^ hat are the signs or symptoms by which it is to be recognised ? 
 A person of experience will almost infallibly pronounce it to be 
 present, from a mere glance at the effects which it so commonly 
 produces upon the system at large, and upon particular parts, and 
 which usually prevail to a greater or less extent in every instance 
 before a professional man is consulted : but, in addition to these, 
 which I shall particularly point out by and by, there are certain 
 signs or symptoms emanating more immediately from the uterus 
 itself, some of which will, in a large majority of cases, enable 
 
 8
 
 114 ON THE DISORDERS OF FEMALES 
 
 the practitioner to decide ; that is, supposing him to make the 
 inquiry, for unless he do so, and very keenly too, patients, either 
 from delicacy or from ignorance of its importance, will most assuredly 
 conceal them. 
 
 The most frequent symptoms of uterine irritation are, irregular 
 menstruation, the discharge being preceded or accompanied by pain 
 in the back, loins, or thighs, or in the region of the uterus itself,[and 
 attended with forcing or bearing down ; the discharge being in excess 
 either in point of mere quantity or in continuance, or in recurrence ; 
 tenderness of the womb itself upon pressure made either externally or 
 per vaffinam, a tenderness in some instances so great as to interfere 
 with the privileges of matrimony ; and, lastly, leucorrltcea. The most 
 frequent symptoms, however, are, unquestionably, painful menstru- 
 ation and leucorrhceal discharge, although the former is often the 
 only symptom acknowledged by the patient herself. Such, gentle- 
 men, are the few plain, simple indications of a state of uterus which 
 is repeatedly overlooked, although productive of the most serious 
 disturbance both of the general health and of particular organs; 
 disturbance which, when once produced, stamps a character upon 
 the general and local ailments of the sufferer, strongly indicative, to 
 the experienced man, of uterine irritation ; a character which 
 confirms him in the belief that it is from such irritation that the 
 evil originates, and that it is to correct the condition of the uterine 
 system that his chief attention is to be directed. 
 
 Before proceeding, however, to notice in detail the constitutional 
 and local effects of this continued irritation, it] may not be improper 
 to say a few words respecting the predisposing and exciting causes 
 of the irritation itself. 
 
 The most powerful predisposing cause of uterine irritation is 
 constitutional irritability, especially in persons naturally of a delicate 
 frame of body ; a state rendering its possessor acutely susceptible of 
 impression generally, and which has not unfrequently, and certainly 
 not very inaptly, been distinguished by the term nervous tempera- 
 ment. The rest of the predisposing causes are such as tend either 
 to produce or to increase morbid susceptibility ; suck as sedentary 
 and luxurious habits, late hours and passions of the mind. Natural 
 irritability of the uterus itself may undoubtedly prove a predisposing 
 cause, but of this it is difficult or impossible to speak with certainty, 
 as the refinements and restraints of society will always furnish, at the 
 same time, other co-operating causes.
 
 CONNECTED WITH UTERINE IRRITATION. 115 
 
 The exciting causes again, are active exertion of any kind during 
 the flow of the menses ; frequent clilld-leanng , especially If the 
 patient suckle her children herself ; excessive venery, and, Indeed, 
 venereal excitement of every kind. Married women, I think, perhaps 
 suffer most from child-bearing, and from imprudence during the 
 menstrual period; unmarried women, on the other hand, from 
 similar imprudence, and, peradventure, from causes of excitement of 
 the genital organs, concerning which it is unnecessary to be very 
 explicit. 
 
 I shall now proceed to describe to you, in the most intelligible 
 manner I am able, the morbid conditions of the general system and 
 of particular organs which result from the continuance of that 
 uterine irritation to which I have just drawn your attention, only 
 premising that they of course vary very much both in kind and 
 degree, but chiefly in degree, according to differences in particular 
 constitutions, and according to the susceptibility of individual 
 organs. 
 
 The first complaint usually made by a female suffering from this 
 irritation, is, of feeling nervous, probably with a disposition to be 
 low-spirited ; but if, in a well-marked case of the kind, you proceed 
 to feel the pulse, and especially if it be your first visit, the chance is 
 that you will perceive a distinct tremor of the hand, and a remarkable 
 acceleration and sharpness of the pulse, evidently arising from 
 mental agitation a degree of mental agitation so great, in a naturally 
 susceptible female, that if you attempt to soothe or encourage her, 
 she will begin to sob, her lips quiver, and she bursts into a flood of 
 tears. Even after she has sufficiently recovered her self-command, 
 she experiences considerable difficulty in describing her feelings and 
 sensations, and often appears to despair of satisfactorily communi- 
 cating to you the nature of her ailment. She tells you, that, 
 without any assignable cause, she gradually declined in health and 
 spirits ; that she has lost her wonted alacrity, has become indolent, 
 and is easily fatigued by comparatively slight exertion ; that she is 
 readily flurried ; that her heart often beats, flutters or palpitates ; 
 that the impressions made upon her mind are altogether dispropor- 
 tionate to the causes producing them ; that she is very prone to 
 weep, and occasionally experiences sudden and transitory feelings of 
 alarm and dread, especially during the night, without being able 
 satisfactorily to account for them ; in short, that both body and 
 mind arc in a morbidly sensitive condition, whilst general distress is
 
 116 ON THE DISORDERS OF FEMALES 
 
 strikingly depicted in her pale or dejected countenance. If you 
 proceed in your inquiries to ascertain the state of the uterus, you are 
 perhaps informed that she is regular; but if interrogated more 
 narrowly, it will almost uniformly be found that she suffers pain, 
 either before or during the flow, in the back or loins, and that in 
 the intervals she is troubled with leucorrhoeal discharge. To these 
 inquiries she gives a reluctant reply ; will often, perhaps from 
 delicacy, conceal the truth, or, if she acknowledge it, will probably 
 add, " Oh, that is of no consequence ; that is not my complaint ; I 
 have long been accustomed to that, and it does me no harm;" and 
 then winds up the case with telling" you that she has taken a load of 
 tonic medicines without benefit. If you ask her whether such 
 questions were ever put to her before, you are generally answered in 
 the negative. Such a case as this, with slight modification?, is of 
 common occurrence, yet it most frequently happens, that, with the 
 general disorder, we have decided derangement of some internal 
 organ or organs ; and of these, the organs of digestion appear to be 
 almost uniformly the first to participate ; indeed the derangement of 
 the digestive organs, to a greater or less extent, is so commonly 
 associated with the general affection I have described, that one cannot 
 but conclude that the general affection is most materially influenced, 
 if not in part produced by it. It is sufficient, however, for our 
 purpose to know that the exalted susceptibility of the general system 
 and this deranged condition of the first passages, are very commonly 
 coexistent, however they may stand in the relation of cause and 
 effect. 
 
 The first appreciable disturbance of the stomach is most frequently 
 a tendency to flatulency, which flatulency is productive of different 
 effects in different individuals, although, in all, the stomach itself 
 appears to be in a morbidly irritable condition, so as greatly to 
 modify or aggravate the consequences that would otherwise arise 
 from the presence of such flatulency. The patient experiences un- 
 easiness at the scrobiculus cordis ; she complains of a sense of load 
 or distension after meals, or, if the stomach be uncharged with food, 
 of prickings and anomalous pains in the organ, all of which symp- 
 toms are pretty uniformly relieved for a time by the expulsion of 
 flatus from the stomach. In other cases, the irritation produced by 
 the flatus about the cardiac orifice, excites a sympathetic affection in 
 the throat, a sort of globus hystericus, which is variously described 
 by patients, some calling it spasm, whilst others compare it to a
 
 CONNECTED WITH UTERINE IRRITATION. 117 
 
 mechanical obstruction, and indeed one lady somewhat fancifully 
 compared it to a bullock in her throat. It is a sensation, however, 
 which will often last, in a greater or less degree, for days, or even 
 weeks, with little intermission. 
 
 At other times the patient suffers from repeated vomiting, or is 
 perhaps seized suddenly, but only occasionally, with vomiting, pre- 
 ceded, accompanied, or followed by an irregularly inverted action, 
 chiefly of the cesophagus, and attended with an ascent of flatus, so 
 as, in some instances, to threaten suffocation. 
 
 Such, gentlemen, are the ordinary affections of the stomach met 
 with in the disorder to which I have alluded ; affections, however, 
 varying both in kind and degree in different individuals ; affections, 
 too, in which the whole alimentary canal appears more or less to par- 
 ticipate, the patient being very commonly troubled with rumblings, 
 distension and anomalous transitory twitchings in the bowels, 
 symptoms undoubtedly depending upon the flatus and other contents 
 irritating these already morbidly sensitive organs. In more rare 
 cases there appears to be a sort of inverted action of a greater or less 
 portion of the alimentary canal ; an inverted action commencing in 
 some part of the bowels; an inverted action accompanied by a 
 rumbling noise in these organs ; an inverted action extending to the 
 stomach, passing up the oesophagus to the pharynx, where it produces 
 a most distressing sense of suffocation, and lastly communicating 
 with and involving in one universal disturbance the brain and entire 
 nervous system. This mysterious communication so closely allied to 
 the aura epileptica is in all probability somewhat of the same nature, 
 and may, perhaps, result from the irritation in the alimentary canal 
 being conveyed through the pneumogastric nerve to the brain ; for 
 when this takes place, the breathing is usually affected at the same 
 time in a very remarkable manner; the whole assemblage of 
 symptoms, the aberration of mind and bodily contortions consti- 
 tuting, when taken collectively, what in common language is under- 
 stood by an hysteric paroxysm. There are, however, divers 
 modifications met with the patient being sometimes seized with 
 violent and involuntary fits of laughter or crying during the 
 paroxysm, at other times she will lie in a perfectly motionless and 
 insensible state, but with a natural pulse, for hours together; or 
 she shall suffer from a more or less perfect paroxysm without its 
 being preceded by any globus whatever. 
 
 Hitherto then, we have traced the effects of uterine irritation as
 
 118 ON THE DISORDERS OF FEMALES 
 
 they appear in the form of a general morbid sensibility and irritabi- 
 lity of the stomach and bowels ; which symptoms alone, but in 
 different degrees, may continue to harass such patients for months, 
 or even years, without either a well-developed hysterical paroxysm, 
 or any other inconvenience deserving particular notice. But it 
 remains to be observed, that this exalted state of the nervous 
 system is not, in a considerable proportion of cases, evinced solely 
 by morbid susceptibility and excessive or irregular action, but, 
 moreover, by morbid sensation, affecting different parts or organs of 
 the body, and this too varying from the slightest uneasiness to the 
 most exquisite torture. 
 
 Now, gentlemen, it is to these painful affections that I am anxious 
 to direct your earnest and special attention ; because, in the first 
 place, it is to relieve these that you will most frequently be called 
 upon to render your assistance, and because, in the next place, these 
 painful affections are perpetually misunderstood and mistaken, to the 
 serious detriment of the patient. I repeat then, I am anxious, most 
 anxious, to impress upon your minds the nature of these secondary 
 painful affections, their most frequent seat, and the various sources 
 of fallacy by which you may be betrayed into error. 
 
 Of these painful affections, the most serious, or at least the most 
 prominent, and certainly by far the most interesting, are those which 
 attack the abdominal viscera, as these are repeatedly mistaken for 
 inflammation, and treated accordingly. I shall not stop to inquire 
 why those viscera, supplied by the ganglionic system in general, or 
 why the abdominal viscera in particular, should be more liable to 
 suffer from such painful affections than other parts of the body 
 supplied by the ordinary nerves of sensation and voluntary motion ; 
 suffice it to say that such is the fact. 
 
 Of the painful affections of the abdominal viscera the most 
 frequent are 
 
 1st. A PAIN SEATED UNDER THE LEFT MAMMA, OR UNDER THE 
 MARGIN OP THE RIBS OP THE SAME SIDE. 
 
 2ndly. A PAIN UNDER THE MARGIN OF THE RIBS OF THE RIGHT 
 SIDE. 
 
 3rdly. PAIN IN THE COURSE OP THE DESCENDING COLON. 
 
 4thly. PAIN IN THE COURSE OF THE ASCENDING COLON, ESPE- 
 CIALLY TOWARDS THE RIGHT IIYPOCHONDRIUM. 
 
 5thly. PAIN AFFECTING THE ABDOMEN GENERALLY.
 
 CONNECTED WITH UTERINE IRRITATION. 119 
 
 6thly. PAIN IN THE REGION OP THE STOMACH. 
 
 And lastly, PAIN IN THE EEGION OF THE KIDNEYS, SOMETIMES 
 
 EXTENDING DOWN THE COURSE OF THE URETERS TO THE BLADDER. 
 
 Such are the painful affections usually met with, attacking the 
 abdominal viscera ; affections too, which, in point of frequency of 
 occurrence, observe the order in which I have enumerated them. 
 You will have noticed that I am reserved in referring these pains to 
 any particular organ, contenting myself with the fact that the pain 
 is felt in a particular situation. The truth is, considerable difficulty 
 presents itself in ascertaining positively what particular organ is 
 affected, as the natural functions of the part or organ do not, in such 
 cases, appear to be necessarily disordered, or at least to such an 
 extent as to indicate with certainty that it is the seat of the pain 
 complained of by the patient ; neither can we have the usual aid of 
 post-mortem examinations, as few die of such complaints, whilst, if 
 the patient be cut off by another disease, 110 organic lesion is disco- 
 verable to satisfy our inquiries. Occasionally, however, this question 
 may be decided during life, as we shall see presently. 
 
 With respect to the pain under the mamma, or under the margin 
 of the ribs of tJte left side, this is out of all proportion of most 
 frequent occurrence, and will often last for weeks, or even months 
 together, with but little intermission. This pain is very circum- 
 scribed; it is not necessarily or constantly increased by a deep 
 inspiration or by external pressure, although this is occasionally 
 observed ; it is seldom attended with cough ; it is not materially 
 affected either by a charged or by an empty state of the stomach, but 
 varies in its intensity, and now and then goes off altogether for a few 
 minutes, hours, or even days, or the pain shall subside and be suc- 
 ceeded by a mere uneasiness or sense of fulness in the part. This 
 pain, as I have said, is of extremely frequent occurrence, and is very 
 often associated with palpitation of the heart, or, what is much more 
 usual, with unnatural pulsation of the organ, if I may be allowed 
 the expression ; i. e. the patient is conscious of the heart's action, or 
 she feels as if its impulse were communicated to a part so sensitive 
 as to excite distinct sensation, which, you know, is not the case in 
 a state of health. With respect to the precise source of the pain, I 
 confess myself at a loss to speak with confidence or certainty, but 
 am upon the whole inclined to assign it, when complained of under 
 the left mamma, to the cardiac orifice of the stomach ; at least in 
 one case in which it had prevailed for a considerable period, and in a
 
 120 ON THE DISORDERS OF FEMALES 
 
 very aggravated degree, I was led to this conclusion. The young 
 woman, to whose case I allude, died suddenly in a fit, and I examined 
 the colon, spleen, heart, and stomach, with the minutest attention, 
 when the only indication of irritation I could detect was a ring of 
 very delicate vessels, or rather a blush of redness surrounding the 
 cardiac orifice of the stomach, such as might be supposed to be the 
 result of any continued irritation or spasmodic action. Whatever 
 may be its precise seat, it is repeatedly, but erroneously, supposed to 
 be purely of an inflammatory nature, and consequently is mistaken 
 for and treated as pleuritis or splenitis. 
 
 The second painful affection to be noticed is that seated close to the 
 margin of the ribs on the right side. This pain, gentlemen, although 
 occasionally circumscribed almost to a point, usually extends from 
 the scrobiculus cordis along the margin of the ribs, nearly to the 
 loin of the side affected; it is neither considerably nor uniformly 
 increased by a full inspiration, yet this is occasionally observed. 
 External pressure, however, aggravates the pain, and sometimes in 
 a very remarkable degree, whilst in some instances there is sucli 
 tenderness, that the patient shrinks from the slightest touch. The 
 pain now and then shoots through to the back or between the 
 shoulder-blades, but very rarely to the top of the right shoulder. 
 The pain will occasionally remain, with slight remissions, for weeks 
 or even months ; at other times, it subsides altogether, and is suc- 
 ceeded, like the pain under the left breast, by a sense of fulness or 
 tension of the part. As to the actual seat of this pain, gentlemen, 
 I again confess myself incompetent to decide. I have sometimes 
 supposed it to be in the colon, as it may now and then be traced 
 from the margin of the ribs into the right iliac region ; in other 
 instances I have supposed it to be seated in the duodenum, from its 
 being occasionally attended with sickness, from its being aggravated 
 during the operation of mercurial purgatives, and from its being in 
 some rare cases attended with a remarkable sallowness or icteritious 
 aspect of the countenance, and indeed with almost complete jaundice. 
 
 Here again, then, I must leave you in doubt, merely remarking, 
 that it is not inflammatory, although repeatedly mistaken for hepatitis, 
 and treated as such. 
 
 The next painful affection to be noticed is that seated in the course 
 of the descending colon. This is not unfrequently associated with the 
 pain under the left mamma, but is also observed to exist alone, 
 extending from below the ribs to the sigmoid flexure of the colon,
 
 CONNECTED WITH UTERINE IRRITATION. 121 
 
 This, like the others described, is variable in its degree, and although 
 more or less permanent, sometimes remits for hours, days, or even 
 weeks together, and again returns. It is, however, more decidedly 
 and obviously effected by flatulence, than the pains in the other 
 situations mentioned ; thereby more clearly pointing out the seat of 
 the malady. The movement of the flatus is occasionally attended 
 with a gurgling or rumbling noise, and a simultaneous aggravation 
 of the local pain in the part. This is now and then mistaken for 
 colitis, or for some organic lesion of the organ. 
 
 Fourthly, Pain in the course of the ascending colon. I have had 
 occasion to observe, that the pain already described as situated 
 behind the margin of the ribs on the right side, sometimes extends 
 down the course of the colon as far as the iliac region ; it not un- 
 frequently happens, however, that the pain is felt exclusively in the 
 situation of the ascending colon, and like that on the opposite side, 
 varies in degree at different times, or for a period disappears alto- 
 gether. This pain too, after a time, is attended with considerable 
 tenderness, so that the least pressure creates inconvenience. 
 
 Fifthly, Pain affecting the abdomen generally. This is by no 
 means of rare occurrence, and in some instances so closely resembles 
 general peritonitis, as to be mistaken for, and treated as that 
 complaint. Indeed, I know of no disease more puzzling than this, 
 and it was not, I confess, till I had witnessed several such cases, and 
 attended minutely to the history and progress of the disorder, that 
 I became convinced of its true nature. It may be called a general 
 neuralgia of the abdomen. It is sometimes attended with a tym- 
 panitic, and at other times, with a flaccid state of the bowels, the 
 former being by far the most distressing. The pain is complained 
 of over the whole of the belly, and the slightest touch, in many 
 instances, cannot be borne, such is the extreme sensibility and ten- 
 derness of the parts. 
 
 If you watch the case attentively, you will, in general, soon detect 
 some incongruity in the symptoms, to excite doubt and suspicion ; 
 but yet, so close is the resemblance in some cases, as almost to set 
 positive diagnosis at defiance. A case of this kind lately occurred 
 in Martha's ward, when I was in so much doubt, that, to err on the 
 right side, I treated it as peritonitis, although the history of the 
 patient, and the condition of the uterus, told against it : I soon 
 became convinced that I had been wrong, as I shall presently explain 
 to you. It may be observed too, that this general pain of the belly,
 
 122 ON THE DISORDERS OF FEMALES 
 
 like peritonitis, frequently occasions but little distress, unless pressure 
 be applied, and, like peritonitis also, it suffers an aggravation at 
 intervals, an aggravation apparently in both cases depending upon 
 the spasmodic action or griping in the bowels. 
 
 The sixth painful affection is that attacking the stomach in parti- 
 cular. This pain is for the most part strongly marked, and the more 
 intense the disorder, the more positive is the evidence of its being 
 really seated in the organ mentioned. Thus it will sometimes come 
 on suddenly, occasioning the most excruciating agony ; the patient 
 screams from the violence of her sufferings, her countenance is 
 expressive of the greatest distress, and she leans forward or bends 
 the body, in order to diminish the pressure of the abdominal parietes ; 
 or, she says that the pain is drawing her double. This, in some 
 cases, will last with little mitigation, for several minutes, or even 
 hours, the patient the whole of the time making loud complaints, 
 and declaring that she must die if not speedily relieved. This pain 
 will probably remit, and be succeeded by another much less severe, 
 though more permanent ; both the intense and more moderate pain, 
 being much increased by pressure made upon the epigastrium. 
 
 Lastly. Such patients occasionally experience a sudden and 
 severe attack of pain in the region of the kidneys, to which region it 
 may be exclusively confined, till it disappear altogether, or it shall 
 extend from thence down the course of the ureters to the bladder, or 
 the bladder alone shall be affected with pain ; in either of the latter 
 cases the patient generally experiences more or less dysuria. 
 
 Having pointed out to your notice the ordinary local affections 
 arising from or connected with uterine irritation, I need only add, 
 that you will often in the same individual meet with more than one 
 of them existing at the same time ; or, what is more usual, you will 
 have them alternating with each other ; whilst you will also observe 
 the greatest variety in the relative severity of the general and local 
 disorders mentioned; the general derangement prevailing occa- 
 sionally in a very high degree with but little local pain, and vice 
 versa. 
 
 Another, and most important question is, the Diagnosis, or the 
 means of distinguishing the painful or neuralgic affections I have 
 described from the inflammatory disorders to which they often bear 
 so close a resemblance, and for which they are so repeatedly mistaken. 
 This, it must be confessed, is not only important, but unfortunately 
 sometimes as difficult as important. I flatter myself, however, that
 
 CONNECTED WITH UTERINE IRRITATION. 123 
 
 you will be less likely to be misled now that your attention is alive 
 to the sources of fallacy sources of fallacy, gentlemen, which, in 
 common conversation, all admit and profess to know ; a source of 
 fallacy, nevertheless, which is more freely acknowledged than attended 
 to in practice, otherwise we should have fewer errors committed than, 
 I know too well, are committed even at the present day. Knowing 
 then that such cases are of frequent occurrence, whenever a female 
 complains to you of pain under the left breast, with or without pal- 
 pitation or pulsation of the heart ; of pain in the right hypochon- 
 drium ; in the situation of the left or right colon ; or of acute pain 
 generally over the whole belly, or in the region of the kidneys or 
 bladder always be upon your guard, and if on inquiry you find a 
 few, or many of the constitutional symptoms I have described, 
 together with indications of uterine irritation, as shown by pain in the 
 pelvis, in the loins, or in the thighs, before or during the catamenial 
 flow ; by too frequent or too profuse menstruation ; or by leucor- 
 rhoeal discharge; I say, when you find such an assemblage of 
 symptoms and circumstances, your suspicions will amount to a high 
 degree of probability, that the complaint is not of an inflammatory 
 nature. The comparative absence too of fever, the appearance of 
 the tongue, and the state of the surface, will materially assist you in 
 the diagnosis ; although it must be confessed that peritoneal in- 
 flammation often exists with but little development of the general 
 symptoms regarded as characteristic of the phlegmasiai ; whilst on 
 the other hand, the painful affections I have been describing are not 
 unfrequently attended with an accelerated, and vibrating, or even a 
 hard pulse, a hot skin, and furred and slightly brown tongue. 
 Generally speaking, however, the pulse varies much in the latter, 
 and seldom has much hardness in its beat, although from the irrita- 
 bility of the heart, it is sometimes sharp or jerking, whilst the skin 
 is usually warm, rather than hot, and with a disposition to moisture ; 
 and lastly, the absence of many, or of some of the symptoms of the 
 phlegmasise simulated, will go far to complete the marks of distinc- 
 tion. But more of this anon. 
 
 It must, nevertheless, be carefully remembered that all or most 
 of the symptoms I have enumerated, as emanating more immediately 
 from the uterus itself, may and often do result from organic changes 
 either in the uterus or in the parts adjacent. Whenever therefore 
 we have the least suspicion of the existence of such causes, an exa- 
 mination of the patient ought on no account whatever to be neglected.
 
 124 ON THE DISORDERS OF FEMALES 
 
 The necessity of such precaution may be said to increase with the 
 age of the patient ; but when obstinate or repeated flooding prevails, 
 whether slight or profuse, such an examination becomes quite impe- 
 rative, especially when it occurs in females somewhat advanced in 
 life. 
 
 I shall not occupy your time by entering upon any minute detail 
 of other morbid affections occasionally arising from the same source. 
 Those enumerated are of most common occurrence, and are most 
 frequently mistaken and maltreated. Amongst the more anomalous 
 and more rare disorders of the kind, I may merely mention the 
 irritalle mamma and obstinate pain in the head, both of which I 
 believe, occasionally, at least, to depend upon the state of uterus 
 alluded to ; whilst many local physical disorders are materially in- 
 fluenced by it, a circumstance which has not escaped the observation 
 of my friend Mr. B. Cooper. Neither will time permit me to point 
 out those peculiarities which present themselves in chlorotic girls, 
 and those observed at the advanced period of life, when the functions 
 of the uterus are about to cease. To explain these peculiarities and 
 the differences of treatment founded thereon, would be incompatible 
 with the limits of a clinical lecture ; I shall, therefore, proceed to 
 the treatment and the mention of a few of our cases in illustration. 
 
 The indications are, ist. To correct the morbid condition of the 
 iiterns. sndly. To remove or mitigate the violence of troublesome 
 symptoms in any individual case ; and 3rdly. To restore tone and vigour 
 to the general constitution. 
 
 In thus laying down the indications of cure, you will perceive 
 that I have ventured to reverse, in some measure, the ordinary mode 
 of procedure. I repeat to you, gentlemen, that the condition of the 
 uterus, to the continuance of which, I ascribe the various disorders 
 enumerated in this lecture, has in most instances been altogether 
 overlooked, or at least, if observed, it has only been in those cases 
 which have had some of the characteristic symptoms present, in a 
 strongly marked degree, such as excessive or very painful menstrua- 
 tion, or profuse leucorrhceal discharge ; and even then, the condition 
 of the uterus has been usually looked upon as a mere effect or con- 
 sequence of the nervous or hysterical state of the entire frame, or in 
 other words it has been considered as merely participating in a 
 universally morbid sensibility. Hence the primary indication has 
 commonly been to restore strength to the general system, regardless 
 of the local disorder, although the ill success of the treatment
 
 CONNECTED WITH UTERINE IRRITATION. 125 
 
 founded thereon has at all times been frankly acknowledged ; so 
 much so, indeed, as almost to have placed the disorders in question 
 amongst the opprobria medicines. Having been led however to take 
 a different view of the subject, I am necessarily induced to make the 
 correction of the state of the uterus, the first, or at least, the princi- 
 pal indication, although of course, the second indication, that of 
 allaying troublesome symptoms, must often go hand in hand with, 
 or in aggravated cases even take precedence of it. What then are 
 the means best calculated to remove the morbid condition of the 
 uterus, the irritable state of the organ ? In the cases in which the 
 uterine disorder has attracted attention, it has been recommended to 
 bleed generally, to take blood by cupping from the loins, or by 
 leeches from the region of the pubes, or from the pudendum ; to 
 purge, to give anodynes, to employ the warm bath, and to keep the 
 patient in a recumbent position, even for months at a time. Of this 
 kind are the principal remedies recommended in an excellent work 
 recently published by a distinguished member of our profession I 
 mean Dr. Gooch. That gentleman treats of the complaint as it is 
 attended with actual tenderness of the os uteri to the touch, when 
 an examination is made per vaginam. He enumerates the remedies 
 I have mentioned, but with those expressions of extreme distrust, 
 which mark the man of candour and of truth, and with that modesty 
 which, when united to extensive experience, commands the assent of 
 every reader. Now, gentlemen, that all these remedies may be 
 occasionally serviceable, or even necessary, I am not presumptuous 
 enough or inclined to deny : depletion, general or local, in the 
 plethoric, and anodynes and laxatives in most cases ; yet speaking 
 from experience, this object, this grand object is secured with much 
 greater certainty, and much more speedily, by applications made 
 directly to the uterus itself, and parts adjacent. The applications to 
 which I allude are cold astringent washes, injected per vaginam by 
 means of a proper syringe. The ordinary womb syringe answers 
 the purpose exceedingly well, but one of any convenient shape may 
 be used, provided it be sufficiently large to contain from four to 
 six or eight ounces of fluid. The injection should be introduced 
 with such a degree of force, as shall secure its application to the 
 upper part of the vagina, and to the os uteri; and the operation 
 should be repeated two, three, or four times a day, according to 
 the circumstances of the individual case. 
 
 Either the mineral or vegetable astringents may be used; the
 
 126 ON THE DISORDERS OF FEMALES 
 
 former however I prefer, as they do not stain the patient's linen, 
 and consequently are not so much objected to. With respect 
 to the precautions to be observed in the employment of these injec- 
 tions, very few are required beyond what common-sense would dic- 
 tate. Should the injection occasion smarting, which is by no means 
 unfrequently the case at first, it may be diluted with water, or 
 water alone may be used till the original tenderness subsides, which 
 for the most part it will soon do. It will also be prudent to instruct 
 the patient to relinquish it a little before the expected period of men- 
 struation, and to resume it as soon as that period is over. These 
 are almost the only precautions I have ever deemed it necessary to 
 observe. Although in very irritable habits, and especially when the 
 stomach is liable to be affected with pain and spasm, it may be as 
 well to direct the wash to be used tepid at first, gradually diminish- 
 ing the warmth till it is brought to the ordinary temperature of the 
 patient's apartment, which will pretty uniformly be borne exceedingly 
 well after a time, except perhaps during a few of the coldest months 
 in winter. The wash I most frequently employ is the Liquor 
 Aluminis Compositus, of the London Pharmacopoeia, i. e. two drachms 
 of alum, and two drachms of sulphate of zinc, to a pint of water. 
 This practice must be persevered in for a length of time, proportion- 
 ate to the obstinacy of the case and the effects it produces. Indeed, 
 I myself recommend females never to relinquish it, but to employ it 
 from time to time, as long as they continue to menstruate, to prevent 
 the recurrence of the disorder, and its unhappy consequences. I 
 have said that the patient should desist from the use of the injection 
 a little before and during the menstrual period, but she ought also 
 to be specially cautioned against using any violent exertion, or un- 
 dergoing any unusual fatigue at that time, as nothing so completely 
 thwarts your purpose as imprudence committed whilst the irritable 
 uterus is performing its functions. 
 
 When the uterine irritation is characterised by frequent and ex- 
 cessive flow of the menses, I have directed the patient to remain 
 quiet in or on the bed, and to desist from the washing during each 
 recurrence ; not having ventured to carry the practice to the extent 
 of attempting to restrain even such excessive discharge by local 
 astringents. But when there is decidedly painful menstruation, or 
 pain felt in the womb, loins, or thighs before the appearance, 
 although there be no leucorrhoeal discharge whatever in the interval, 
 I nevertheless apply the cold wash to such subjects, precisely in
 
 CONNECTED WITH UTERINE IRRITATION. 127 
 
 the same manner as if such leucorrhoeal discharge were present, on 
 the principle that this leucorrhoeal discharge is itself a mere symp- 
 tom or effect of the state of the uterus and neighbouring parts, 
 which I am anxious to remove. Such, gentlemen, is the local treat- 
 ment that experience and observation have led me to adopt, and 
 which, after a long trial, I venture, with some confidence, to recom- 
 mend to you. It is just possible that circumstances not noticed by 
 me may occasionally occur to interfere with or forbid the practice ; 
 but, gentlemen, I speak of generalities, and not of universal prin- 
 ciples universal principles are unknown in our profession. 
 
 I would only remark further, that, very recently, Mr. Jewell has 
 recommended the Nitrate of Silver, either in substance or in solu- 
 tion, as an application in leucorrhcea ; and I have no doubt, from 
 what we observe in its general use, that it will have a powerful 
 effect in destroying morbid sensibility ; but I have had no experience 
 with it myself, whereas I have extensively employed the astringent 
 wash before mentioned for the last ten years, and declare to you that 
 I have never known any serious inconvenience to result from it in a 
 single instance; if ever injurious, therefore, it is unknown to 
 me. 
 
 The second indication to allay or remove troublesome symptoms 
 must, of course, be variously fulfilled, according to the circum- 
 stances of the particular case, but the remedies employed for the 
 purpose will necessarily co-operate with the local treatment to afford 
 relief to the patient ; unless, indeed, the severity and character of the 
 troublesome symptoms be such as to render the immediate applica- 
 tion of the wash either doubtful or hazardous as e.g. when the 
 stomach is the seat of severe spasm, or the bladder or abdomen 
 generally acutely painful, in which cases the second indication must 
 take precedence of the first. Should the symptoms merely consist 
 of the susceptible state of body and mind before described, or should 
 this be accompanied by that modification of derangement of the 
 digestive organs characterised by flatulency and irritability of the 
 stomach and bowels, the general treatment need be very simple. I 
 say nothing of bloodletting, as the propriety or impropriety of this 
 must be apparent from the state of the circulation, always keeping 
 in mind that such subjects bear bleeding badly, especially in large 
 quantity, and that mere frequency even with sharpness of the pulse, 
 is, in the highest degree, fallacious : a full, hard pulse, with consi- 
 derable heat of skin, and more or less throbbing or pain in the head,
 
 128 ON THE DISORDERS OF FEMALES 
 
 will point out the expediency of a moderate bleeding. Purgatives 
 or rather Laxatives, ought never to be neglected/ but much caution 
 and judgment are required in their proper selection and application. 
 The bowels, it is true, are generally costive, but it must be remem- 
 bered that they are as uniformly in a weak and irritable state ; hence 
 those purgatives should be selected which give the least pain, and 
 have the least tendency still further to weaken their tone. Watery 
 saline purgatives are ill-suited to the majority of such cases ; they 
 often perform their office imperfectly, and although they may not 
 produce much pain, which they often do in such subjects, they, 
 nevertheless, tend, by frequent use, further to impair the tone of 
 the bowels, and to increase the disposition to flatulency. Except, 
 therefore, at the commencement, in plethoric subjects, or where the 
 disorder exists in connection with menorrhagia, the saline purgatives 
 are not commendable. Castor oil, when it agrees with the patient's 
 stomach, will be found more generally serviceable, perhaps, than any 
 other. In many cases, the warm and resinous purgatives, though 
 at all times more irritating, answer exceedingly well, emptying the 
 bowels of their feculent contents, and expelling flatus without leav- 
 ing any increased tendency to flatulency afterwards, as is the case 
 with the watery saline purges. A little Compound Extract of 
 Colocynth, or equal parts of this and Extract of Rhubarb with a 
 little Extract of Hyoscyamus to obviate griping ; or the above ex- 
 tracts may be given with a little Slue Pill, should a mercurial 
 laxative be indicated by the appearance of the secretions. Calomel 
 very often gripes severely, whether alone or combined ; yet such is 
 the variety of constitutions met with, that the Compound Extract of 
 Colocynth with Calomel often proves the most effectual, and not the 
 most painful purge. One or other, then, of these laxatives may 
 be necessary once or twice a week. 
 
 Iii the case I am now treating of, that is, where there is no 
 abdominal pain, the medicine that I have found to afford the greatest 
 relief is unquestionably the Ammonia, given either in common mint 
 or camphor julep, alone or with a few grains of Magnesia ; about 
 ten or fifteen minims of the Liquor Ammonia Subcarbonalis, with 
 from eight to ten or fifteen grains of Subcarbonate of Magnesia two 
 or three times a day. If it create any approach to pain in the 
 stomach, or a disagreeable sense of heat there, these effects may 
 sometimes be obviated by adding about half a drachm of Tincture 
 of Hyoscyamus, or a drachm or so of the Tincture of Hops, to each
 
 CONNECTED WITH UTERINE IRRITATION. 129 
 
 dose. This ammoniacal mixture seems, by its stimulus, to expel 
 flatus, and thereby to afford relief to many of the uneasy and un- 
 happy sensations, and to raise the spirits of the patient. I have often 
 given the Ammonia along with the Mistura Myrrhse of Guy's Hos- 
 pital, an ounce or a dose of which contains, I believe, about twenty 
 grains of Myrrh, and is made with the Decoction of Liquorice root. 
 
 But suppose that, with more or less of the general symptoms, we 
 have pain under the left mamma, or in any of the other situations 
 pointed out, what modification of treatment ought we then to 
 adopt ? 
 
 The pain under the left mamma is of such frequent occurrence, 
 that it becomes a matter of the very first practical importance to bear 
 it carefully in mind when called upon to treat the disorders of young 
 females. There is no local pain more frequently mistaken, and there 
 is, perhaps, no local disorder so maltreated as this. Over and over 
 again have I known patients blooded, cupped, blistered, and 
 anointed with acrid ointments, for months in succession, not only 
 without relief, but with the most serious injury to their general 
 health, whilst the uterine irritation has been altogether overlooked. 
 Indeed, gentlemen, in thus declaring and denouncing such a mis- 
 take and such bad practice, I candidly confess that I am only de- 
 claring and denouncing " qufgque ipse miserrima vidi, et quorum pars 
 magnafui" In truth, it was the frequent occurrence of this obsti- 
 nate and intractable pain that first led me to a close and minute 
 investigation of the subject of uterine irritation, having, like others, 
 repeatedly blooded, cupped, and blistered in vain in such cases. 
 Since, however, I have been guided in the treatment by the principles 
 I have ventured to lay before you, my success has been much more 
 certain and decided, and when the treatment founded thereon has not 
 fully answered my expectation, it has at least been attended with the 
 negative advantage of inflicting no unnecessary injury on the patient's 
 general health. 
 
 In pointing out its non-inflammatory nature, gentlemen, do not 
 imagine that I contend for the impropriety of bleeding or cupping, 
 or blistering in every instance. On the contrary, in plethoric sub- 
 jects, one or two general or local bleedings may occasionally prove 
 of service, but merely, I believe, as such practice might be expected 
 to afford relief in an ordinary colic, or any other similar painful affec- 
 tion. Depletion, however, is very far from being in general neces- 
 sary, and probably will, in a majority of cases, be positively hurtful, 
 
 9
 
 130 ON THE DISORDERS OF FEMALES 
 
 teasing and exhausting the patient, without any adequate or permanent 
 benefit. I have known Cupping, Leeches, a Blister, or an Opiate or 
 Belladonna plaister afford relief, but they all often fail, and will gene- 
 rally do so, or at least be merely followed by a temporary respite, 
 unless the condition of the uterus, and other circumstances I have 
 pointed out, be attended to. Hot fomentations to the part will 
 sometimes afford relief, but are attended with the same uncertainty 
 as the other local remedies mentioned. Under the use of the injec- 
 tion, however, and the ammoniacal mixture, with Tincture of 
 Hyoscyamus, or with three, four, or five grains of the Extract 
 of Coniuni, in the form of pill, alone or with a grain or so 
 of blue pill, according to the state of the secretions, the pain 
 will generally yield, although the patient, as might be expected, will 
 for a longer or shorter period be liable to a recurrence, until the 
 original irritation, and its effects upon the abdominal viscera, shall 
 have been overcome by a steady perseverance in the use of appro- 
 priate remedies. In some instances the ammonia cannot be borne, 
 when the plain Camphor, or Mint julep, may be substituted, with 
 half a drachm or so of the Tincture of Hyoscyamus, for four or five 
 grains of the Extract of Conium may be given in the form of a pill 
 twice or thrice a day. In other cases again, you may try six or eight 
 drops of Batley's Liquor Opii Sedativus at bed-time, unless it offend 
 the stomach or the head. Should it constipate the bowels, proper 
 laxatives must be had recourse to, in order to obviate such an effect ; I 
 prefer, myself, the Conium, or Hyoscyamus. Unless, however, it 
 happen thus to disagree with the patient, the ammonia will answer 
 best, guarded, of course, by the anodynes. 
 
 In those cases, in which the pain shifts its seat from time to time, 
 I limit my external remedies generally, to hot anodyne fomenta- 
 tions ; such as the Decoction of Poppy-heads, or what often answers 
 very well, the hot Infusion of Chamomile Flowers, the flowers them- 
 selves being inclosed in folds of flannel, the more effectually to re- 
 tain the warmth. I may also here observe again, that this tendency 
 to shift its seat, together with the unsteadiness in the degree of the 
 pain, form the most important diagnostic indications ; whilst in most 
 instances, we shall find, on inquiry, that the patient had suffered 
 more or less from the complaint for some time before she applied for 
 advice. Attention to these circumstances, will materially assist us in 
 our diagnosis, not only in these, but in the other painful or neural- 
 gic affections attacking the abdominal viscera,
 
 CONNECTED WITH UTERINE IRRITATION. 131 
 
 A\ lieu the pain is situated in the right Jiypochondrium, or under 
 the margin of the ribs of the right side, it is, as I have before said, 
 repeatedly mistaken for, and treated as, hepatitis, and many are the 
 times that I have known poor delicate women blooded, cupped, 
 blistered, and salivated on this supposition, till they have been 
 brought almost to the very brink of the grave. It is to be distin- 
 guished by the symptoms and circumstances already pointed out, and 
 when ascertained, is to be treated upon precisely similar principles 
 to those so minutely detailed. In these cases, patients sometimes 
 tell us that our medicines, especially mercurial and resinous purga- 
 tives, greatly aggravate the pain of the part during their operation. 
 Cupping, Leeching, and Blistering, will each occasionally, but only 
 occasionally, afford relief : whilst, generally speaking, I would say, 
 that in this form of the complaint, hot anodyne fomentations, assi- 
 duously applied, are more decidedly beneficial than in the former 
 case, but in other respects the same means may be pursued. In some 
 cases, four or five grains of Dover's powder, twice a day, will afford 
 relief ; in other instances, the more powerful combination of calomel 
 and opium has been tried with effect. The calomel, however, ought 
 to be given with great reserve, and never, if possible, to such an 
 extent as to affect the system ; in short, in all cases, the less violent 
 measures we employ the better. 
 
 When the pain seizes the track of the colon on either side, the 
 same treatment will apply, as it will also when the stomach becomes 
 the seat of the pain, unless indeed severe spasm accompany it, when 
 more active measures must be had recourse to ; as, a full dose of 
 Liquor Opii Sedativus, or even a full dose of Laudanum and Sul- 
 phuric jfflther, as I shall presently show. 
 
 I have said that the pain occasionally attacks the whole of the 
 belly, exactly simulating acute peritonitis. This may be attended 
 either with a flaccid or a tympanitic state of the intestines, the 
 latter proving by far the most painful of the two, the slightest touch 
 causing the patient to cry out. 
 
 This generally diffused pain is not unfrequently associated with 
 that modification of uterine irritation marked by excessive menstrua- 
 tion, both in point of quantity and frequency. But in such cases, 
 whether with or without menorrhagia, it will require all your tact 
 and discernment, and, what is more, it will require all your philoso- 
 phy and forbearance, to abstain from copious depletion under an 
 apprehension that it may be peritonitis* This history of the case
 
 132 ON THE DISORDERS OF FEMALES 
 
 will generally raise a doubt, and will often bring conviction ; but 
 if a doubt do really exist, it will always be prudent to err on the 
 right side, and treat it as inflammation. I shall mention a case or 
 two of this kind presently. 
 
 When unaccompanied by excessive menstruation, the same general 
 rules of treatment are to be observed as have already been detailed ; 
 moderate bleeding if much plethora and headache, with a full pulse, 
 prevail ; and the free use of laxatives and fomentations. In both 
 forms of the complaint to relieve the pain in this situation, I hold 
 the Liquor Opii Sedativus to be by far the most efficient remedy, as 
 well as attended with the least inconvenience to the patient. With 
 due attention to the bowels, therefore, six, eight, or ten drops may 
 be given every night, or every night and morning, according to the 
 urgency of the pain. 
 
 When attended with excessive menstruation, there very usually 
 prevails a plethoric condition of such irritable subjects, so that a 
 moderate bleeding will commonly form a very good mode of com- 
 mencing our practice : or if there be much forcing, or bearing 
 down, the patient may be cupped from the loins. In all cases of 
 this kind too, the patient during the flow, and for a short time 
 before the expected recurrence, should be strictly enjoined to remain 
 in the horizontal posture, to be kept cool, and to live upon low and 
 bland diet. Nothing so certainly, or so greatly aggravates cases of 
 rnenorrhagia, even when without abdominal neuralgia, as the ill- 
 founded, and ill-judged practice of giving tonics and stimulants, on 
 the erroneous supposition that such excessive discharges are the 
 result of weakness. Repeatedly have I known the most serious 
 mischief result from the practice here pointed out ; patients having 
 been given Bark, Port wine, and cold Porter, merely because they 
 complained of great debility, and because such complaints of debility 
 have tallied with the preconceived notion of the practitioner, that 
 the disease had its origin in weakness. You must be careful, gen- 
 tlemen, to distinguish a weak and relaxed, from a merely Irritable, 
 or a delicate and Irritable habit : it is the latter in which you most 
 frequently meet with the meuorrhagia, of which I now speak. The 
 excessive discharge is intimately connected with such irritability of 
 the system at large, and of the uterus in particular; tonics and 
 stimulants only tend, therefore, to produce excitement ; to augment 
 the action going on in the irritable uterus, and thereby to increase 
 the sufferings, and exhaust the strength of the patient. As far as
 
 CONNECTED WITH UTERINE IRRITATION. 133 
 
 the discharge is concerned, therefore, your object is to allay the vas- 
 cular excitement by moderate depletion and purging, and to allay 
 irritation by anodynes and rest. A free action on the bowels exerts 
 so powerful an influence over excessive uterine discharge, that I am 
 often induced to administer divided doses, either of the Magnesia 
 and Salts mixture, or of the Salts dissolved in the Compound In- 
 fusion of Roses ; endeavouring to obviate the increase of the neural- 
 gic pain of the belly, which is liable, when it prevails, to be 
 aggravated by the Salts, by giving at the same time about five 
 grains of Extract of Conium, or Extract of Hyoscyamus, three 
 times a day instead of the Liquor Opii Sedativus. In general, how- 
 ever, other laxatives may be given occasionally, to maintain a free 
 discharge from the bowels, and to counteract the effect of opiates, 
 should we determine upon a trial of them ; for this purpose Castor- 
 oil, or Calomel and Rhubarb may be given : or the object may be, to 
 a certain extent, accomplished by the use of glysters. If in spite of 
 our depletion, laxatives, and rest, the flooding still continues to 
 prevail, without neuralgia of the abdomen, I generally direct the 
 patient to apply cold vinegar and water, by means of a sponge, to 
 the lower belly, two or three times a day ; employing at the same 
 time anodynes, or anodyne glysters, in order to allay the irritability 
 of the womb itself. 
 
 If you have flooding alone then, without neuralgia of the belly, 
 you will bleed generally or locally, according to the state of the 
 patient's system at the time ; keep up a free action on the bowels ; 
 keep your patient cool, and on low diet, and administer anodynes, 
 either by the mouth or by glyster, with or without cold sponging 
 according to the severity of the case. Should flooding prevail along 
 with the neuralgia of the belly, precisely the same remedies, with the 
 exception perhaps of the cold sponging, will be required ; whilst, if 
 the neuralgia exist alone, the case becomes much more simple, must 
 be treated on common principles ; i. e. general bleeding, according 
 to the degree of excitement of the heart and arteries : perhaps 
 leeches to the belly, hot fomentations, laxatives, and anodynes, either 
 given by the mouth, such as Liquor Opii Sedativus, Conium, or 
 Hyoscyamus ; or in the form of glyster, as thirty or forty minims 
 of Laudanum, with a little thin starch. Even in flooding cases I 
 never give the lead, as I never fail by more gentle means to subdue 
 the disorder, and I have known the lead induce severe colic. 
 
 I need only observe further, that, if you should feel disposed to
 
 134 ON THE DISORDERS OF FEMALES 
 
 try the Oleum Terebmthinje, I should consider it best suited to the 
 general neuralgic state of the belly, without flooding or excessive 
 menstruation in any form. From two drams to half an ounce may 
 be given with three or four drams of castor oil. I am, however, 
 averse to it myself from its liability to offend the stomach, and be 
 rejected, but more especially from its tendency to act with violence 
 on the kidneys. You had a good illustration of this in a female 
 patient, No. 10, in the clinical ward; obstinate and dangerous 
 Hfematuria having been produced by Turpentine taken with a 
 wicked intent. 
 
 Such, gentlemen, are the means which I have found most fre- 
 quently of service in alleviating the more prominent and distressing 
 symptoms attendant upon uterine irritation ; means, I confess, often 
 insufficient for the purpose, unless long persevered in, and this too 
 in conjunction with the local treatment already mentioned. Many 
 other medicines and expedients will undoubtedly suggest them- 
 selves in particular cases, as Camphor, Musk, the Warm-bath, and 
 such like ; or should the secondary local pains described, not be con- 
 siderable, the fetid gums, especially Assafcetida, will often afford 
 some, though tardy relief. Indeed these fetid gums have attained 
 a high character as antiJiysterics, but appear to me, chiefly, if not 
 exclusively adapted to relieve some of the symptoms more particu- 
 larly connected with the condition of the bowels; they expel flatus, 
 raise the spirits, and moreover appear to restore tone to the alimen- 
 tary canal, provided the original source of the evil be attended to at 
 the same time. In the less painful forms therefore of the disorder, 
 these fetid gums are worth a trial, and will often afford considerable 
 relief to the feelings of the patient. 
 
 Much of what has been said, gentlemen, merges in the Html 
 indication ; viz. to restore strength and vigour to the general habit. 
 Of the best means of accomplishing this I need say very little, 
 beyond remarking that the early use of tonics has been extensively 
 adopted, and has consequently been given a fair trial, whilst almost 
 all are agreed as to the very unsatisfactory results, in a large ma- 
 jority of cases ; the cause of which you will now be able, in some 
 degree, to appreciate ; I mean, of course, inattention to the local 
 irritation, from which I suppose the whole mischief to proceed. In 
 the highly irritable and susceptible state of the body at large, and of 
 the alimentary canal in particular, the more stimulating or irritating 
 tonics cannot be borne, creating sickness, pain or uneasiness at
 
 CONNECTED WITH UTERINE IRRITATION. 135 
 
 stomach, loss of appetite, headache, and divers unhappy sensations 
 not easily denned by the patient. Chalybeates not only offend in 
 this way, but are extremely apt to excite the uterus, so as to produce 
 excessive menstruation, if it did not previously exist, or to aggravate 
 it, if it have already prevailed. Exceptions do undoubtedly occur, 
 but the objections to them stated are founded on personal expe- 
 rience. The Sulphate of Zinc, however, may sometimes be given 
 early, with advantage, provided it do not offend the stomach. A grain 
 to begin with may be given night and morning, alone, or with a few 
 grains of the Extract of Conium, or of Hyoscyamus, or with a little 
 of the Pil. Galban. Comp. ; or it may be given along with two or 
 three grains of fas Extract of Gentian, or Extract of Bark; or these 
 latter may be given without the Zinc. Any of these may be tried, 
 and persevered in, till the local disorder and the most prominent of 
 the general symptoms shall have been subdued to a certain extent, 
 when less reserve may be observed as to the nature of the tonics we 
 employ ; the chief of them are Baric, Bitters, Chalybeates, the Cold 
 Bath, and Country air. 
 
 The prophylactic measures have already been alluded to, and need 
 not be repeated, further than to impress upon you the necessity of 
 the patients avoiding all irritation or excitement during the menstrual 
 periods. 
 
 A most important matter to be attended to in every case, is the 
 proper regulation of the diet of our patient. Bearing in mind that 
 the stomach is almost uniformly in a weak and irritable condition, 
 all those articles which are of difficult digestion, and all such as are 
 calculated to produce excitement, ought to be most carefully 
 avoided. Hence the patient should abstain from salted meats, made 
 dishes, pickles, and high-seasoned food, whilst almost all vegetables, 
 especially in a raw state, such as salad and celery, prove extremely 
 inconvenient to the subjects whose case we are now considering. Of 
 course, the quantity of nutriment necessary in any individual case, 
 will be sufficiently indicated by the state of the patient's constitution ; 
 but, generally speaking, animal is better suited than vegetable food, 
 to such irritable habits, whilst all warm and watery slops prove per- 
 nicious, by increasing the susceptibility of the system at large, and 
 by impairing still further the tone of the stomach in particular. Of 
 course, every variety of idiosyncracy will be met with in practice, 
 but, as I have said, generally speaking, such patients rather require 
 a generous diet than otherwise, whilst vegetables, especially of the
 
 136 ON THE DISORDERS OF FEMALES 
 
 raw and more flatulent sorts for the most part prove highly objec- 
 tionable. I usually recommend patients to take chocolate or cocoa, 
 or tea, with a large proportion of milk, for breakfast ; and if the 
 appetite and digestion will admit of it, a bit of plain cold meat. I 
 prefer plain roast or boiled meat, with a good potato or mashed 
 turnips, for dinner. As to drink, much must depend upon the rank 
 and habits of the individual. Spirits are uniformly objectionable as 
 a habitual indulgence, but a little wine, or wine and water, or a 
 little porter, or ale, may often be allowed with advantage. To con- 
 clude, as the stomach is weak, do not load, or oppress it, either by 
 the quantity or quality of the food ; as the stomach is irritable, do 
 not excite it by articles that are hot and stimulating ; as there is a 
 tendency to flatulency, abstain from vegetables that are wont to pro- 
 duce it ; but as there is a general want of tone, and a correspond- 
 ing morbid susceptibility, let the diet be at once bland and 
 nourishing. 
 
 Before I proceed to illustrate our subject by a reference to the 
 patients admitted into the clinical ward, it is right to observe that 
 you are not to expect what can with any propriety be regarded as a 
 complete and permanent CURE of the patients in question. All I 
 pretend, all I profess to do, is to place before you a few examples of 
 which the short duration of my attendance has enabled me to avail 
 myself, and to point out the peculiarities observed in the general 
 character or modification of each, with the variety of treatment 
 founded thereon. 
 
 It would indeed be not less unreasonable than vain to expect that 
 the irritable condition of the uterus, and the consequences imparted 
 by its continuance to the general system and to particular parts, 
 should be completely and permanently removed during a short stay 
 in the wards of an hospital. All we can hope to effect in the wav 
 of cure, whilst such patients remain with us, is to relieve the more 
 urgent symptoms, and to contribute more or less towards a result 
 which is only to be accomplished by the patients themselves. 
 Accordingly it becomes necessary on discharging them, strongly to 
 impress upon their minds the fact, that their relief is but partial and 
 temporary, and that unless they strictly obey your injunctions, and 
 pay unremitting attention to the precautions you point out, all their 
 ailments and discomforts will certainly return. You ought, there- 
 fore, on taking leave, to insist upon the necessity of their using 
 regularly, during the intervals of menstruation, the cold astringent
 
 CONNECTED WITH UTERINE IRRITATION. 137 
 
 washes already noticed ; you ought to urge in strong terms the pro- 
 priety of their avoiding all violent exertion, and all sources of bodily 
 or mental excitement, whilst the uterus is performing its functions ; 
 they should be directed to remain as quiet as possible, and to take 
 some gentle aperient a short time before the expected period ; and 
 lastly, they are to be told what sort of diet is most likely to benefit 
 their disorder, and improve their general health. 
 
 Such, gentlemen, is the advice you will do well to inculcate in 
 every instance ; for, unless you do so, and your advice be attended 
 to, depend upon it any relief you may afford during a professional 
 attendance will be but temporary, whilst each accession of trouble- 
 some or painful symptoms will call for medical interference, and tend 
 still further to increase morbid susceptibility, and thereby to aggra- 
 vate the disorder in the end. 
 
 I have said that the complaint assumes different forms in different 
 persons, or even in the same person at different times ; that it some- 
 times presents a general morbid susceptibility both of body and 
 mind such as I have already described, together with more or less 
 disorder of the digestive organs, but without either hysterical parox- 
 ysms or local pain, whilst in other instances together with a greater 
 or less degree of the general disorder, we have either a hysterical 
 paroxysm or pain situated in one or more of the parts before speci- 
 fied, or both. Cases of the former description are not often to be 
 found in hospitals ; because, in the first place, such patients rarely 
 apply for admission, from a persuasion that their disorder is purely 
 constitutional, and consequently not to be relieved by medicine; 
 and, in the next place, such patients are seldom selected by the 
 attending physician, partly, I fear, from a similar feeling, but chiefly 
 perhaps from a well-founded apprehension, an apprehension founded 
 on past experience, that the remedies usually employed will, in all 
 probability, disappoint both him and his patient. 
 
 This general disorder, however, constitutes what may be called the 
 simplest, and in one degree or other by far the most frequent form of 
 the complaint. The extent, too, to which it proceeds, in some in- 
 stances, without local pain or an actual hysterical paroxysm, is not 
 less surprising to the observer than it is distressing to the patient. 
 I remember a young woman being brought to me by her mother as 
 an out-patient, the state of whose body and mind presented one of 
 the most melancholy pictures of human infirmity I ever beheld. 
 Her mind was so extremely susceptible that she wept from the
 
 138 ON THE DISORDERS OF FEMALES. 
 
 slightest emotion; in aspect, expression and manner she literally 
 approached to a state of fatuity, whilst her entire frame was so in- 
 volved in weakness and tremor as almost to resemble an aggravated 
 form of chorea. I was told that her ailments had been coming on 
 and gradually increasing for some years in spite of the various reme- 
 dies, chiefly of the tonic class, that had been recommended by 
 several practitioners whom she had consulted. I ascertained from 
 her mother that she had all along suffered from profuse leucorrhcea, 
 which, as usual, had never been inquired into, or even hinted at. 
 This young woman made comparatively rapid amendment under the 
 use of the means I have ventured to recommend to your notice. 
 
 This is perhaps the extreme of those cases of general disorder 
 unattended by secondary local pain ; in practice you will meet with 
 every variety, from the slightest dyspeptic and hypochondriacal 
 tendency to the exquisite form just mentioned. 
 
 As presenting a sort of transition from a state of merely general 
 disorder to one in which we have such general disorder associated 
 with an imperfectly developed hysterical paroxysm and local pain, 
 I may direct your attention to our patient, No. i, in the clinical 
 ward. Her case, as drawn up by our clinical clerk, Mr. Borrett, is 
 as follows : 
 
 " Elizabeth Smith, setat. 26, has been subject to hysteria, accord- 
 ing to her own account, from the age of twenty, when she first 
 became regular, and the affection has gained so great an ascendancy 
 of late as to indispose her completely from her ordinary occupations. 
 She is of a highly nervous and excitable temperament, is flurried and 
 agitated, and goes off into a fit without any obvious cause, which 
 has of late become a very common occurrence. The heart begins to 
 flutter and throb on the slightest emotion of mind, or any bodily 
 effort, or the fit is ushered in by a sudden burst of tears, or by an 
 involuntary fit of laughter, a sense of tightness and oppression is felt 
 at the epigastrium, but there is no ascent of flatus. The fingers of 
 both hands are firmly closed, with numbness of the left side, cramps 
 of the limbs, and general trembling. She is, however, not convulsed, 
 nor does she lose her senses ; indeed the fits are very slight, may be 
 prevented by rousing her, and arrested by the cold affusion : they 
 leave, on passing off, a sense of chilliness, which is followed by heat 
 of surface and flushing of the face. She is regular every month, but 
 has more or less leucorrhoeal discharge during the intervals, none 
 however at present, bowels costive, pulse 80, small and feeble ; she
 
 CONNECTED WITH UTERINE IRRITATION. 139 
 
 is a dyspeptic subject, troubled with flatulence of stomach, and 
 disturbed by fearful dreams at night." 
 
 The most prominent of the permanent symptoms existing at the 
 time of her admission were pain, giddiness, and uneasy sensations 
 within the head, palpitation or pulsation of the heart, pain in the 
 left side, extending occasionally towards the scrobiculus cordis, and 
 remarkable weakness and irritability of the stomach ; but with these 
 she presented in a very exquisite degree the general morbid sensi- 
 bility both of body and mind, to which I have had occasion to 
 direct your attention. The secondary local pain, affecting the left 
 side below the mamma, was by no means considerable, and was 
 moreover very variable in its intensity, it was, however, as is very 
 usually the case, associated with palpitation, or more uniformly with 
 unnatural pulsation of the heart. The hysterical paroxysm was in- 
 complete, it was generally preceded, we were informed, by a tight- 
 ness and oppression at the epigastrium, but by no distinct globus, 
 whilst neither the mental aberration nor the bodily contortions were 
 so considerable as are commonly observed; but the patient was 
 described as experiencing at the time a numbness of the left side of 
 the body, spasms, impediment in the speech, and other symptoms 
 indicative of disorder of the cerebral functions. 
 
 This disturbance in the cerebral functions presents one of the most 
 interesting phenomena of the complaint, and naturally leads to an 
 inquiry into the pathological condition of the brain and nervous 
 system, from whence it proceeds. The symptoms enumerated closely 
 resemble, or indeed are the same as those which attend morbid con- 
 ditions of the ,brain of the most serious character ; but, as in the 
 complaint under consideration, we know, that, however alarming in 
 appearance, they rarely prove permanent, or rather are rarely fol- 
 lowed by serious or fatal consequences, it becomes a most interest- 
 ing question, both to the pathologist and to the physiologist to 
 determine in what this peculiarity consists ; or, in other words, as 
 we have no evidence in many instances of either vascular or organic 
 disturbance, what is the pathological condition of the brain in 
 hysteria ? 
 
 In making any attempt to solve this interesting question, we are met 
 by difficulties at every step. We still remain in ignorance of the essen- 
 tial properties of cerebral and nervous matter, we are consequently igno- 
 rant of the mode in which the functions of the nervous system are per- 
 formed ; whilst we are unfortunately just as ignorant of the ultimate
 
 140 ON THE DISORDERS OF FEMALES 
 
 impression made upon that system by remedies given to restore health. 
 In an investigation like the present, therefore, we must be content 
 to take as our only guide general deductions drawn from accumu- 
 lated facts. Erom a consideration of these general deductions it 
 would appear, that disorder of the functions of the brain is chiefly 
 referrible to three distinct sources : first, altered nutrition of the 
 brain, of its membrane, or of parts adjacent ; such as hardening or 
 softening of the brain alone, or tubercles or tumours of the brain, its 
 membrane, or of the skull. Secondly, inflammation of the brain or its 
 membrane ; and thirdly, irregular circulation within the head, as is 
 observed in threatening or complete simple apoplexy, and in syncope. 
 Such are the three principal sources of direct disorder of the cerebral 
 functions. To which of these sources, then, are we to ascribe the 
 disorder met with in the complaint we are now considering ? Cer- 
 tainly not to organic lesion, the result of altered nutrition : with as 
 little reason can we ascribe it to inflammation, whilst, in many in- 
 stances at least, we have no evidence of its depending upon irregu- 
 lar circulation. "What then is the state of the nervous system which 
 characterises hysteria ? 
 
 Now, the nervous system is, so far as we know, the only source 
 of sense and motion ; it is through this system that impressions are 
 conveyed to the mind without, and it is through this system alone 
 that the operations of the mind manifest themselves. Providence has 
 so constructed the human machine, and so balanced the susceptibi- 
 lity of the various organs with the impressions made upon them, 
 that in perfect health, and under ordinary circumstances, we acquire 
 such a knowledge of the external world, and experience such emo- 
 tions, as are best suited to the station in which we are placed. 
 Disease, however, occasionally disturbs or destroys this healthy 
 balance existing between the susceptibility of the sentient organs and 
 the external excitants or stimuli to which they are exposed ; so that 
 an immoderate action shall be produced, or an undue, or even pain- 
 ful sensation shall be communicated by ordinary causes such as in 
 a state of health would have no such effect. This morbid susceptibility 
 of impression, however, is not under such circumstances confined to 
 the sentient organs, but appears to involve the mind in a similar ratio, 
 so that extraordinary emotions are excited by very inadequate causes, 
 or by such as in health would be accounted inadequate. 
 
 Analogous to this appears to be the actual state of the nervous 
 system in hysteria, a state, nevertheless, infinitely varied in degree,
 
 CONNECTED WITH UTERINE IRRITATION. 141 
 
 and consequently infinitely varied in its effects in different indi- 
 viduals. It is a state, however, which, so far as we are able to 
 judge from facts, exists independently of any particular condition of 
 the vascular system, although it is not denied that it may be mate- 
 rially influenced by certain states of that system. It is a morbid 
 state of the nervous system generally, which, by way of distinction, 
 may be said to depend upon some inscrutable change induced by 
 certain causes in the organism or vital endowments of that system, 
 independent of appreciable derangement either of structure or of 
 vascular action a change, nevertheless, which is sufficiently mani- 
 fested by the disturbance of the functions of that system, whether 
 that disturbance consist simply of a general morbid susceptibility of 
 body and mind, whether it consist of partial disorder of nervous 
 function in particular parts, or whether it be such as to involve the 
 entire frame in what we designate a hysterical paroxysm. If you 
 ask me why I suppose this state to exist independently of vascular 
 disorder, I can only observe in reply, that I suppose so, because in 
 many instances, even where the disorder of the cerebral functions is 
 most alarming, I have failed to observe, either in the aspect of the 
 patient or in the state of the pulse, any indication of vascular 
 derangement ; because, in the next place, I find such disorder of 
 the brain occasionally removed or relieved by remedies which 
 experience teaches us prove injurious in cases where analogous 
 symptoms result from manifest vascular disorder; and, lastly, 
 because, however alarming in appearance, I have seldom known 
 such disturbance prove permanent, or to be followed by serious or 
 fatal results, which cannot be said of cases of a different description. 
 Admitting it then to be probable that the morbid condition of the 
 nervous system is of the character I have supposed, you will pro- 
 bably be disposed to inquire why I conclude that it proceeds in this 
 case from uterine irritation, and HOW I suppose such uterine irrita- 
 tion to produce it. In reply to the first question, I would say that 
 I suppose it to arise from uterine irritation because of the frequency 
 of their coexistence because, making due allowance for original 
 differences of constitution, the disturbance of the nervous system is 
 found to be proportionable to the degree or duration of the uterine 
 irritation, and because I find that whatever abates or removes the 
 irritation mitigates or removes the disorder of the brain and nervous 
 system. To the second question, HOW uterine irritation produces 
 this state of the nervous system, my only answer is, I know not.
 
 142 ON THE DISORDERS OF FEMALES 
 
 AVlien Iodine taken in excess produces general morbid irritability, I 
 acknowledge the fact, but cannot explain it; of the quo modo I 
 know nothing ; when the irritation of a rusty nail, or a thorn, or a 
 burn, involves the entire nervous system in tetanus, I acknowledge 
 the fact, but cannot explain it; when long- continued suckling pro- 
 duces a state of the nervous system analogous to that of which I now 
 treat, I acknowledge the fact, but cannot explain it ; so in like manner 
 uterine irritation, by its continuance, disorders the functions of the 
 nervous system, as observed in hysteria, but I cannot explain its 
 modus operandi. All these phenomena are so intimately connected 
 with nervous and vital endowments, concerning which we still remain 
 in ignorance, that, were I to attempt more it would only betray me 
 into useless speculation and waste of time. 
 
 I have been led into this digression in order, if possible, to convey 
 to your minds such a view of the disorder under discussion as shall 
 prepare you to understand and account for the ever-varying character 
 which it presents according to differences of original constitution, and 
 the susceptibility or degree of derangement of individual organs : a 
 character varying not only in these respects, but moreover through 
 every modification of disordered action and morbid sensation, from 
 the slightest twitching in the alimentary canal to the most violent 
 convulsions of every voluntary muscle of the body or complete 
 though transitory hemiplegia : from the most trifling uneasiness 
 to the most exquisite torture. But to revert to our case : As she 
 had no severe pain, and as she was troubled with flatulency, I 
 ordered her the Ammoniacal mixture with Magnesia thrice a day, 
 and four grains of Extract of Conium and one of Blue pill night and 
 morning, and to use the Zinc and Alum injection. In this instance, 
 as not unfrequently happens at first, the injection occasioned some 
 smarting, attended with slight leucorrhceal discharge ; by persevering 
 in its use, however, these effects soon disappeared. To open her 
 bowels, I ordered her, on the following day, four grains of the 
 Compound Extract of Colocynth, four of the Extract of Bhubarb, and, 
 to obviate smarting, two grains of Extract of Conium. This having 
 failed to act on the bowels, she took, on the following morning, ten 
 grains more of the Compound Extract of Colocynth, which operated, 
 but griped her a good deal. Her stomach was in so weak and irri- 
 table a state that the Conium and Blue pill made her sick, and were 
 afterwards withdrawn. Her appetite was almost completely lost; 
 she had long subsisted entirely upon tea and slops, whilst solid food,
 
 CONNECTED WITH UTERINE IRRITATION. 143 
 
 especially meat, caused a distressing sense of weight and oppression 
 in the epigastrium. Here then we had an exquisite case of general 
 susceptibility, with a state of stomach which not only precluded the 
 possibility of giving those laxatives which prove the least irritating 
 and those medicines most likely to relieve the local pain, but such 
 as prevented the patient taking even a moderate proportion of that 
 food which was most likely to benefit her disorder. Under such 
 circumstances I was compelled to content myself with exhibiting 
 the Ammoniacal mixture, to each dose of which I added a dram of 
 the Tincture of Hops, employing at the same time the injection, and 
 keeping the patient quiet in bed. For the local pain in the left 
 breast we tried at first a Belladonna plaister, and afterwards a blister, 
 but with little relief. 
 
 She was admitted on the 3ist of December, and on the loth of 
 January the injection was directed to be desisted from, as the 
 menses were expected, and on the following morning the report 
 \vas that they had appeared, without being preceded by a hysterical 
 paroxysm as usual, and accompanied by much less pain and suffering 
 than she had previously experienced. All this relief I attributed to 
 the open state of her bowels, and to her being kept quiet in bed ; in 
 twelve hours the flow of the menses ceased, when she experienced a 
 considerable aggravation of all her general and local distress. From 
 this state she gradually rallied under the use of Tincture of Hops 
 in Camphor Julep, the use of the injection, and an occasional 
 laxative ; so that on the 1 6th I allowed her a bit of meat, which, 
 however, she herself objected to, in consequence of the uneasiness it 
 was apt to produce in the stomach. It was the extreme irritability 
 of the stomach that compelled me to deviate from the advice I have 
 given you as to the selection of laxatives ; here I was obliged to 
 give the Colocynth and Calomel, or the Calomel and Rhubarb in the 
 form of pill, although they always produce much griping. I did, 
 indeed, order a glyster, but her bowels were so torpid, that I could 
 not trust to it effectually to evacuate them. I need only further 
 add, in reference to this case, that, under the use of the Ammonia 
 and Magnesia, which were resumed, the Extract of Gentian, and 
 the injection, this young woman got gradually better, and left the 
 hospital, I believe, on the 3oth, in much better health than she had 
 experienced for a long time. Her general susceptibility was greatly 
 diminished ; the disturbance in her head was very much relieved, the 
 hysterical paroxysms ceased to appear, the distension of the stomach
 
 ON THE DISORDERS OP FEMALES 
 
 and sense of globus were removed ; she could digest animal food, 
 and was going on gaining both mental and bodily vigour but, 
 gentlemen, she was not cured ; this must be accomplished by her 
 own discretion and by attention to the injunctions given her on 
 quitting our ward. 
 
 The next case I shall notice is that of ELIZABETH MARTIN, 
 setat. eighteen, whose case, as drawn up by Mr. Dashwood, is as 
 follows : l 
 
 " The catamenia have not been regular for the last two years, 
 occurring at intervals of from six weeks to two months, accompanied 
 with much pain in the back, and lasting a week or ten days ; four 
 months ago had pain of the left side, frequent attacks of globus 
 hystericus, sometimes amounting to an absolute hysterical paroxysm; 
 soon after an eruption, having the characters of large blisters 
 filled with serum, arose about the chest, and since which she has 
 had no return of the hysterical symptoms until a week ago, when 
 during the period of menstruation she again became the subject of 
 acute pain of the side, apparently along the course of the arch, 
 and descending portion of the colon ; this pain is increased on in- 
 spiration, and also by pressure ; the bowels are habitually costive ; 
 has some cough, accompanied by thin mucous expectoration ; pulse 
 88, soft and quiet; tongue furred in the centre, but clean at the 
 edges ; face a little flushed ; has frequent palpitations of the heart ; 
 has no pain of the head, and has never observed any leucorrhceal 
 discharge." 
 
 This young woman appeared to be naturally of a somewhat deli- 
 cate and susceptible constitution, as indicated by her slender form, 
 her brilliant eye, and thin transparent skin. She had suffered much 
 from painful and excessive menstruation, so that her whole frame 
 was in a remarkably sensitive state ; her stomach too was exceed- 
 ingly weak and irritable, so that no active opiate given to relieve the 
 pain in the track of the descending colon could be retained. Her 
 head too was so much affected with pain and giddiness that even 
 the Conium and Blue Pill could not be persevered in. The cough 
 was purely catarrhal, and had nothing at all to do with the local 
 pain, although the case was presented to our notice as a very good 
 specimen of pleurisy. The pain was indeed, as often happens, in- 
 
 1 I ought to apologise to the clinical clerks for transcribing literally, cases 
 drawn up without any intention of publication. I have given them thus to 
 avoid bias and partiality.
 
 CONNECTED WITH UTERINE IRRITATION. 145 
 
 creased both by a full inspiration and by pressure ; but its situation, 
 independently of its character, precluded the possibility of its being 
 pleuritic ; it varied not only in its intensity, but moreover in its seat, 
 so that, after remaining for some time fixed in the region of the 
 descending colon, it moved a little higher up, and afterwards 
 attacked the sigmoid flexure and bladder, attended with painful 
 micturition. 
 
 On the 6th of January, or about ten days after admission, I 
 ordered the injection to be used, and on the following day was told 
 that pain in making water had been experienced for the first time. 
 I was, therefore, disposed to attribute it to the wash, which will, in 
 very susceptible habits, occasionally produce an increase of pain, if 
 used quite cold at first. It turned out, however, that the injection 
 had not been used at all in our absence, so that it had nothing 
 whatever to do with the pain in this situation. 
 
 On the 3Oth the menses appeared, and continued four days with- 
 out pain, a circumstance which I am disposed to ascribe to her 
 having been kept quiet in bed, to the laxative medicines given her, 
 and in part perhaps to a pill of four grains of extract of poppies, and 
 one grain of ipecacuanha, night and morning, given to relieve the 
 cough. Little attention was paid either to the disturbance in the 
 head, to the palpitation of the heart, or to the local pain, till the 
 cough became relieved under the simplest treatment. 
 
 Suffice it to say, in conclusion, that during her stay she was once 
 blooded : that she had a few leeches applied to the region of the 
 sigmoid flexure, a blister to the left side, repeated fomentations, and 
 that on the 1 2th of February she began the use of the wash, at first 
 tepid. Both the general and local symptoms, however, though vari- 
 able, proved remarkably stubborn, owing, I believe, to the bad 
 condition into which both the uterus and general system had been 
 brought before we saw her. She remained with us till I quitted the 
 ward, little more than a month, above a fortnight of which we were 
 debarred from the use of proper remedies, by the bronchial affection 
 under which she laboured at the time of admission. We therefore 
 effected less than we otherwise might have done had we had more time. 
 
 The next case I shall notice, is one in which we had the pain 
 diffused more generally over the abdomen ; the case itself, as well as 
 the outline of the progress and treatment, being furnished me by my 
 friend and able assistant, Mr. Dashwood, as follows : 
 
 Jane Buss, set. 20, admitted January 13, says, that between five 
 
 10
 
 146 ON THE DISORDERS OF FEMALES 
 
 and six weeks ago she was admitted into this Hospital, labouring 
 under acute peritonitis, for which she was copiously blooded and 
 leeched, &c., and \vas discharged about a fortnight from the time of 
 her admission. At the time of her discharge she had pain of the 
 left side still remaining ; soon after she was again seized with severe 
 pain over the whole abdomen, with great tenderness on pressure, 
 accompanied by difficulty and pain on micturition. The catamenial 
 discharge appeared nine days since and lasted three days, with acute 
 pain in the back, loins, and down the inside of the thighs. The 
 discharge was in smaller quantity than usual during the last week 
 for the first time has had frequent attacks of the globus hystericus, 
 with vertigo and headache, but not amounting to an absolute hyste- 
 rical paroxysm. At present she complains of acute, constant pain, 
 and tenderness in the lower part of the abdomen, which is full and 
 soft ; her easiest position is with the thighs flexed. Respiration is 
 slightly hurried, being about twenty-eight in the minute. Pulse 92, 
 and small. Has frequent palpitations of the heart, generally occur- 
 ring during sleep. Her bowels have lately been much relaxed, but 
 are now regular ; tongue slightly furred. The ankles and legs are 
 swollen and painful on pressure ; urine is clear and light-coloured, and 
 does not coagulate on the application of heat. Foveatur Abdom. c. 
 Decoc. Papaveris. Pil. Conii. c. Hydr. ter die. Jul. Camph. ter die. 
 
 1 5th. On falling asleep is suddenly awoke with a sense of suffoca- 
 tion, with most acute pain under the left breast. Pulse 60, soft and 
 quiet ; bowels open ; countenance quite tranquil ; abdomen tender 
 on the least pressure ; has some pain on micturition. Eep. Potus 
 et Pil. Eep. Julep Ammonias, ter die. 
 
 1 8th. The pain of the side and abdomen in general, which had 
 been somewhat less during the last two days, again suddenly 
 became much more intense last night, shooting through to the back, 
 accompanied with nausea. Pulse still remains soft and quiet; 
 tongue a little more furred. 
 
 22nd. The catamenial discharge appeared in a slight degree on 
 the 1 9th, with much pain in the back, loins, and thighs, but ceased 
 on the same day. The pain and tenderness of the abdomen has 
 varied from being occasionally most severe to perfect freedom from 
 all uneasiness. Complains to-day of great pain during micturition. 
 Lolio tepida Zinci et Aluminis injicienda. Rep. Med. 
 
 3oth. The pain and globus hystericus generally recurring during 
 the night, eight drops of Battley's sedative liquor were given at
 
 CONNECTED WITH UTERINE IRRITATION. 147 
 
 bedtime with the most beneficial effect. The sulphate of zinc was 
 also tried, but was obliged to be withdrawn on account of its exciting 
 nausea. Her appetite now remains good ; she sleeps well at night ; 
 has had no return of the globus for some days ; the pain and tender- 
 ness of the abdomen less in severity, and occurring at longer 
 intervals, and during those intervals she is perfectly free from all 
 uneasiness. 
 
 Although the next case did not occur in the clinical ward, as it 
 was seen by some of you I shall not scruple to quote it as an example 
 of one of the more acute and equivocal forms of general neuralgia 
 affecting the abdomen. 
 
 Ellen Jones, set. 27, admitted into Charity Ward on Wed- 
 nesday, October 14, 1829. Is of a sanguine temperament, with 
 red hair. The menses first appeared at the age of twelve, having 
 been preceded by no other inconvenience than drowsiness. They 
 shortly afterwards entirely ceased till the age of twenty, she 
 having had during the whole of the interval a leucorrhceal discharge 
 occurring at irregular periods. She had also during the con- 
 tinuance of the amenorrhoea experienced a slight hemiplegic 
 attack, from which, however, she is now entirely free. When the 
 menses re-appeared at the age of twenty they continued to recur 
 every two or three weeks, often lasting a whole week, exceedingly 
 copious, and mixed with clots, but attended by no pain in the loins, 
 till her marriage a year and nine months ago. Since then she has 
 had neither a child nor a miscarriage, but the menses have ever 
 since been profuse, recurring every two or three weeks, and attended 
 with violent pains in the loins and pain under the left mamma, the 
 latter often going off and returning again. She says she has had 
 medical advice for the last year past, and has been three times 
 blooded has had leeches applied, and taken medicine, but in spite 
 of which she got gradually worse up to the present time. The pain 
 she now experiences commenced a fortnight ago whilst the menses 
 were flowing, and has gradually increased to its present severity. 
 The pain affects the whole of the abdomen, and is so extremely acute 
 that she cries out from the slightest touch. There is, however, no 
 great expression of distress in the countenance ; skin rather warm 
 than hot, with a disposition to moisture ; tongue foul and slightly 
 brown ; pulse frequent and sharp. 
 
 There was a time when I certainly should have set this down as a
 
 148 ON THE DISORDERS OF FEMALES 
 
 case of peritonitis, which had come on gradually, and had arrived at 
 its present severity from neglect : an opinion, indeed, which seemed 
 to prevail in the minds of some of those pupils who saw the patient 
 with me. As it occurred, however, in a young female, I was, for the 
 reasons I have mentioned, upon my guard, and expressed my doubts 
 and suspicions to those present. It so happened that whilst 
 we were conversing, the girl actually experienced an imperfect hys- 
 terical paroxysm, which appeared in some degree to remove the pre- 
 vailing scepticism. I ordered twenty leeches to be applied to the 
 belly, and warmth afterwards to encourage the bleeding from the 
 bites, and two grains of calomel and one grain of opium every six 
 hours. As she had had no stool, in the following day I ordered the 
 senna and salts j immediately after the operation of which she had 
 relief, and only felt pain in the track of the colon on each side, which 
 also speedily vanished. 
 
 On the 23rd I ordered the cold wash and the aninioniacal mixture. 
 
 On the 27th she had a return of the pain under the left mamma, 
 but this soon subsided; and she was discharged on the 3ist, free 
 from any pain whatever. 
 
 Of course this case is related merely with a view to illustrate 
 the general neuralgic pain of the abdomen, and its connection with 
 the irritable uterus, but without any pretensions to having cured 
 the patient. By being kept at rest, and by employing the ordinary 
 means recommended in such cases, she obtained relief, but only, I 
 believe, temporary, unless followed up by attention to the prophy- 
 lactic measures already pointed out. 
 
 The last of our hysterical cases is that of the patient No. 3. 
 Before noticing it, however, it may not be amiss to relate a few 
 examples of those modifications of the complaint which have not 
 been presented to our notice in the clinical ward ; and in order to 
 be brief, I will dispense with all comment upon them. 
 
 Louisa Burgess, set. 21, single woman, and apparently of a 
 good constitution, first became regular about the age of sixteen, 
 the appearance having been preceded for five or six months by pain 
 in the back and head, which symptoms were relieved by the change 
 which then took place. She represents herself as having been 
 regular every month, but that the flow has generally been preceded 
 for two days by pain in the loins and legs, giddiness, and occasionally 
 by fits, one of which, she says, lasted three hours. She had four 
 such fits, each preceded by giddiness, and occurring immediately
 
 CONNECTED WITH UTERINE IRRITATION. 149 
 
 before the menstrual period. Although she has uniformly experienced 
 pain at the period, it is only during the last three months that she 
 has suffered from leucorrhosal discharge. About six weeks ago was 
 seized with violent sick headache, fainting fits, pain in the right side, 
 under the margin of the ribs, sometimes extending downwards or 
 over the whole belly, with great tenderness on pressure and occa- 
 sional palpitation or pulsation of the heart. These pains continued 
 to increase till the time of her admission into the hospital, at which 
 time they were found to be greatly aggravated by pressure, and in 
 some degree by a deep inspiration. 
 
 Elizabeth Beauchamp, jet. 24, admitted October lyth, became 
 regular at fifteen, having suffered from pain in the loins for some 
 months previously. Ever since that time she has experienced pains 
 in the loins and thighs, aching in the legs, and coldness of the legs and 
 feet, before and during the discharge. She married about five years ago, 
 soon after which she miscarried in consequence of a fright. She mis- 
 carried a second time at the sixth month, but afterwards bore a living 
 child. Prom the time of her first miscarriage, except while pregnant, 
 she has menstruated every fortnight or three weeks. After the second 
 miscarriage, she first felt severe pain under the left, mamma, with 
 beating or pulsation of the heart, which has prevailed more or less 
 ever since, but has always been worst during the flow of the men- 
 strual discharge. Five months ago she was suddenly seized with 
 excruciating pain in the loins, so severe that she could not stand, 
 but which subsided gradually in three or four hours, leaving a ten- 
 derness over the whole of the abdomen. On the I4th of the pre- 
 sent month she was seized suddenly with most severe pain in the lower 
 belly. It came on about five o'clock in the morning and lasted 
 three hours, and was attended with a violent desire but with inability 
 to pass her water. After being well fomented, she succeeded in 
 voiding a little, and the pain went off gradually about eight o'clock. 
 On the following day she was seized with intense pains in the pit of 
 the stomach, extending across to each side, without vomiting, but 
 accompanied with considerable nausea and pulsation at the scrobicu- 
 lus cordis. This pain occasionally abated, but never went off en- 
 tirely, and two days afterwards returned in so severe a degree, that 
 on being requested to see her I immediately admitted her into the 
 hospital. She appeared at the time to be in the greatest agony, she 
 could not bear the slightest pressure on the parts ; she leant forward
 
 150 ON THE DISORDERS OF FEMALES 
 
 and declared that she must speedily die unless relieved. I gave her 
 ether and laudanum at once with only partial relief. I then had 
 her bled to twelve ounces, ordered calomel and opium, fomentations 
 and glysters, by which on the following day she was free from com- 
 plaint in the stomach, the pain being then confined to the loins and 
 left side. Her stomach long remained in a very irritable state. 
 
 I have within a very short period had three cases of the general 
 neuralgia of the belly, attended with menorrhagia, but such cases 
 present no peculiarity of sufficient interest to warrant me entering 
 into detail. I have, however, observed that instances of this general 
 neuralgia, accompanied by a tympanitic state of the bowels, although 
 the most distressing, are happily of least frequent occurrence. I 
 remember a very curious case of this kind, which must be in the 
 recollection of some present. It occurred in the person of a middle- 
 aged woman. I was told that she laboured under chronic perito- 
 nitis, and, under the influence of high authority, I concluded that it 
 was so. Her belly was as tense as a drum, exquisitely tender, and 
 presented a most singular appearance from the thousands of leeches 
 which it appeared had at various times been applied. Shortly after 
 I first saw her, however, I was astonished, on visiting her, to find 
 the parietes of the belly quite relaxed and altogether free from pain. 
 This led me to investigate the case narrowly, and I found my patient 
 suffering from irritable uterus and leucorrhoeal discharge. Under 
 the appropriate treatment she was relieved, and discharged. 
 
 In the next bed to the above, we had a patient supposed to pre- 
 sent a case of hepatitis, as indicated by pain under the margin of the 
 ribs of the right side, and a sallow or icteritious aspect of the coun- 
 tenance. This case, however, turned out to be of the same nature as 
 the former, and was treated accordingly. 
 
 I have already told you that a case lately occurred in Martha's 
 Ward, which proved so puzzling that I really could not positively 
 determine whether it was peritonitis or mere neuralgia, although 
 from the history of the patient, a young girl of nineteen, who had 
 fallen into prostitution, and from the state of the uterus, there were 
 strong grounds for suspecting it to be merely neuralgia. However, 
 to err on the right side, the case was treated as one of peritonitis. 
 She was blooded to faintness, had calomel and opium, leeches, and 
 so forth. I soon was convinced, however, that I had been wrong. 
 The pain became extremely unsteady, now affecting the ascending, now 
 the descending colon, and then attacking more or less of the abdo-
 
 CONNECTED WITH UTERINE IRRITATION. 151 
 
 men generally, with intervals of perfect ease. She had a very pro- 
 tracted convalescence, which I ascribed to the severe practice into 
 which my mistake had betrayed me. I need only remark further, 
 that I have known patients literally blanched by repeated bleeding 
 and cupping to remove the neuralgic pains described ; and on the 
 other hand, I have known them, after months or years of such inju- 
 rious practice, speedily relieved, and enabled to enjoy the ordinary 
 comforts of life, by a treatment founded on the principles which I 
 have presumed to recommend to your notice. 
 
 The clinical case which remains to be noticed is interesting, inas- 
 much as it is calculated to remove, in some measure, any doubt that 
 might have prevailed in your minds as to the real connection existing 
 between the condition of the uterus and the local neuralgic pains of 
 which I have said so much. It certainly, as far as it goes, tends to 
 confirm the opinion I have advanced, as to these two phenomena 
 standing to each other in the relation of cause and effect. The case 
 is as follows : 
 
 "Elizabeth Harris, set. 26, a woman of irritable habit, subject 
 to frequent pain of the head and left side, with palpitations of 
 the heart on the least exertion her menstrual periods are regular, 
 and generally attended with but little pain, but the discharge 
 is usually rather profuse, with passage of clots, and lasting a 
 week. Last Tuesday, while the catamenia were flowing, accidentally 
 got wet by upsetting a tub of ice-water over her legs and feet; the 
 discharge ceased almost immediately, but she did not feel any incon- 
 venience until Wednesday afternoon, when she was seized with pain, 
 first commencing at the scrobiculus cordis, but soon became fixed at 
 the lower part of the abdomen. This pain gradually becoming more 
 acute, she came into the hospital on Thursday afternoon (February 
 1 1 th). At that time it was very severe ; the abdomen acutely tender 
 to the touch on first making pressure upon it, but after continuing 
 the pressure it was tolerated. Bowels had not been relieved ; pulse 
 1 20, but without jerk ; tongue slightly furred." 
 
 When I first saw her she could not bear even slight pressure on 
 any part of the belly, and as she was rather of a full habit of body, I 
 ordered her to lose sixteen ounces of blood to take a smart dose of 
 colocynth and calomel, and to have the belly fomented with the 
 chamomile fomentation. As I was satisfied as to the character of 
 the pain, you might perhaps have expected me to order, with mode-
 
 152 ON THE DISORDERS OF FEMALES 
 
 rate depletion, some form of opiate, either by the mouth or by 
 glyster, with a view to relieve the violence of the pain ; whilst you 
 were probably surprised at my giving the colocynth and calomel, as 
 I have elsewhere said that such a combination usually irritates, and 
 causes an increase of pain in such subjects. I adopted the practice, 
 however, with a hope that this aloetic compound might, in conjunc- 
 tion with the bleeding and fomentation, bring about a return of the 
 menstrual discharge, which I calculated, with tolerable certainty, 
 would afford speedy relief. In the evening she experienced great 
 aggravation of her pain, evidently from the irritation of the pills, so 
 that at nine o'clock Mr. Dashwood gave her six drachms of castor 
 oil, applied thirty leeches to the belly, and repeated the fomentation. 
 On the following day, her bowels having been freely opened, she 
 obtained considerable relief, the severe pain only coming on at 
 intervals, and being chiefly felt in the region of the sigmoid flexure. 
 
 On the evening of the 13th, or the third day from her admis- 
 sion, she had a slight return of the catamenia, and next morning we 
 found her entirely free from pain. In the evening, however, they 
 again ceased, and at two o'clock in the morning the pain again re- 
 turned in the lower belly. This pain gradually subsided under the 
 treatment adopted, but on the I7th she was represented to be suffer- 
 ing from acute pain under the margin of the ribs of the right side. 
 This was supposed by some to be pleuritic, but although it was 
 manifestly increased by inspiration, it varied very much in its inten- 
 sity, and at intervals was very much aggravated, which with the other 
 symptoms and history of the case, left no doubt in my mind that it 
 was abdominal and purely neuralgic. I applied a blister and gave 
 the conium. On the following morning she was nearly altogether 
 free from pain. 
 
 In this case it is scarcely possible not to associate the state of the 
 uterus and the neuralgic pain in the abdomen as cause and effect, 
 in whatever way or by whatever medium the one may bring about 
 the other. This is a relation, indeed, which must be familiar to 
 every one who has had opportunities of witnessing the consequences 
 which so often arise from a sudden suppression of the lochia shortly 
 after delivery, the check being quickly followed by a severe neuralgic 
 pain attacking the abdomen more or less extensively in different indi- 
 viduals; nor do I think it improbable that some of those cases 
 which have been published as anomalous forms of puerperal fever, 
 may have partaken of the same nature, as the painful affections of
 
 CONNECTED WITH UTERINE IRRITATION. 153 
 
 the abdomen to which I have directed your attention. But this is 
 mere conjecture. 
 
 Now, gentlemen, after all that has been said, I dare say you will 
 be disposed to exclaim, " What you have told us is as old as Hip- 
 pocrates, the old doctrine of hysteria revived I" Be it so ; it is to 
 me a matter of total indifference whether my opinions be regarded 
 as novel or as a revival of the old, provided the impression made 
 upon your minds be permitted to accompany you in practice, and 
 tend to secure you credit and advantage. In truth, gentlemen, 
 although I do not believe with Plato that the uterus is a living 
 animal, producing the Protean forms of hysteria by a sort of predatory 
 excursion made into different parts of the body, I nevertheless do 
 agree with Hippocrates and many moderns in ascribing the disease, 
 usually so called, to a certain condition of that organ ; but I go 
 further, and only regard what they call hysteria as a mere part and 
 parcel of that extensive series of morbid phenomena which I have 
 endeavoured to point out to your notice in this lecture ; for as to 
 the stale objection to the term hysteria, that some of its symptoms, 
 as the globus, occasionally occur in the male, it is scarcely worthy of 
 serious refutation. Since in hysteria the digestive organs amongst 
 the rest are disturbed, it would be singular indeed if some of its 
 symptoms did not present themselves in affections of these organs 
 arising from other causes ; and the same may be said of many other 
 apparent anomalies that have been dwelt upon in a similar manner. 
 Neither will I stop to inquire whether any and what sources of 
 mental or bodily irritation are capable of inducing a state resembling 
 that I have described as resulting from the condition of the uterus. 
 My business has been to treat of the latter alone ; I leave the rest to 
 others. I shall merely observe that lactation produces a state very 
 analogous to it, if not the same, whilst the two causes combined exert 
 a most powerful and deleterious influence upon the general health, 
 but too extensive to be treated of in this lecture. 
 
 Gentlemen, you must extend indulgence to me if I have appeared 
 too egotistic or too sanguine in this matter. If I have been egotistic, 
 you will ascribe it to the influence of my conviction as to the import- 
 ance of the subject ; if too sanguine, you will attribute it to my 
 anxiety ~ fc to furnish you with those advantages which I know must 
 spring from its attentive and careful investigation. But, gentlemen, 
 if you really require an apology for detaining you so long, I find 
 ample material for that apology in the lively interest which we must
 
 154 ON THE DISORDERS OF FEMALES. 
 
 all feel in the comfort and happiness of the other sex, doomed as 
 they are, both by the decrees of providence and by human institu- 
 tions, to drink deep of the bitter cup of suffering. Whatever may 
 be her lot in this world, we, as men, must at least acknowledge that 
 whilst Infinite Power gave us being, Infinite Mercy gave us Woman.
 
 CASE 
 
 op 
 
 OVARIAN DROPSY 
 
 REMOVED BY THE ACCIDENTAL RUPTURE OP THE CYST. 
 
 THE subject of the following case was received into the Female 
 Clinical Ward on the I9th of March, 1834. The history, as taken 
 by Mr. Bird, Clinical Clerk at the time, is as follows : 
 
 "Ann Binks, aged 44, a tolerably healthy-looking woman, who 
 has been a widow three years, and who has always resided in London, 
 states that her health has usually been very good, till within the last 
 five years. She had one child, twenty-five years ago; has never 
 miscarried ; and at the present time menstruates regularly. She has 
 had some cough almost every winter. Five years ago she first 
 noticed a swelling in the left iliac fossa, about the size of an orange, 
 but which rapidly grew larger. For this, and for some general 
 anasarca, she was admitted into this ward, two years ago. She was, 
 at that time, about the size of a seven months' pregnancy. At the 
 end of three months, she was discharged, cured of the anasarca; but 
 still the subject of ovarian dropsy, the abdominal tumour at the 
 period of her discharge equalling the size of a five-months' preg- 
 nancy. She, however, was able to go out to service ; and continued 
 tolerably well until Monday, the loth instant; when, being engaged 
 in closing some heavy shutters, and standing upon a pair of steps 
 for that purpose, her foot slipped, and she fell ; pulling on her, in 
 the fall, the steps, which struck her across the abdomen. She suf- 
 fered at that moment excruciating pain ; became sick and faint ; arid 
 was then placed in bed, and had medical assistance procured. She 
 now perceived that the fluid accumulation, which before the accident
 
 156 OVARIAN DROPSY. 
 
 was circumscribed, had spread over the whole abdomen, rising to the 
 diaphragm, and obstructing respiration. She appears to have then 
 had an attack of peritoneal inflammation ; for which she was bled, 
 cupped, and leeched, with some relief; but being unable to perform 
 her duties, she applied to be admitted here this day, the I9th of 
 March. On admission, her face was pale and anxious, surface cold, 
 circulation languid, abdomen distended with fluid; and she com- 
 plained of great pain, on applying pressure over the abdomen gene- 
 rally, but especially over the lumbar and iliac regions. The bowels 
 were open; tongue very red; she felt thirsty; her pulse was 98, 
 and small ; urine copious, and very turbid ; and she stated that she 
 had occasionally passed blood by stool since the accident." 
 
 It is unnecessary to enter into any minute details respecting 
 either the progress or the treatment of the case. Her symptoms, on 
 admission, were 'those of general peritonitis, and a moderate degree 
 of bronchitis : for these she was bled to a small amount, fomented, 
 and had calomel, antimony, and opium administered internally. 
 Under this treatment she improved : her gums were reported to be 
 sore on the 22nd; after which the fluid rapidly decreased; so that 
 on the 5th of April there was no fluctuation whatever, and the 
 remains of the ovarian tumour could be distinctly traced, stretching 
 across from one iliac fossa to the other. 
 
 On the ytli of April, the descent of the cyst, or some other change 
 induced by the accident, appeared to offer an obstruction to the 
 ascent of the blood through the iliac vein ; for she had an attack of 
 phlegmasia dolens, but by no means severe, affecting the left lower 
 extremity. This was subdued, and almost entirely removed in about 
 a fortnight. 
 
 This woman is now, December, 1835, servant in a family residing 
 in Cheapside ; and although she can still distinguish a small tumour 
 in the left iliac region, she has never experienced any return of the 
 dropsical enlargement.
 
 ON A CERTAIN AFFECTION OF THE SKIN, 
 
 VITILIGOIDEA . PLANA, |3. TUBEROSA. 
 
 PREFACE. 
 
 UNLIKE the other diseases which Dr. Addison was 
 the first to describe, Vitiligoidea appears to have 
 attracted but little notice from the members of the 
 profession. Its uncouth name, and its great rarity, 
 have alike tended to this result. The view which most 
 medical men seem to entertain concerning it is that it 
 is one of those " anomalous " and exceptional skin- 
 diseases which are occasionally met with in practice, 
 but which are of very little interest to any, save to 
 professed dermatologists, whose systems they seem to 
 set at defiance. This idea, however, is very far from 
 being well founded. 
 
 In the paper by Dr. Addison and Dr. Gull, which 
 appeared in the ' Guy's Hospital Reports ' for 1850, 
 and to which these remarks are intended as a preface, 
 five cases are recorded. In three of these the symp- 
 toms and appearances were most remarkable, and the 
 nature of the disease was generally the same in all. 
 Mrs. B had had jaundice for fourteen months, when 
 patches of a light opaque Colour appeared round the 
 eyelids, and on the palms of the hands and on the 
 fingers. Eliza Parachute had had jaundice for fourteen 
 months, when a similar affection showed itself on the 
 hands, and a little later patches were found on the 
 
 10
 
 ii PREFACE TO V1TILIGOIDEA. 
 
 eyelids. Afterwards tubercles appeared on the ears, 
 over the convexities of the finger -joints, and at other 
 parts. Mrs. J had had jaundice for several years, 
 and for about five years her eyelids had presented a 
 peculiar appearance, similar to that observed in the 
 other two patients. 
 
 Since the publication of this paper three cases of 
 the same disease are known to have been under ob- 
 servation at Guy's Hospital. One of these has not 
 hitherto been published. It occurred in a patient of 
 the late Dr. Barlow, admitted into the Clinical "Ward 
 in October, 1864. Eight or nine years before, she had 
 had jaundice. From this she is stated to have per- 
 fectly recovered; but when she came under observa- 
 tion her face and the upper part of her body were of 
 a dark olive colour, her complexion having originally 
 been fair. For some months she had had dropsy of 
 the abdomen, and to some extent of the legs. There 
 were patches of light buff discoloration in the eyelids 
 of both eyes. These were recognised as being identical 
 with the affection which had been described by Dr. 
 Addison and Dr. Gull. 
 
 The second case is that of Laura L , a patient of 
 Dr. Pavy, who has recorded it in the ' Guy's Hospital 
 Reports' for 1866. She had then had jaundice for 
 three years, and the peculiar changes in the skin had 
 existed for two years. They appeared in both the 
 " plane " and the " tuberose " forms ; and affected, in 
 precisely the same way, the same regions as in Dr. 
 Addison' s case of Ellen Parachute. As in that case, too, 
 the tubers were not confined to the skin. One, at least, 
 was more deeply seated, being attached to one of the 
 extensor tendons over the knuckles, the skin covering 
 it being quite free and movable. This woman is now
 
 PREFACE TO VITILIGOIDEA 111 
 
 attending as an out-patient under the care of Dr. Fagge. 
 She is still jaundiced, and the cutaneous affection has 
 reached a more extreme degree than in any case 
 hitherto recorded. Dr. Fagge has noticed that parts 
 of the mucous membrane of the mouth are altered, in 
 the same way as the skin. 
 
 The third case has recently been under Dr. Haber- 
 shon's care. This patient, a man, set. 33, has had 
 jaundice for two years, and for about eight months he 
 has observed certain small patches of a creamy yellow 
 colour on the eyelids. These are as yet the only signs 
 of the peculiar change in the skin, but the mucous mem- 
 brane of the mouth is affected, as in the other patient 
 now under observation. In both these cases the liver is 
 greatly enlarged. In the woman it fills a large part of 
 the abdomen. The enlargement appears to be uniform. 
 The bile-ducts seem to be free, for the motions are of 
 a dark colour. The urine contains bile-pigment. 
 
 Our main object, in the preceding observations, is 
 to show how remarkable, and at the same time how 
 constant, are the characters of Vitiligoidea. These 
 cases, taken in conjunction with those recorded in the 
 paper by Dr. Addison and Dr. Gull, surely prove that 
 the disease is no mere curiosity, interesting only to the 
 specialist. On the contrary, it affects various tissues 
 skin, mucous membrane, tendon, liver. Its pathological 
 nature is as yet a mystery, for it seems to have hardly 
 any tendency to destroy life, and no post-mortem 
 examination of any case has been recorded. Dr. Pavy 
 has shown that the tubercles consist of dense fibrous 
 tissue with interspersed fat-granules, and that the 
 peculiar cream-coloured patches are probably due to 
 the deposition of similar granules in the skin.
 
 IV PREFACE TO VITILIGOIDEA. 
 
 It must be admitted, however, that two of the cases 
 (the first and the third) included in the paper of Dr. 
 Addison and Dr. Gull appear not to be examples of 
 the same affection. In these instances there was no 
 jaundice. An examination of the model of the first 
 case, preserved in the museum of Guy's Hospital, con- 
 firms the opinion that the disease was of a different 
 nature. Thus, the paper on Yitiligoidea is like Dr. 
 Addison's work on ' Disease of the Supra-renal Cap- 
 sules,' in containing cases which seem to be essentially 
 distinct from those on which it is mainly based, and 
 which are really examples of an affection previously 
 undescribed. The analogy may aid us in accounting 
 for the erroneous views which have prevailed as to 
 their real character and importance 
 
 It may perhaps add to the apparent value of this 
 paper if we remark that we do not know of any re- 
 corded example of vitiligoidea, with the exception of 
 those here referred to. Several writers have alluded 
 to the subject in their works upon cutaneous diseases, 
 and some have mentioned in general terms that they 
 have seen cases of a similar kind. But, so far as we 
 are aware, no clinical histories of such cases have been 
 published. It is in most instances tolerably evident, 
 from the way in which the matter is treated, that the 
 writers referred to possessed no well-defined mental 
 images of Yitiligoidea, in the sense in which this term 
 was used by Dr. Addison and Dr. Gull, who invented it. 
 
 It is right to state that the preceding paragraphs are 
 in part based upon the remarks made by Dr. Hilton 
 Fagge at a recent meeting of the Pathological Society, 
 at which he exhibited the two cases of Vitiligoidea 
 which are now under observation at Guy's Hospital.
 
 ON A CERTAIN AFFECTION OF THE SKIN, 
 
 VITILIGOIDEA-a. PLANA, p. TUBEROSA, 
 
 WITH REMAKES AND PLATES. 
 
 THE object of this communication is to call attention to a some- 
 what rare disease of the skin,, which, so far as our observations 
 extend, presents itself under two forms : namely, either as tubercles, 
 varying from the size of a pin's head to that of a large pea, isolated 
 or confluent ; or, secondly, as yellowish patches of irregular outline, 
 slightly elevated, and with but little hardness. Either of these forms 
 may occur separately, or the two may be combined in the same 
 individual. Under the latter circumstances we are able to trace the 
 connection of the two through an intermediate series of gradations, 
 which clearly demonstrate their essential relations. 
 
 It is doubtful whether this disease has been hitherto described. 
 The only account which at all corresponds to it is that given by 
 Willan of vitiligo. He defines vitiligo to consist of " white, shining, 
 smooth tubercles arising in the skin, about the ears, neck, and face, 
 terminating without suppuration." Bateman adds, " this disease is 
 somewhat rare, and perhaps but little known." The plate he gives 
 of it is very unlike the appearances presented by the cases we have 
 seen, yet the further description given by him would, to a certain 
 extent, apply to them. "It is characterised," he says, "by the 
 appearance of smooth, white, shining tubercles, which rise on the 
 skin, sometimes in particular parts, as about the ears, neck, and face, 
 . and sometimes over nearly the whole body, intermixed with shining 
 papulse. They vary much in their course and progress : in some 
 cases they reach their full size in the space of a week (attaining the 
 magnitude of a large wart), and then begin to subside, becoming
 
 158 ON A CERTAIN AFFECTION OF THE SKIN, 
 
 flattened to the level of the cuticle in about ten days. In other in- 
 stances they advance less rapidly, and the elevation which they 
 acquire is less considerable : in fact, they are less distinctly tuber- 
 cular. But in these cases they are more permanent; and as they 
 gradually subside to the level of the surface, they creep along in one 
 direction, as, for example, across the face, chequering the whole 
 superficies with a veal-skin appearance. All the hairs drop out 
 where the disease passes, and never sprout again ; a smooth, shining 
 surface, as if polished, being left, and the morbid whiteness remain- 
 ing through life. The eruption never goes on to ulceration." We 
 have extracted the whole description given by this author of vitiligo, 
 that our readers may judge how near it applies to the cases we have 
 to record. As many particulars are named in it which were not 
 present in our cases, and also many are wanting which we have ob- 
 served, there may be a doubt whether it is here applicable. The two 
 forms of the affection are indicated, and perhaps the want of exact 
 correspondence may be attributable to the want of a sufficiently 
 large number of cases from which to frame a more accurate general 
 description. Believing it to be probable that Willan would have in- 
 cluded the cases here recorded under vitiligo, or an allied affection, 
 we have named them accordingly, distinguishing the two varieties by 
 the terms Yitiligoidea tuberosa, and Vitiligoidea plana. We would 
 note here, that authors have not generally used the ' term vitiligo as 
 Willan and Batenmn used it. Alibert limits it to a simple loss of 
 pigment, without alteration of texture, and in this he is generally 
 followed, Neither Alibert nor Eayer gives any description which 
 would apply to the cases we have to record. The "keloide" affec- 
 tion of these authors is altogether of a different character.* It 
 generally exists as a single tumour, arising either spontaneously 
 or upon a cicatrix. Its course is remarkably slow, and leads, sub- 
 sequently, to contraction and seaming of the skin. 
 
 * Keloide " c'est une excroissance faite aux depens du tissu cellulaire de la 
 peau d'une configuration tantot oblougue et cylindracee, tantot ovale ou ronde, 
 ct bombee d'une couleur rose pale, dure et renitente au toucher, profondemeut 
 adherente et comme incrustee dans le tegument offrant parfois a sa surface une 
 multitude de petites veines iujectees, imitaut assez bien la forme d'une cicatrice 
 qui succederait a une forte brulure poussant d'ordinaire vers ses bords des pro- 
 longemens bifurques, qui ont quelque ressemblance avec les pieds d'une tortue 
 ou les pattes d'un crabe, phenomene constant qui Justine completement la 
 denomination qui a cte imposeepar M. Alibert a cette tumeur veritablement ex- 
 traordinaire." RAYER, Maladies de la Peau.
 
 VITILIGOIDEA a. PLANA, ft. TUBEROSA. 159 
 
 The following is an outline of the history of the cases which we 
 have observed. 
 
 Several years ago a young woman, oet. 24, was admitted into the 
 hospital with a peculiar eruption, extending across the nose and 
 slightly affecting both cheeks. It consisted of shining tubercles, 
 varying from the size of the smallest papule to that of ordinary 
 acne. They were of a lightish colour, with here and there super- 
 ficial capillary veins meandering over them, giving them a faint rose 
 tint. The changes they underwent were very slow; whilst some 
 advanced others subsided. The further course of the case was not 
 ascertained. 
 
 The Model 2733 lst presents an accurate copy of the appearances. 
 
 It was not until the winter of 1848 that our attention was again 
 drawn to the subject, when the following case occurred : Mrs. B , 
 set. 42, of fair complexion and blue eyes, married, mother of eleven 
 children, had been the subject of jaundice for two years, with much 
 pain about the right hypochondria. After the jaundice had lasted 
 fourteen months a change began in the integument, about the eye- 
 lids, and in the palms of the hands and flexures of the fingers. The 
 skin was at this time of a lemon tint. The affection of the eyelids 
 consists of patches of a light opaque colour, with the surf ace, and edges 
 slightly raised, extending from the middle of the upper lid inwards 
 around the inner canthus, and then outwards along the lower lid 
 to nearly the same extent. There is a small isolated patch at the 
 outer canthus. The disease affects both eyes equally and sym- 
 metrically, with the exception of two spots in the right lower lid, 
 about the size of a hemp-seed, more elevated than the rest. The 
 cuticle over the affected parts is healthy. There is no appreciable 
 induration. The patches are more sensitive than the surrounding 
 parts. The capillaries of the cheeks are slightly tortuous. The 
 palms of the hands are of an olive-brown ; along the ridges on either 
 side of the flexures, both of the palms and fingers, there is the same 
 opaque, yellowish discoloration. The appearance is much as if the 
 cuticle were thickened, and the disease confined to it; but, on a 
 complete investigation, it is evident that here, as on the face, it is 
 healthy, and that the morbid change is seated in the cutis, which is 
 rather thickened, altered in colour, and has increased sensibility. 
 The disease remained stationary until death, at the end of four years 
 from the beginning of the jaundice. Towards the end the colour 
 of the general surface deepened to a mahogany-brown. ]\*o affec-
 
 160 ON A CERTAIN AFFECTION OF THE SKIN, 
 
 tion of the 'skin, similar to that described on the face and hands, 
 appeared elsewhere. 
 
 The Models 2733 2d , and 2J33 U , exhibit the appearances presented 
 by this case. 
 
 On the 1 8th August, 1848, a patient was admitted into the 
 hospital, under the care of Dr. Hughes, for diabetes. The following 
 is an outline of his history at the time : John Sheriff, set. 27, of 
 middle stature ; by occupation a tailor, residing near KiDgsbridge, 
 in Devonshire. About six months before he began to pass an un- 
 usual quantity of water, feeling at the same time weak and feverish, 
 with a dry, harsh skin. On admission he presented the ordinary 
 symptoms of diabetes; he voided four pints and a half of urine 
 daily, sp. grav. 1050. The treatment pursued was various, but 
 without any obvious improvement. On the 2jth January of the 
 following year (1849), the quantity of urine was seven pints and a 
 half, sp. grav. 1042. At this time an eruption somewhat suddenly 
 appeared on the arms, at first apparently of a lichenous character. 
 In the course of ten days it had extended over the arms, legs, and 
 trunk, both anteriorly and posteriorly, also over the face and into 
 the hair ; it consisted of scattered, tubercles of various sizes, some 
 being as large as a small pea, together with shining, colourless 
 papules. They were most numerous on the outside and back of the 
 fore-arm, and especially about the elbows and knees, where they 
 were confluent. Along the inner side of the arms and thighs they 
 were more sparingly present, and entirely absent from the flexures of 
 the larger joints. Besides the compound character produced by the 
 confluence of two or three tubercles, many of the single ones had also 
 a compound character, or appeared to have such, as shown by the 
 prominent whitish nodules upon them. Some looked as if they were 
 beginning to suppurate, and many were not. unlike the ordinary 
 Molluscum, but when incised with a lancet they were found to con- 
 sist of firm tissue, which, on pressure, gave out no fluid save blood. 
 They were of a yellowish colour, mottled with a deepish rose-tint, 
 and with small capillary veins here and there ramifying over them. 
 They were accompanied with a moderate degree of irritation, hence 
 the apices of many were rubbed and inflamed. The nature of the 
 eruption gave rise at the time to much discussion. On its first 
 appearance, some suspected it to have a secondary venereal affection ; 
 but there was nothing in the case, nor indeed in the character of the 
 eruption, when carefully examined, to support this view. The only
 
 VITILIGOIDEA a. PLANA, |3. TUBEROSA. 161 
 
 cutaneous affection with which we could associate it, was that of a 
 young woman, whose case we have given above, where the tubercles 
 had occurred in the face only. The eruption continued almost sta- 
 tionary from the end of January to the beginning of March, when 
 many of the tubercles began to subside, having no obvious change 
 in the texture of the skin. At the end of March the patient left the 
 hospital, and the further course of the case was not ascertained. 
 The appearances presented by the eruption in this case are well 
 shown in Model 2733 flth in the museum of Guy's Hospital. 
 
 Up to this time we had, therefore, these three cases of anomalous 
 affection of the skin, without our being able to do more than suspect 
 a relation between the first and the third. Some further light was 
 thrown upon the subject by the following case. 
 
 Eliza Parachute, set. 33, of middle stature, moderately well nour- 
 ished; mother of six children; catamenia regular. Her present 
 illness began in 1848; she attributes it to fright, and to a blow re- 
 ceived in the left groin whilst attempting to separate two men who 
 were fighting. Two days after this she became jaundiced, and had 
 from time to time severe paroxysmal pains about the hypochondria, 
 lasting for a day or two ; the liver being also enlarged and tender. 
 Four months after the commencement of the jaundice (August 4th, 
 1848) she was admitted into the Hospital under the care of Dr. 
 Hughes. She remained in until the 26th of September, and left 
 much in the same state she was in when admitted. There was at 
 this time nothing complained of beyond the itching and irritation of 
 the skin common in jaundice. The present affection began after the 
 jaundice had continued fourteen months, when she again came under 
 the care of Dr. Hughes. It first appeared in the hands, spreading 
 across the flexures of the joints of the fingers and palms. Soon 
 afterwards a yellowish patch of discoloration began near the inner 
 canthus of the eyelid, and then a precisely symmetrical one at the 
 same part on the opposite eyelid. These patches are very slightly 
 raised, and not obviously indurated ; they have extended very slowly. 
 In the early part of the year 1850, two models, 2733 4th and 2733 5th 
 were made of the case. At this time the patches on the face existed 
 as above described. Along the ridges bounding the flexures in the 
 palm and about the joints of the fingers, there were yellowish, opaque, 
 irregular, and somewhat raised lines. About the thumb, first joints 
 of the fingers, and inner and interior parts of the wrists, there is a 
 gradual transition to a tubercular prominence of the affected parts, 
 
 11
 
 16.2 ON A CERTAIN AFFECTION OF THE SKIN, 
 
 and some distinct tubercles exist on the elbow and knee. The dis- 
 eased parts are tender, so as to give her pain in using a knife to cut 
 bread. The whole surface of the body is of a dull lemon tint. 
 Yarious means were employed without avail, the disease showing a 
 tendency to progress slowly. . Through the kindness of Mr. Startin, 
 under whose care the patient now is, we have been able to observe 
 it up to the present time. The jaundice still remains occasionally 
 deepened by the exacerbation of the hepatic symptoms. The skin 
 is of a dull lemon hue. During the last seven months the 
 affection has become more tubercular, especially about the back of 
 the joints of the fingers of the right hand. The patch of con- 
 fluent tubercles on the elbow has much increased since the model 
 was taken. Both elbows are similarly affected. There are also 
 tubercles on the right knee, on the superior surface of the great toe, 
 and on both ears. On the hands the gradations from the plane to 
 the tubercular variety are well marked, and the essential relations of 
 the two forms demonstrable. This case has been of the greatest 
 value in enabling us to connect together the cases which had pre- 
 viously occurred. The tubercles about the ears, elbows, joints of 
 the fingers, &c., are of the same character they were in Sheriff's case. 
 They are firm, rather irregular on the surface; have much the 
 appearance, at first sight, of small compound follicles, but on closer 
 inspection are proved to depend upon a change in the cutis. On 
 the surface small venous capillaries may be here and there seen, pro- 
 ducing a mottled appearance. In the hands we pass insensibly from 
 the tubercles on the back of the joints to the state described in 
 Mrs. B 's case, namely, the slightly raised, opaque, yellowish lines 
 about the flexures of the palms and fingers. The further identity of 
 the disease in the two cases is shown by the presence of similar 
 patches about the eyelids in both. 
 
 Mrs. J , set. 43, of spare frame, and below the middle stature ; 
 married ; mother of two children, and in good health, until about 
 eight years ago, when her catamenia ceased, probably from fright. 
 After their cessation she was never well, had pains about the right 
 side and through the shoulders ; and for several years past, indeed, 
 nearly ever since the commencement of her ailment, has been jaun- 
 diced. She was constitutionally of a dark complexion; this has 
 now become a deep olive brown. During the last five years there has 
 been a gradual change in the integument of the eyelids, giving her 
 a strange expression. This affection of the skin began in the upper lid
 
 VITILIGOIDEA a. PLANA, /3. TUBEROSA. 163 
 
 of the left eye, and extended round by the inner canthus to the lower 
 lid. A similar affection then commenced in the right eyelid, and the 
 appearances now presented by the two are remarkably symmetrical. 
 The surface of the affected parts is slightly raised, and the edge 
 denned. The colour is a light opaque yellow, ' ' coloration feuille 
 morte," with a mottling of the faintest rose tint, with a small mean- 
 dring vessel or two especially on the patches, which are recent and 
 extending. On passing the finger over the surface, there is a slight, 
 yet but very slight, feeling of resistance. The older spots are the 
 most raised. The cuticle is unaffected, and by slight tension of the 
 skin, will be seen to pass unchanged from the normal to the diseased 
 parts. The discoloured patches often smart, and to use the patient's 
 expression, "seem as if gathering;" they have also an increased 
 sensibility. 
 
 It will be observed, that, as the disease extended it has run along 
 the lids so as to avoid the Meibomian region, and that in the left 
 eyelid are two sebaceous follicles, enlarged and filled with dark pig- 
 ment cells ; during the last two years a spot of black pigment has 
 appeared on the mucous membrane of the lower lip. The whole 
 course of the disease has been very slow, and its increase, by degrees, 
 almost insensible. There is no affection of the skin of any other 
 part of the body, beyond the change in its colour above indicated. 
 The liver is enlarged, and there is much tenderness about the left 
 hypochondria. The urine contains bile ; and the conjunctivas are of 
 a decided jaundiced tinge. 
 
 We have preferred thus recording the cases which have formed 
 the source from which our knowledge of this affection is drawn, to 
 giving any more abstract dissertation upon it ; hoping thus that the 
 experience of others may be the more easily compared with our own, 
 for, doubtless, cases of the like kind have occurred to most ; although, 
 until attention is especially drawn to a subject, the individual im- 
 portance of isolated cases is apt to be overlooked. The connection 
 of this affection of the skin with hepatic derangement is obvious, and 
 the exception which occurred in diabetes is of the more interest, in- 
 asmuch as modern pathology points to the liver as the faulty organ 
 in this disease. In what way the defective action of the liver 
 operates, can, perhaps, be no further explained at present, than by 
 the general theory of disordered circulating fluids. It is a matter 
 of experience, that varions affections of the cutaneous surface, such 
 as numbness, itching, lichen, urticaria, &c., are closely connected
 
 164 VITILIGOIDEA . PLANA, Q. TUBEROSA. 
 
 with jaundice, depending, probably, upon the direct action of the 
 morbid fluids upon the cutaneous tissues. 
 
 The treatment of these cases has been hitherto unsuccessful. 
 They have manifested an inveteracy equal to that of the morbid con- 
 ditions of the liver, with which they seem to be associated. In the 
 case of Sheriff, many of the tubercles had slowly subsided before he 
 left the hospital, but in the others there was no tendency to disap- 
 pearance, especially in the patches r about the eyelids. Some slight 
 benefit seemed to follow the careful and repeated application of 
 Nitrate of Silver, but when the disease is extensive this would hardly 
 be practicable. Mrs. Parachute informs us, that although none of 
 the tubercles have disappeared, yet they are now rather less promi- 
 nent than they were a year ago.
 
 ON THE 
 
 KELOID OF ALIBERT, 
 
 AND ON 
 
 TRUE KELOID. 
 
 PREFACE. 
 
 THIS paper on " the Keloid of Alibert" has recently 
 acquired a new interest from the light thrown upon 
 the subject by the researches of Dr. Hilton Fagge 
 ('Guy's Hospital Reports,' 1868). Dr. Fagge, al- 
 though he considered that Addison was labouring 
 under some error as to the connection of the disease 
 known by this name with that described by Alibert, 
 has arrived at the conclusion that, for this very reason, 
 Addison exhibited, in his description of it, more origi- 
 nality than is generally supposed. 
 
 Addison described a very remarkable affection of the 
 skin characterised by an indurated and scar-like con- 
 dition, and which before that time had found no place 
 in literature. It so often presented an appearance so 
 closely resembling that of a cicatrix from a burn or 
 scald, that the most appropriate term for it which 
 occurred to Addison' s mind was " kelis" or " keloid." 
 As, however, Alibert had already adopted the word
 
 11 PREFACE TO KELOID. 
 
 " cheloide" to represent an affection of the skin which 
 he had described, Addison, with that deference which 
 is the characteristic of the honest, scientific labourer, 
 adopted the term, regarding the condition which he 
 had observed as simply a variety of the form previously 
 described by Alibert. This adoption arose from the 
 belief that the expression " cheloide" by Alibert was 
 derived from the Greek " icr?AU-, a scar or brand," a 
 term so perfectly apposite to the cases which had come 
 under his observation. It is curious that when 
 Addison insisted on spelling the word with a " K" 
 that it should not have occurred to him that Alibert's 
 term, differently spelt, had another derivation. 
 
 Dr. Hilton Fagge has now cleared up the difficulty 
 by his discovery of Alibert's original paper, read before 
 one of the societies, in which he does not apply to 
 the disease which he describes the term " K>jXic" at all. 
 
 The paper is a description of cases in which tumours, 
 having a superficial resemblance to cancer grow on the 
 skin, and which he at first styled " cancroide ;" but 
 recognising the confusion to which this term might 
 give rise, he substituted for it the name " cheloide," 
 derived from " x^V a claw of a crab, which was the 
 Greek equivalent. 
 
 It would thus appear that Addison 5 s appellation 
 " keloid" was an entirely original expression, adopted 
 under a wrong conception of Alibert's meaning ; and 
 that Alibert's " cheloide" and Addison' s " keloid" are 
 distinct diseases, the one having a significance differing 
 from that of the other. 
 
 Dr. Fagge has, moreover, shown that subsequently 
 to the publication of Addison's paper on this subject,
 
 PREFACE TO KELOID. iii 
 
 several German and French writers have described 
 remarkable affections of the skin under the names of 
 " scleroma" or " scleriasis," which, in his judgment, 
 are identical with Addis on' s " kelis." 
 
 It will, therefore, be desirable that future writers on 
 the subject should be agreed upon some common 
 designation ; and as Addison's title is so like the one 
 already in use for the definition of Alibert's disease, it 
 is possible that the term " scleriasis" may be best 
 adapted to general acceptation. 
 
 We do not reprint " The Practice of Medicine" 
 which he published conjointly with the late Dr. 
 Richard Bright, nor the paper on " The Actions of 
 Poisons" by Morgan and Addison, because it is im- 
 possible to distinguish what share he had in the 
 publication of either.
 
 ON THE 
 
 KELOID OF ALIBEKT, 
 
 AND ON 
 
 TRUE KELOID. 
 
 Read before the Royal Medical and Chirurgical Society, Feb. 28! A, 1854. 
 
 THE term keloid, or kelo'ide, the name given to the singular affec- 
 tions of the integument about to be described, has been variously 
 interpreted; some deriving it from K.r]\r\, a tumour; others, in 
 reference to certain supposed resemblances, from \r\\r\, a crab's 
 claw ; or from \t\ve, a tortoise ; whilst others, apparently with 
 much greater propriety, derive it from KTjAlc, ' quasi ustione facta 
 macula,' the disease in every instance presenting a greater or less 
 resemblance to some one of the diversified effects left by a burn. 
 
 The more immediate object of this very slender communication 
 is to show that the keloid originally described by Alibert, and now 
 so generally recognised, is altogether different in its mode of de- 
 velopment, character, and progress, from another disease occurring in 
 the same tissue, and to which, with much greater aptitude, the term 
 keloid may be applied, if we are to regard resemblance to the effects 
 of a burn as its correct interpretation ; for I think it will be shown, 
 that whilst the keloid of Alibert and others can hardly be regarded 
 otherwise than as a fibrous tumour developed in the subcutaneous 
 areolar tissue, the other form of disease to which I have alluded, 
 although originating in the same tissue, is of a character and leads 
 to consequences widely different. In order, however, to illustrate 
 and confirm this proposition, it will be necessary to give a descrip- 
 tion of both diseases ; and in so doing, I will, as far as possible,
 
 170 KELOID OF ALIBERT, 
 
 avoid trespassing too much upon the time and attention of the 
 Society. 
 
 I propose distinguishing the two diseases in question by the terms 
 "Keloid of Alibert," and " True Keloid." 
 
 KELOID OP ALIBERT. 
 
 I have given the name " Keloid of Alibert" to this form of dis- 
 ease, because I believe Alibert to have been the first to discriminate 
 and accurately describe it. In his celebrated work, ' Description 
 des Maladies de la Pe.au/ will be found a very accurate representa- 
 tion of it, executed with all the artistic skill, and perhaps a little 
 of the exaggeration of colouring, for which that work is so remark- 
 able. He there suggests its holding a middle place between what 
 he so vaguely and indiscriminately calls " dartre" and cancer, and 
 was led in consequence to give it the name of " cancroide/' like 
 cancer; further justifying the appellation, however, by comparing, as 
 others have done, the claw- like rays or processes of the extending 
 disease to the claws of a crab. Since the period of Alibert's ori- 
 ginal publication, several other writers have furnished cases and 
 commentaries to illustrate the character, progress, or pathology of 
 the disease. Amongst these we find the names of Biett, Yelpeau, 
 Cazenave, Coley, and others; but by far the most complete and 
 elaborate essay on the subject has only lately been written by Dr. 
 Dieburg, of Dorpt, and published in the 'Deutsche Klinik' at 
 Berlin, and for a knowledge of which I am indebted to my 
 colleague Mr. Birkett and Dr. Whitley. 
 
 The keloid of Alibert first appears in the form of very small, 
 hard, shining, tubercular-looking elevations, of a roundish or oval 
 shape, somewhat firmly set, of a dusky or deep red colour, and 
 generally attended with itching or pricking, shooting or dragging 
 pains in the part. These tumours slowly increase until they attain a 
 height of two or three lines, and comprise an area varying from that 
 of a horse-bean to that of a small almond. So long as they con- 
 tinue to be abruptly prominent, the summit, or even the entire sur- 
 face of each tumour, instead of remaining uniformly red, not unfre- 
 quently presents a pale or blanched appearance, as if from pressure 
 of the increasing tumour upon the cutis situated above it, and which 
 might at first sight be mistaken for some sort of fluid effusion. On 
 close inspection, however, it is found, that from far as this being the 
 case, the tumour displays a hardness, firmness, and elasticity, which
 
 AND OF TRUE KELOID. 171 
 
 almost convey the notion of so much fibro-cartilage, to which in- 
 deed it has been not unaptly compared. After an uncertain period, 
 these hard shining tumours become broader, of more irregular out- 
 line, and occasionally slightly depressed in the centre. At this time, 
 and sometimes even earlier, by the aid of an ordinary magnifying 
 glass, or by the naked eye, delicate whitish tendinous-looking lines 
 may be perceived, stretching across the surface of the tumours, 
 mingled with minute blood-vessels of a bluish, purplish, or pinkish 
 colour. The extension of each individual tumour now seems to be 
 effected by certain tapering claw-like processes of seldom more than 
 from half a line to a line in breadth, and probably from a quarter of 
 an inch to as much as an inch in length, proceeding from the edges 
 or angles of the expanding tumour. These claw-like processes 
 appear to produce a puckering of the skin ; and, as it were, draw 
 the healthy integument into which they pass, towards the original 
 excrescence, and within the influence of the local changes ; appear- 
 ances, nevertheless, which are probably the mere consequences of 
 the stretching and dragging of the integument occasioned by the 
 increasing size of the tumour beneath. 
 
 The slow and gradual increase of these tumours may proceed 
 for months or years, and at last attain a size of an inch, an inch 
 and a half, or two inches in length, as much as half an inch or an 
 inch in breadth, and probably an elevation of three or four lines 
 above the level of the surrounding skin. There may be but a single 
 tumour, or there may be several ; when more than one, they may 
 be congregated together in the same neighbourhood, or may occupy 
 parts of the integument remote from each other; when of the 
 largest size, the tumour may so stretch and attenuate the integument 
 as actually to protrude beyond it, exposing a red shining excoriated- 
 looking surface. The development of the tumour is occasionally 
 preceded or accompanied by heat, and some degree of puffiness or 
 tumefaction of the surrounding parts, but without redness or other 
 discoloration; a state of things, indeed, which may temporarily 
 supervene at any period of the disorder, either in consequence of 
 some accidental cause of general excitement, some irritation applied 
 to the tumours themselves, or spontaneously, and without any very 
 appreciable cause whatever. 
 
 From the very commencement, as has been already observed, the 
 disease is attended with itching and pricking sensations, which, as 
 the former increases, are aggravated to a sense of constriction, or to
 
 172 KELO1D OF ALIBERT, 
 
 severe pricking or stabbing pains, which prove extremely distressing 
 to the patient. Under such circumstances, pressing or handling the 
 tumour is loudly complained of ; the sufferings of the patient, if a 
 female, are not unfrequently such as to harass her during the whole 
 of the day, and almost completely to deprive her of rest at night. 
 
 The morbid deposit which essentially constitutes the keloid of 
 Alibert takes place in the subcutaneous areolar tissue, between the 
 cutis and adipose membrane. The occasional heat and tumefaction 
 of the neighbouring integument, as well as the itching pain and 
 redness of the tumour itself, sufficiently attest that the morbid 
 process is at least accompanied by a degree of vascular excitement 
 nearly allied to inflammation, an inflammatory state which, it would 
 appear, gives rise to a certain amount of adhesion amongst the 
 meshes of areolar tissue around; and, as we know that tumours of 
 considerable size may be developed in the subcutaneous areolar 
 tissue without either uneasiness, pain, or any very obvious change 
 in the appearance of the skin itself, I am inclined 'to attribute to 
 this accompanying inflammatory and adhesive process the fixed 
 condition of the tumour, the great vascular injection of the super- 
 incumbent skin, and the intensity of the local pains, as well as those 
 remarkable puckerings of the integument which attend the increase 
 of the tumour, and constitute the claw-like processes from which 
 some have derived the name " keloid ." 
 
 The disease most frequently attacks females from the age of 18 
 to 35 or more, and in a large majority of instances is found situated 
 near the sternum, between or upon the mamma? ; it nevertheless 
 occasionally affects the male, and in both sexes has been known to 
 occur on other parts of the body, as the arms, shoulders, neck, 
 belly, or even the head or face. Alibert, as already observed, con- 
 sidered it in some way allied to cancer ; an opinion unsupported by 
 any facts with which I am acquainted ; whilst others, with perhaps 
 no better evidence, have attributed the predisposition to a scrofulous 
 taint. The development of the disease in different parts of the 
 integument at the same time, or in succession, and its almost certain 
 recurrence after extirpation by the knife or by caustics, clearly point 
 to some peculiar constitutional condition ; but what that condition 
 is remains to be ascertained. All that we at present know respect- 
 ing the exciting cause of the disease, amounting to no more than 
 the fact, that, instead of arising spontaneously, on parts to all 
 appearance previously sound, as is commonly the case, it has not
 
 AND OP TRUE KELOID. 173 
 
 % 
 
 unfrequently been observed to be developed upon and apparently 
 excited by a cicatrix, as of a bum, a boil, or a recent wound, such 
 as that inflicted by the punishment of flogging. To the disease, 
 when occurring under the latter circumstances, Alibert, in a subse- 
 quent work, applied the term spurious or false Jceloid the cicatrix 
 keloid of Dieburg a form of the complaint, however, which is 
 sometimes altogether painless. 
 
 CASE i. (PI. I58 5 , Model 231, 23I 11 ) 1 reported by Mr. Pratt. 
 Susannah Black, set. 18, a single person, who has been residing 
 with her mother, at Snowsfields, was admitted on the 6th October, 
 1853, having been transferred from No. 5, Mary, by permission of 
 Dr. Babington, under whose care she had been since the I4th ult. 
 
 She is below the middle height ; has dark hair, eyes, and com- 
 plexion ; a narrow forehead and heavy expression ; but seems intel- 
 ligent and is highly hysterical, and was formerly apprenticed to a 
 laundress, but not strong enough to continue this occupation. 
 
 Her catamenia first appeared at the age of 15, and have recurred 
 regularly since, generally continuing about three days, but with pain 
 in the back and loins, and during the last two years with clots, 
 sometimes of the size of a shilling. 
 
 Her father died of diseased heart, but the other members of her 
 family are healthy, and none of her relations have suffered as she 
 now does. 
 
 She is marked by the smallpox which she had when three or four 
 years old, but does not look unhealthy, and states that she was 
 always in good health until about two years ago, when, from expo- 
 sure to cold at Gravesend, while lightly clad, she first became ill, 
 with pain in her head and right side, and at the scrobiculus cordis, 
 shooting thence to the back. Six weeks after this, in Berkshire, 
 having been gradually getting worse in the meanwhile, with loss of 
 appetite and increase of pain, which for a time was so severe as to 
 keep her in a bent position, but occasionally left the scrobiculus 
 cordis and appeared in the loins, she suddenly vomited about a pint 
 of dark clotted blood, after which she became better, but did not 
 lose the pain in her back, and suffered from palpitation of the 
 heart. About three months after this, having returned to London 
 in the interim, the vomiting of blood recurred, and from this time 
 was repeated at intervals, sometimes of two or three months, at 
 1 The references are to plates and models in Guy's Hospital Museum.
 
 174 KELOID OF ALIBERT, 
 
 others of two or three weeks only, until a few days before admission ; 
 and once in the hospital, about two weeks since, she brought up a 
 teacupful of blood. 
 
 About twelve weeks since she had a gathering in her right breast, 
 which discharged a small quantity of matter ; two weeks after, and 
 just as this was healing, her neck, chest, and both breasts swelled a 
 good deal, with a dull aching pain, but without oedema ; one week 
 after this, or two or three days after the swelling had subsided, she 
 first noticed two small red pimples on the right breast, at its upper 
 and inner part, which were painful, with a pricking sensation, and 
 tender. Then, about one week after, two other similar raised spots 
 appeared on the left breast, at about the same position, but not 
 symmetrical, and then two smaller ones above these ; these all gra- 
 dually increased in size ; but in varying degrees, and, as they did so, 
 at certain stages of their existence became white (?). 
 
 There are at present two raised spots on the right breast, nearly 
 oval in shape, and of considerable size ; four on the left breast, two 
 large and two small : one on the upper part of the sternum ; several 
 at the upper part of the abdomen ; and one on the left shoulder ; 
 and a cluster of equivocal white spots at the lower part of the back 
 on the right side. 
 
 They seem to be in every stage of existence ; some small, red, or 
 white; others of varying size, more vascular, generally of a red 
 colour, and marked with small vense, and traversed by peculiar white 
 lines ; but they all change colour occasionally (?) from white to red 
 or even purple, and have a peculiar, firm, and unyielding feel. They 
 have always a dull and aching sensation, converted into a more acute 
 pricking pain by pressure ; are more or less raised above the level 
 of the surface, the largest as much as one eighth of an inch, or even 
 more; have irregular margins, much resembling the contraction of 
 a cicatrix, and appear to increase in size by an extension of the 
 white lines which traverse them into the surrounding tissue, like 
 feelers, to which, indeed, their irregular margins are due. 
 
 Her chest is well formed, her nutrition good ; she seems to be 
 subject to boils ; has old cicatrices of venesection on each arm, and 
 a small hard nodule on the left side of the neck, just above the 
 sterno-clavicular joint, resembling an enlarged gland. Her tongue 
 is white and moist : her pulse 80, full and regular ; her countenance 
 rather flushed ; her bowels, which have been much relaxed, now act 
 about three times daily, the motions being very loose ; her appetite
 
 AND OF TRUE KELOID. 175 
 
 is bad; she complains of pain in her head, across the top. The 
 sounds of respiration and of the heart are normal, as well as the 
 resonance of the chest on percussion, but the heart's impulse is 
 strong and heaving, and the pulsations of the aorta felt above the 
 sternum. 
 
 CASE ir (Model 229, pi. I58 57 , pi. I58 54 ), furnished by Mr. 
 Whateley, surgeon, of Berkhampstead. William Garrett, set. 37, 
 applied to me, about May, 1851, with a small tumour on the skin 
 of the left breast, slightly elevated above the surrounding skin, 
 silvery red in appearance, exquisitely tender, and about one inch in 
 diameter. I recommended its removal, to which he would not then 
 consent. On seeing him about a month afterwards, there was a 
 second appearing, about an inch from the first, and subsequently a 
 third. Such being the case, and fearing that others might still 
 appear, I did not think it advisable to press the operation. He 
 was then sent to Guy's Hospital, at the request of the late Bransby 
 B. Cooper, Esq., in order that a model, &c., might be taken of the 
 tumour in its then state. 
 
 After remaining some time, he again came into the country, and 
 was under my care at the West Herts. Infirmary. 
 
 The tumour still continuing to grow, and the three having coalesced 
 into one, and having no appearance of any fresh growth in the 
 neighbourhood, I again advised an operation, to which he consented, 
 and I removed it on the loth of May, 1852, removing with it about 
 a quarter of an inch of the sound skin all round, and fully down to 
 the bone. The wound was dressed with warm water dressing and 
 oil-silk, and was cicatrized. The cicatrix is now sound, and the 
 man in good health. 
 
 The tumour, when freshly cut through, in structure, colour, and 
 appearance most nearly resembled a cow's udder. 
 
 The slight sketch, No. 4, represents the result of a microscopic 
 examination of the tumour, made, however, under very unfavorable 
 circumstances, by Dr. Habershon, of Guy's Hospital. 
 
 A more minute and careful examination of a keloid tumour has 
 been supplied by Dr. Dieburg, of whose account of it the following 
 is a translation : 
 
 " On section we observe a dull white colour, a dense tissue in 
 which fibrous structure is visible to the naked eye, and a creaking 
 sound is produced by the knife. On pressure, no fluid exudes in
 
 176 KF.LOID OF ALIBERT, 
 
 most cases ; in a few, a watery fluid is seen, sometimes reddened by 
 blood. This is characteristic, as different from the ' tumores verru- 
 cosi cicatricum' of C. Hawkins, from which a peculiar fluid may 
 generally be expressed. Microscopical examination shows the dif- 
 ferent stages of development of the cells and fibres. "We distin- 
 guish i. More or less rounded bodies, the largest 0*05 of a milli- 
 metre ; in their interior, we see a nucleus, and frequently other 
 molecules. 2. Cells elongated in the direction of one of their 
 diameters, in great numbers : they seem to constitute a character- 
 istic element of all the tumours of ' cicatrix-keloid' (spurious keloid 
 of Alibert). These cells, called by Follin 'elliptical bodies/ are 
 rounded at their extremities, and their sides present central bulging. 
 These cells are about 0*0 1 millimetres in breadth, and 0*06 in 
 length. They contain a nucleus easily distinguishable by its bright- 
 ness from the dull surrounding parts. 3. Spindle-shaped bodies, 
 bulging in their centre, and having long, waving appendages. 4. 
 Fibres of cellular tissue and elastic fibres. The fibres of cellular 
 tissue are formed into bundles, which cross each other, and consti- 
 tute a pretty dense web. The elastic fibres are less numerous and 
 larger than the latter, and are not easily seen without immersion in 
 acetic acid. When a slice of keloid in an early stage of develop- 
 ment is placed under the microscope, it is found to consist almost 
 entirely of the spindle-shaped bodies ; at a somewhat later period 
 these are seen to have lost their nuclei, and assumed a fibrous ap- 
 pearance : this is most frequent. At a still later period, we see 
 distinct fibrous bundles, crossing each other, and by immersion in 
 acetic acid the elastic fibres become visible. The whole is nou- 
 rished by a comparatively small number of blood-vessels. The sur- 
 face is covered by a very thin layer of epidermis, consisting of 
 tesselated cells, very closely pressed together, which require softening 
 before they become visible under the microscope/' 
 
 The following translation from M. Lebert's ' Traite pratique des 
 Maladies Cancereuses, et des Affections curables, confondues avec le 
 Cancer/ will probably not be considered out of place. 
 
 " Among the cases of spontaneous and multiplied keloid that we 
 have observed, there were two especially curious, in consequence of 
 their multiplicity and extent. In one case, under M. Velpeau, at 
 ' La Charite/ the whole pectoral region of one side was covered with 
 these tumours; many of which were sufficiently large to have 
 reddened and eroded the surface of the skin at their borders.
 
 AND OF TRUE KELOID. 177 
 
 "In the second case, a child set. 101 had a very great number of 
 keloid tumours, developed upon its back, red on their surfaces, and 
 which had formed in the cicatrices which were consecutive to nume- 
 rous applications of caustic potash, applied to the poor child by a 
 charlatan, who promised to cure, by this method, a scrofulous dis- 
 ease under which the child laboured/'' 
 
 I may add to this passage from Lebert, the fact, that I have 
 myself very recently been consulted in the case of a young lady of 
 about eighteen years of age, upon whose back, shoulders, and breast, 
 I counted as many as thirty keloid tumours. I was told that they 
 originated in the cicatrices of boils which broke out about six or 
 seven months before. From the situation, it had been a case pro- 
 bably of acne. 
 
 In regard to treatment little can be said. Various internal and 
 external remedies have been tried in vain ; and when extirpated by 
 the knife or destroyed by caustics, the disease has, I believe, very 
 generally returned on the seat of the original disease. When, how- 
 ever, the disease has been first developed in a cicatrix the spurious 
 keloid of Alibert extirpation has proved more successful, the dis- 
 ease not having again made its appearance in several instances. It 
 has indeed been asserted that the keloid tumour may subside sponta- 
 neously, leaving behind a white and depressed cicatrix; but I 
 believe this to be extremely rare, and is in itself a very improbable 
 event, after the tumour has attained any considerable size. 
 
 TRUE KELOID. 
 
 What I have ventured to call " True Keloid" presents a very 
 remarkable character, and leads to much more serious consequences 
 than the keloid of Alibert. It is a disease, too, which, so far as I 
 know, has not hitherto, with the exception of a slight allusion of 
 Dr. Coley, been either noticed or described by any writer. Like 
 the keloid of Alibert, it has its original seat in the subcutaneous 
 areolar tissue, and is first indicated by a white patch or opacity of 
 the integument, of a roundish or oval shape, and varying in size 
 from that of a silver penny to that of a crown piece, very slightly 
 or not at all elevated above the level of the surrounding skin, and 
 probably unattended, in the beginning, with pain or any other local 
 uneasiness or inconvenience, although a more or less vivid zone of 
 redness surrounding the whole patch, or a certain amount of venous 
 
 12
 
 178 KELOID OF ALIBERT, 
 
 congestion in its immediate vicinity, sufficiently attests the vascular 
 activity or inflammatory process going on in the parts beneath. 
 Occasionally, and especially when the original white patch is of 
 considerable diameter, its surface presents here and there a faint 
 yellowish or brownish tint communicating to the whole spot a some- 
 what mottled appearance. The slow and insidious change taking 
 place in the areolar tissue either stops and the spot disappears, or it 
 proceeds, and at length begins to declare itself by a feeling of itch- 
 ing, pain, tightness, or constriction in the affected part, and fre- 
 quently by a certain amount of subcutaneous hardness and rigidity, 
 extending 'beyond the site of the original superficial patch, although 
 as yet without any necessary change in the appearance of the super- 
 incumbent skin. This hardness and rigidity can be distinctly felt, 
 and, especially w 7 hen situated on the extremities, may sometimes be 
 traced along the ^course of the neighbouring tendons or fasciae, or 
 stretching like a cord along the limb, so as to bend or shorten it, 
 and even interfere with natural progression. At length the part 
 originally affected becomes more or less hide-bound, and a similar 
 change taking place around the more superficial fascia? and tendons, 
 the latter become so tightened, fixed, and rigid, as to be no longer 
 capable of performing their proper functions, and to such an extent, 
 that the whole of a limb, but especially the fingers, may be perma- 
 nently contracted, bent, and rendered almost as hard and immov- 
 able as a piece of wood ; thereby impeding progression, distorting 
 the gait, and making the patient a poor miserable cripple for the 
 remainder of his life. 
 
 As these changes proceed, the patient continues to experience 
 itching, pain, or a sense of tightness or constriction of the parts, 
 till at length the disease begins to tell upon both cutis and cuticle. 
 The skin, which may have previously presented only a slightly drawn 
 or puckered look, imparting, to a greater or less extent of it, a 
 ray-like appearance, now shrinks or shrivels ; it assumes a dry, 
 smooth, or glistening aspect ; it undergoes a more decided change 
 of colour, becoming reddish, pinkish, yellowish, or of a dead leaf 
 colour; the cuticle exfoliates; the cutis manifests a tendency to 
 superficial ulceration or excoriation, with consequent scaliness or 
 scabbing, or, when not excoriated, is occasionally surmounted by 
 obscure tubercular or nodular elevations the whole appearance 
 very closely resembling the remains of an extensive and imperfectly 
 cicatrised burn. Prom some part of the boundary of the discoloured
 
 AND OF TRUE KELOID. 179 
 
 and shrivelled skin, there may now and then be seen reddish, ele- 
 vated, claw-like processes, of from half an inch to two inches in 
 length, extending into the sounder integument, and bearing a very 
 exact resemblance to those mentioned as being so characteristic of 
 the keloid of Alibert. It must also be observed that, during the 
 progress of the disease, it is by no means uncommon to find, scat- 
 tered over various parts of the apparently sound surface, certain 
 oval or roundish and flattened tubercular-looking elevations, which 
 are somewhat hard to the touch, about the size of a split pea or 
 horse-bean, and without any other discoloration than what appears 
 to be the result of accidental friction or irritation. 
 
 The above description of true keloid clearly points to some morbid 
 change slowly taking place in the subcutaneous areolar tissue, whilst 
 the itching, pain, and uneasiness experienced by the patient, the red 
 zone surrounding the patch, and the injection of the neighbouring 
 veins, as well as the subsequent appearances presented by the parts 
 affected, would indicate that the morbid process going on in that 
 tissue is one very nearly allied to inflammation, probably of a strumous 
 kind. It would also appear that the inflammatory product, by its 
 subsequent contraction, seriously interferes with the proper nutri- 
 tion of the cutis, fixes it more or less firmly to the parts beneath, 
 and, when deposited in the immediate neighbourhood of fasciae and 
 tendons, may, probably, after the lapse of months or years, lead 
 to all those serious inconveniences which I have already described. 
 
 I will not abuse the patience of the Society by entering into any 
 speculations respecting the origin and essential nature of this very 
 singular disease ; neither is it necessary to dwell upon plans of treat- 
 ment, further than to observe that, with the exception of iodine, 
 none of the many remedies tried seemed, in extreme cases, to make 
 the slightest impression upon either the appearance or the progress 
 of the disorder. In one instance, however, less advanced, iodine, 
 taken internally, with the simultaneous application of iodine oint- 
 ment to the affected parts, did appear to arrest the advance of the 
 local changes, and somewhat lessen the rigidity of the affected ten- 
 dons. Whether the preparations of iodine administered at a very 
 early period of the disorder would prove more effectual, I have had 
 no opportunity of ascertaining, although I am inclined to entertain 
 a strong opinion in its favour. 
 
 The following case presents an example of the disease in its 
 earlier stages :
 
 180 KELOID OF ALIBERT, 
 
 CASE in (Models 222, 223, 224, PI. I58 52 ), reported by Mr. 
 Towne. Eliza Watkins, a young woman between 19 and 20 years 
 of age, of ruddy complexion, fleshy and well looking, with light 
 eyes, and hair tending to red, presented herself amongst the out- 
 patients of Guy's Hospital early in June last. 
 
 She was in the situation of lady's-maid, and had for some time 
 been residing at Cheltenham. Her general health was good, and at 
 this time apparently undisturbed. She had been suffering from pain 
 and stiffness in the left arm and left leg, for which she was now 
 seeking relief. 
 
 The first appearance of the disease had been noticed twelve 
 months previously, when a small white spot, about the size of a 
 shilling, was observed on the left side ; but, as neither pain nor in- 
 convenience accrued, no anxiety was felt with reference to it until 
 about eleven weeks prior to her appearance at the hospital, when she 
 first became sensible of pain, attended with a dragging sensation in 
 the left arm and left leg, both limbs being affected simultaneously. 
 Medical assistance was now called in; poppy fomentations were 
 ordered, and for some time persisted in ; the disease still making 
 slow but steady progress. 
 
 The lady with whom she was living, having occasion to visit 
 London, brought the young woman with her, and took the oppor- 
 tunity of having a second opinion. The case was now treated as a 
 sprain ; but the patient, not feeling satisfied, determined to come 
 to the hospital. 
 
 The two limbs were in a very similar condition. Atj[this time 
 they presented to the eye but slight indications of the disease, which 
 principally consisted in a hard, drawn, tight look, on the limb being 
 extended ; there might, however, be felt, through nearly the whole 
 length of both arm and leg, a rigid band, which gave to the touch 
 the impression of some inelastic substance tightly strained under the 
 integument. 
 
 The shoulders presented a mottled appearance, and had several 
 whitish patches interspersed with numerous small tubercular -looking 
 growths. There also existed a chain of spots which nearly sur- 
 rounded the right nipple, and several others about the neck and 
 breasts. The spot on the left side (described as the first appearance 
 of the disease) had now attained the size of a five-shilling piece, 
 and had thrown out a band upwards towards the cartilage of the 
 ribs, and a second descending towards the pubes.
 
 AND OF TRUE KELOID. 181 
 
 During the second week in August, I again saw the patient. 
 The pain in the arm and leg had much increased, with " a feeling of 
 shortening" in the limbs affected; and, after sitting for some time, 
 it was with difficulty the foot could now be extended. The band down 
 the arm had become more distinctly expressed, had assumed a slightly 
 tendinous and glistening character, and had thrown out several small 
 lateral processes. A fresh spot had appeared on the upper lid of 
 the left eye, and a second on the outer side of the right leg. Those 
 on the shoulders had become more evident ; the larger one had in- 
 creased in size, become yellowish in colour, glazed on its surface, 
 was hard to the touch; and did not move freely with the surrounding 
 integument. 
 
 The next case exemplifies a more advanced stage of the disease : 
 
 CASE iv (Model 225, PL I58 46 ), reported by Mr. King. 
 Louisa Burston, set. i T, was admitted, under Dr. Addison, December 
 8th, 1852. 
 
 The patient, who is a very strumous-looking subject, was very 
 strong and healthy as a baby, but was noticed to be slightly rickety 
 when she began to walk ; this was between eighteen months and 
 two years of age ; but when she was three and a half or four years 
 old she had nothing remarkable about her. 
 
 From this time her mother always considered her delicate; but, 
 beyond frequent attacks of ophthalmia, which have deprived her of 
 most of her eyelashes, and appear to have been of a strumous 
 character, she has never suffered any decided illness. 
 
 Attention was first directed to the right thigh, about fourteen 
 months ago, on account of complaints on the part of the child 
 of itching in that situation ; and this appears to have been so in- 
 tense, that measures were taken, by tying her hands, &c., to prevent 
 her flaying herself. "When first examined, red spots, like flea-bites, 
 were observed thickly studding the inner part of the thigh, about its 
 middle third, but not imparting any feeling of elevation to the finger. 
 
 This condition lasted about a fortnight, and was then succeeded 
 by a flaky desquamation of the cuticle, which persisted for two 
 months, during which time the itching continued to be almost in- 
 tolerable, and when the part was scratched the spots before alluded 
 to would reappear. About or soon after this time the part began to 
 feel thickened, puckered, and hard, and gradually assumed its 
 present appearance.
 
 182 KELOID OF ALIBERT, 
 
 On the right thigh, about one inch below Poupart's ligament, 
 and nearer the spine of the pubes than the crest of the ilium, com- 
 mences this singular appearance of the skin, which more nearly 
 resembles the scar left by a burn than anything else. There is a 
 strip, about one inch broad, nodulated and irregular on its surface, 
 and discoloured in a peculiar manner, being partly red, with a pre- 
 dominance of a light brown tint. 
 
 This strip of disease proceeds down the thigh, following the course 
 of the sartorius muscle as far as the junction of the upper two 
 thirds with the lower third of the thigh, at which point the most 
 marked discoloration of the skin ceases ; but it is found, by exami- 
 nation with the finger, that the same condition of the cellular tissue 
 follows the sartorius to its insertion, and also appears to involve the 
 tendons of the internal hamstring muscles. 
 
 In the lower part of the same leg the cellular tissue over the an- 
 terior part of the ankle appears to have become involved, and, in 
 particular over the internal malleolus, the integument is firmly- 
 attached to the bone. 
 
 She has at the present time no peculiar sensation in the affected 
 parts, nor is the use of her leg in walking at all impaired. 
 
 Since she has been in the hospital she has taken various medi- 
 cines, without the slightest perceptible effect. 
 
 The next is an instance of the disease in its most aggravated form, 
 reported by Dr. Collingwood. (Models 228, 227, PI. I58 55 , I58 45 .) 
 
 Elizabeth Alexander, set. 12, resides at Ellirfield, in Hampshire, 
 where her father follows the occupation of shepherd. She has 
 a comfortable home, plenty of wholesome food, and attends the 
 village school. The following account is given by the gentleman 
 under whose care she has been for some years : 
 
 " When I first saw Elizabeth Alexander she was about 4 years 
 old, and was a robust, healthy child, and has been in good health 
 up to the present time. When nine months old, she, whilst crawling 
 about the house near the fireplace, touched a piece of hot iron with 
 the left arm, between the elbow and wrist, which soon healed up, 
 leaving a slight scar, not so large or deep as that produced by vacci- 
 nation, and to my own knowledge she has had no- other burn or 
 scald. When seven years old she had a mild attack of measles, 
 which was so slight that she was not confined to her bed for a day, 
 and perfectly recovered from it. A few mouths after the measles, 
 she had a white spot appear on her left side, below the breast, about
 
 AND OF TRUE KELO1D. 183 
 
 the size of a fourpenny piece, with a brownish, hard, inelastic 
 state of skin, about the size of a five-shilling piece, surrounding the 
 white spot, and looking as though the skin had been scorched with 
 hot iron, and I asked the question if such had been the case, and 
 was assured by both mother and child that it was not ; and in a few 
 weeks I found the brown part of the skin extending to a large 
 circumference, very much more thickened, puckered, and inelastic, 
 giving no pain on pinching up the skin, or on pressure. About six 
 months after, a similar spot made its appearance on the left shoulder, 
 and from a note I made of the case twelve months after, the follow- 
 ing were the appearances then presented. 
 
 " The shoulder had been affected for a year and a half. About 
 a year and a half ago a white spot 'appeared upon the shoulder, 
 surrounded by a brownish discoloration, just as though it had been 
 touched with a hot iron, not painful or tender to the touch ; it has 
 gradually extended itself around the shoulder- joint and down the 
 upper third of the arm j the skin is shining, hard, and puckered, 
 like the cicatrix from a burn, and the deltoid and other muscles 
 of the shoulder are so diminished as to leave no appearance of their 
 form ; the skin thickened, and apparently adhering to the bone, 
 with considerable loss of power and motion, and contraction of the 
 arm. 
 
 "About eighteen months after, the hip (left) became affected 
 exactly in the same manner as the side and shoulder. Two years 
 after this, the right shoulder was the seat of mischief of the same 
 nature as that already existing in the other regions/' 
 
 From the above account, then, it appears that the disease com- 
 menced in the left hypochondriac region, next attacked the left 
 shoulder, then the left hip ; up to this time, upwards of four years 
 from the first appearance of the disease, the right side was unaffected, 
 while nearly the whole of the ^'sidewas contracted by it. About 
 a year before her admission the right shoulder became the subject 
 of this singular disease, and on a careful examination I discovered 
 upon her right thigh a small patch of puckered skin about as large 
 as a sixpence, the right leg and thigh being otherwise free. Of the 
 existence of this small patch the patient was ignorant, which was 
 suggestive of its being the commencement of the disease in a 
 hitherto sound part ; but on careful watching for a period of several 
 weeks, it does not appear that it has increased in size, but rather to 
 have diminished, and the patient affirms that whereas the disease
 
 184 KELOID OF ALTBERT, 
 
 has steadily increased as a whole, individual spots or small patches 
 made their appearance for a short time and have receded again. 
 
 On November loth, 1852, she was admitted into Guy's Hospital, 
 Lydia 18, under Dr. Addison, when she presented the following 
 appearances. The right shoulder is contracted, hard, and tubercu- 
 lated, the muscles are wasted, and a strip of skin, about one inch 
 and a half wide, extending from the back and shoulder to the 
 inner part of the elbow, is bound to the bone. This part was for- 
 merly ulcerated, and the only part which ever was so. It now pre- 
 sents a scaly appearance, and is very hard. The left shoulder is 
 more tuberculated, and more hide-bound, but the disease on this 
 side is more confined to the shoulder proper, and does not extend 
 far down the arm. On the front of each shoulder is a considerable 
 patch, but the chest is otherwise free. Both the elbow-joints are 
 tightly contracted, and permanently bent at nearly a right angle, 
 and the forearms and hands are considerably wasted. The fingers 
 are nearly all bent inwards, and the hands are small, like those of a 
 child six or seven years old. 
 
 From the lower angle of the scapula, a semilunar patch (the ori- 
 ginal disease) runs round to the mesial line, half way between the 
 umbilicus and the nipples. A large irregular patch exists on the 
 left side, immediately below the umbilicus. 
 
 The outside of the left thigh is affected throughout its whole 
 length, together with the whole of the left buttock ; the left calf is 
 wasted, and measures two inches in circumference less than the 
 right, while the right thigh measures two inches and three quarters 
 more than the left. The left foot is contracted, and the ankle 
 stiff; the toe is pointed downwards, and she walks upon the ball of 
 the toe. 
 
 The right thigh is free from the disease, except a small irregular 
 discoloration about as large as a sixpence, on the front of the thigh. 
 These hard shining places have diminished sensibility, and never 
 were painful. None other of the family ever was affected with the 
 same disease. Her general health is excellent. 
 
 Case of Keloid disease. Furnished by John Birkett, Esq., Sur- 
 geon to Guy's Hospital. (Models 220, 221, PI. I58 56 .) 
 
 E. K , set. 31, a female, was born in Devonshire, lived some 
 years in the country, but the greater part of her life has been passed 
 in the suburbs of London. 
 
 She married at the age of 15 years and 8 months, was confined
 
 AND OF TRUE KELOID. 185 
 
 with her first child at 16 years and 8 months, and never men- 
 struated until after her marriage. She has given birth to eight 
 children, all of whom she suckled with both breasts, although most 
 with the left. 
 
 Of regular and temperate habits ; she has of late subsisted, since 
 the death of her husband, by working a mangle. 
 
 She has always enjoyed good health, with the exception of pal- 
 pitation of the heart; and her aspect was formerly healthy. At 
 present she is pallid and careworn, from anxiety and a scanty means 
 of subsistence. 
 
 I first saw this patient in July, 1851, through the kindness of 
 Dr. Bossey, of Woolwich, who had watched the case. 
 
 In December, 1850, and whilst suckling her last infant, she felt 
 an acute pain under the right arm, and observed a curious appear- 
 ance in the skin of the part. 
 
 Now, July, 1851 six months from the discovery of the dis- 
 ease it occupies a surface of about six inches by three in extent. 
 It is situated on the axillary half of the right mamma, and extends 
 into the right axilla. The skin feels rigid, as if the tissues were 
 of the nature of parchment. Tt exhibits a peculiar corrugation, 
 resembling that state of the integument known as " cutis anserina," 
 in an exaggerated condition. It is of a peculiar dull, yellowish 
 tint, resembling that of ivory. The part is painful ; often there is 
 numbness, and at other times sharp, tingling, shooting pains. The 
 right nipple is retracted more than usual, for it has never been 
 so well developed as the left. 
 
 A patch of the same disease, about one inch square, is deve- 
 loped in the skin of the left axilla. 
 
 In the summer of 1852, a third patch was developed, in the skin 
 of the inside of the left arm. 
 
 At present and I saw her in January, 1854 the diseased patches 
 of skin have but little changed their appearances. 
 
 They have all increased a little, they all give her more or less 
 pain, and no treatment hitherto adopted has produced any beneficial 
 result. 
 
 The patch on the right breast and axilla is longer ; the nipple is 
 deeply retracted, indeed invisible, and the gland atrophied. She is 
 much more obese than when I first saw her, and her general health 
 is very good. 
 
 The application which seemed to afford her the most relief was 
 the liquor plumbi diacet. dil.
 
 ON THE 
 
 DISORDERS OF THE BRAIN 
 
 CONNECTED WITH 
 
 DISEASED KIDNEYS. 
 
 THE object of this communication is threefold: First, To point 
 out the general character and individual forms of cerebral disorder 
 connected with interrupted function of the kidneys, from whatever 
 cause such interrupted function may arise. Secondly, To show 
 that, in recent as well as in chronic disease of the kidney, the cere- 
 bral disorder is not unfrequently the most prominent, and occa- 
 sionally the only obvious symptom present. And, thirdly, To 
 establish a means of diagnosis, in such obscure or in unsuspected 
 cases, upon the peculiar character of the cerebral affection. 
 
 That suppression of urine has the effect of inducing disorder 
 of the brain, has long been familiar to the profession ; and was re- 
 cently illustrated, in a valuable communication made by Sir H. 
 Halford to the Royal College of Physicians. It is also well known 
 to surgeons that mechanical obstruction to the discharge of urine, 
 when long continued, is occasionally followed by a similar result ; 
 and Dr. Bright has not failed to demonstrate that there exists, in 
 many instances, a corresponding connection between disorder of the 
 brain and the peculiar change of kidney he has so well described, 
 and so fully illustrated, in his recently published works. 
 
 I am not, however, aware that any attempt has hitherto been made 
 to specify with precision, and in detail, the several forms of cerebral 
 disorder arising in connection with disease of the kidney ; or that 
 any one has sought to found, upon the character of these cerebral 
 affections, a means of diagnosis available in cases in which, from the
 
 188 ON THE DISORDERS OF THE BRAIN 
 
 absence of the ordinary symptoms of nephritis, of every form of 
 dropsical effusion, and of an albuminous state of the urine, the 
 diseased condition of the kidneys is liable to be altogether over- 
 looked. Experience and observation having led me to the belief 
 that such obscure cases are by no means of very rare occurrence, 
 and that, in the absence of other indications, the renal disease may 
 occasionally be recognised with tolerable certainty by the character 
 of the cerebral disorder alone, I venture to offer what follows as 
 embracing an outline although a very imperfect outline, I confess 
 of the general character and individual forms of cerebral disorder 
 arising in connection with interrupted function of the kidneys. 
 
 According to my experience, the general character of cerebral 
 affections connected with renal disease is marked by a pale face, a 
 (juiet pulse, a contracted or undiluted and obedient pupil, and the 
 absence of paralysis : this general character, however, being some- 
 what modified, in certain cases, by circumstances attending the 
 individual attack. 
 
 So far as I have yet been able to observe, the individual forms 
 of cerebral disorder connected with renal disease are the five follow- 
 ing : 
 
 1 . A more or less sudden attack of quiet stupor ; which may be 
 temporary and repeated; or permanent, ending in death. 
 
 2. A sudden attack of a peculiar modification of coma and 
 stertor ; which may be temporary or end in death. 
 
 3. A sudden attack of convulsions; which may be temporary 
 or terminate in death. 
 
 4. A combination of the two latter ; consisting of a sudden 
 attack of coma and stertor, accompanied by constant or intermitting 
 convulsions. 
 
 5. A state of dulness of intellect, sluggishness of manner, and 
 drowsiness, often preceded by giddiness, dimness of sight, and pain 
 in the head ; proceeding either to coma alone, or to coma accom- 
 panied by convulsions ; the coma presenting the peculiar character 
 already alluded to. 
 
 With respect to the first-mentioned form of cerebral disorder 
 connected with renal disease, that of quiet stupor, it is, in its most 
 exquisite form, probably the least frequently met with ; the face is 
 pale, the pulse quiet, the pupil natural, or at least obedient to 
 light ; and although the patient may lie almost completely motion- 
 less, there is no paralysis; for, on atteotively watching him for
 
 CONNECTED WITH DISEASED KIDNEYS. 189 
 
 some time, he will be observed slightly to move all the extremities. 
 By agitating him, and speaking loudly, he may sometimes be par- 
 tially roused for a moment, but quickly relapses into stupor, as 
 before ; or it may not be possible to rouse him at all. There is 
 little or no labour of respiration, no stertor, and no convulsions. 
 Slight degrees of it occasionally precede and pass into the next or 
 second form. 
 
 This second form of cerebral affection is that of a sudden attack 
 of coma with stertor, or, in other words, apoplexy : it is, never- 
 theless, different from ordinary apoplexy : it is the serous apoplexy 
 of authors, and presents the usual general characters of cerebral 
 affection depending upon renal disease; for the face, instead of 
 being flushed, is, in almost every instance, remarkably pale; the 
 pulse, though sometimes small, and more rarely full, is remarkably 
 quiet, or almost natural; the pupil, also, although occasionally 
 dilated or contracted, is often remarkably natural in size, and 
 obedient to light ; and there is no paralysis. "When the labour of 
 respiration is very great, the general character is apt to be modified 
 by an accelerated pulse, and occasionally by a slight flush of the 
 countenance. The coma is for the most part complete, so that the 
 patient cannot be roused to intelligence for a single moment. The 
 stertor is very peculiar, and in a great measure characteristic of this 
 form of cerebral affection connected with renal disease : it has not, 
 by any means, in general, the deep, rough, guttural, or nasal sound 
 of ordinary apoplexy ; it is sometimes slightly of this kind ; but 
 much more commonly the stertor presents more of a hissing cha- 
 racter, as if produced by the air, both in inspiration and in expira- 
 tion, striking against the hard palate or even against the lips of the 
 patient, rather than against the velum and throat, as in ordinary 
 apoplectic stertor : the act of respiration, too, is usually, from the 
 first, much more hurried than is observed in the coma of ordinary 
 apoplexy. The peculiar stertor coupled with the pale face has, in 
 more instances than one, enabled me to pronounce with confidence 
 the disease to be renal, without asking a single question, and, in 
 cases, too, in which no renal disease whatever had for a moment 
 been suspected. 
 
 The third form of cerebral disorder connected with renal disease 
 is that of a sudden attack of convulsions. In this case, also, the 
 countenance is, for the most part, remarkably pale, although, occa- 
 sionally, slightly flushed at intervals : the pupil is often but little
 
 190 ON THE DISORDERS OF THE BRAIN 
 
 affected: in slight attacks of the kind, the pulse is sometimes 
 singularly quiet ; but when the convulsions are severe, and especially 
 when there is such a degree of coma as to be attended with stertor, 
 the heart often sympathises, and the pulse becomes rapid, irregular, 
 and jerking. This form of cerebral affection often passes into the 
 fourth variety ; or the cerebral affection shall take on the form of 
 the fourth variety from the commencement : in the latter case, we 
 have merely a combination of the second and third varieties the 
 coma, hurried breathing, stertor, and convulsions being so blended 
 together, as often to have led to a dispute, whether the affection 
 ought to be designated apoplexy or epilepsy. From what has been 
 already stated, it may in general be very easily recognised as one of 
 the common forms of cerebral disorder connected with renal dis- 
 ease. 
 
 The fifth variety is that in which the cerebral disorder makes its 
 approach in a more gradual and insidious manner, usually com- 
 mencing with dulness of intellect, sluggishness of manner, and 
 drowsiness, gradually proceeding to coma, and more or less stertor, 
 with or without convulsions ; these states being at the same time 
 distinguished by the general indications already pointed out. This 
 form of cerebral disorder appears to be that which most commonly 
 supervenes in the progress of the morbid change of kidney described 
 by Dr. Bright ; and is very frequently preceded by giddiness, dim- 
 ness of sight, and pain in the head. 
 
 It is scarcely necessary to acknowledge that it remains for future 
 experience and observation to furnish the details of this very imper- 
 fect sketch, both as regards the general character and the individual 
 modifications and complications of the cerebral disorders connected 
 with interrupted function of the kidneys. There is, however, one 
 highly interesting question, to which I may briefly advert ; and that 
 is, whether there really exists any discoverable relation between the 
 character of the renal affection and of that of the brain whether 
 the form, permanence, and violence of the cerebral disorder bear any 
 relation whatever to the activity, duration, and extent of the renal 
 disease. This part of the inquiry is, so far as I know, altogether 
 new ; and although I am not, at present, in possession of a sufficient 
 number of well-digested facts to justify any very decided or confident 
 conclusions, I nevertheless have imagined that I have already per- 
 ceived a certain degree of relation between the actual condition of 
 the kidney and the character of the cerebral affection.
 
 CONNECTED WITH DISEASED KIDNEYS. 191 
 
 Of all the more serious affections of the brain arising in connec- 
 tion with renal disease, the mildest form appears to be that of a 
 tendency to a state of quiet stupor, varying in degree from a mere 
 torpidity of manner and sluggishness of intellect, to complete insen- 
 sibility to all surrounding objects. Accordingly, I have found this 
 form of cerebral disorder most frequently present in what may be 
 regarded as the least formidable, or more temporary derangements 
 of the kidney. The most exquisite example I ever saw, occurred in 
 a man who at the time presented no dropsical symptom whatever, 
 whose urine was not albuminous, and who made no complaint of 
 pain or uneasiness in his loins. After death, the cortical part of 
 the kidneys was found highly injected, of a deep red or almost 
 chocolate colour, and somewhat softened in its texture ; in short, 
 furnishing the strongest indications of a recent nephritic attack in a 
 subdued form : it is also my belief that the same state of things 
 not unfrequently takes place, at an early period, in the progress of 
 scarlatina : we observe an approach to a similar condition of brain 
 in cases of fever, in which the bladder has been allowed to become 
 over-distended : and most assuredly in cases of retention from stric- 
 ture, and in cases of calculus in the kidney. In all these instances 
 the interruption or impediment to the urinary secretion may be said 
 to be recent or incomplete ; and hence, probably, the less degree of 
 severity of the cerebral affection, and the less peril to the patient ; 
 for in such instances the symptoms very commonly pass away, and 
 the patient recovers. When, however, the hurtful cause is of an 
 originally nephritic character, the chance of recovery will be less 
 than when the cause of obstruction happens to be merely mechanical 
 and temporary. 
 
 The next, in point of severity, of the cerebral affections connected 
 with renal disease appears to be that of convulsions, with compara- 
 tively little stertor ; convulsions, however, which may prove speedily 
 fatal ; or which may be repeated an indefinite number of times, but 
 from which the patient very often completely and permanently re- 
 covers. Accordingly, I have observed this form of more simple 
 convulsions most frequently associated with what may fairly be re- 
 garded as a more exquisite and enduring form of renal disease than 
 that just alluded to : I have observed it most frequently in cases of 
 renal dropsy, subsequent to scarlatina ; and in that form of renal 
 dropsy supposed to arise from direct exposure to damp and cold, 
 and commonly known by the name of inflammatory dropsy. As
 
 192 ON THE DISORDERS OJb 1 THE BRAIN 
 
 the renal affection has already proceeded to induce dropsy, we cannot 
 but regard it as more fixed and more formidable than in the cases 
 described as being attended with more or less of quiet stupor : and 
 accordingly, instead of merely a certain degree of this latter condi- 
 tion, we have convulsion which may indeed prove fatal, but from 
 which, as already observed, the patient often completely and perma- 
 nently recovers. 
 
 As might have been expected, the most stubborn and intractable, 
 as well as the most fatal cases of cerebral disorder connected with 
 renal disease, are unquestionably those found associated with the 
 chronic and irremediable disorganization of kidney described and 
 illustrated by Dr. Bright. It is nevertheless very far from being 
 true that every such case of renal disease is associated with cerebral 
 disorder : on the contrary, in no very inconsiderable proportion of 
 such cases, even till the period of their fatal termination, no cerebral 
 derangement whatever, or, at least, none of sufficient intensity to 
 attract particular attention, has been observed. Why cerebral 
 symptoms should supervene in one case and not in another, or, in 
 other words, what it is that determines their development in this 
 and in other forms of renal disease, it is impossible in the present 
 state of our knowledge to ascertain : for although a simultaneous 
 diminution of the urinary secretion may occasionally be observed, 
 such a coincidence is by no means constant ; the secretion in some 
 instances continuing to flow in a very fair quantity, even at the period 
 of the most formidable attacks of cerebral disorder. 
 
 Considering the gravity, permanence, and irremediable nature of 
 the disorganization in this form of renal disease, we might naturally 
 expect that the cerebral disorder, when it does supervene, would, in 
 its constancy, urgency, and intractability, be found in some measure 
 to correspond ; and, accordingly, this has really appeared to me to 
 be the case ; the patient suffering repeatedly, or more or less con- 
 stantly, from heaviness, drowsiness, giddiness, or pain or sense of 
 tightness in the head, and being peculiarly liable to be suddenly 
 seized with the most alarming and most fatal of all the forms of 
 cerebral disorder occurring in connection with renal disease profound 
 coma and stertor, with or without convulsions. 
 
 I have purposely omitted to notice the morbid changes discovered 
 in the brain after death ; they are well known to be very often, in 
 appearance at least, extremely slight ; and do not, as far as we are 
 yet aware, either in their kind, degree, or situation, offer any expla-
 
 CONNECTED WITH DISEASED KIDNEYS. 193 
 
 nation of the form or severity of the cerebral disorder which proved 
 the immediate cause of death. 
 
 In concluding this brief and imperfect communication, I would 
 again repeat, that my object has been to direct attention to an im- 
 portant and interesting inquiry, rather than to profess a knowledge 
 of the many details and exceptions which must necessarily arise out 
 of future well-directed observation and experience. My pretensions 
 extend not beyond a conviction, that the cerebral affections which 
 occur in connection with renal disease, or other cause of interrupted 
 urinary secretion, present a character generally recognisable by 
 obvious indications ; and that these cerebral disorders of renal origin 
 not unfrequently supervene in the absence of ischuria, of dropsy 
 and of those symptoms usually regarded as essential to ordinary 
 nephritis, or, at least, of such a degree of the latter as would be 
 sufficient to attract particular attention, unless supported by the 
 character of the cerebral disorder. 
 
 13
 
 ON THE INFLUENCE 
 
 ELECTRICITY, 
 
 AS A REMEDY IN CERTAIN CONVULSIVE AND SPASMODIC 
 
 DISEASES. 
 
 IT must have occurred to every one engaged in extensive practice, 
 to meet with cases of convulsive and spasmodic disorders affecting 
 females, arid with cases of chorea in both sexes, which, whilst they 
 occasioned extreme distress to the patient, and to the patient's 
 friends, have baffled every attempt to afford permanent, and, in 
 some instances, even temporary relief. It was whilst brooding over 
 the humiliating failure of a host of remedies employed in one of 
 such cases, and which will be described in the sequel, that, as a last 
 resource, I determined upon giving electricity a fair trial. I was 
 perhaps, in some measure, induced to do so, in consequence of 
 having an opportunity of securing the assistance of Mr. Golding 
 Bird, in its application. The effect produced by it at once gratified 
 and surprised me, and led to further trials, the results and parti- 
 culars of which will not, I trust, be deemed altogether unworthy the 
 attention of the profession. 
 
 Of course, all claim to originality, or even novelty, is out of the 
 question ; electricity having long been enumerated amongst the 
 ordinary remedies applicable to convulsive disorders generally. It 
 is, nevertheless, much to be feared, that many persons, like myself, 
 have been led greatly to underrate its efficacy, either in consequence 
 of its vague and indiscriminate recommendation, or from the ineffi- 
 cient and careless manner in which it has been applied. Certain it 
 is, that, although I have often ordered it myself, and have more
 
 196 ON THE INFLUENCE OF ELECTRICITY 
 
 frequently witnessed its employment by others, I had never for a 
 moment entertained the belief that it possessed the power over the 
 disorders alluded to, which I am now inclined to concede to it. It 
 is almost superfluous to observe, that the convulsive and spasmodic 
 disorders of females alluded to, are such as, in a large majority of 
 instances, are connected with some irregularity of menstruation : 
 neither is it necessary to dwell upon the difficulty of distinguishing 
 merely functional from organic diseases of the nervous centres; 
 these being matters with which the profession at large is perfectly 
 familiar. 
 
 It is but right to state, that the following cases have not been 
 selected because the treatment proved more or less successful, to the 
 exclusion of others in which it failed : on the contrary, they com- 
 prise the whole of the cases hitherto subjected to the electrical 
 process about to be described ; and hence afford, as far as they go, 
 a fair promise of at least occasional benefit, from the application of 
 this powerful agent in the treatment of the disorders specified. 
 
 However undesirable it may be to encumber our Reports with a 
 detailed history of cases, such a mode of procedure becomes almost 
 indispensable in the present instance ; but, in order that the length 
 of this communication may not greatly exceed its importance, I 
 shall, without further comment, proceed to lay before the profession 
 a brief description of the mode in which electricity was applied 
 in the subjoined cases, as drawn up by our electrician, Mr. Frederick 
 Bird. 
 
 " In the following cases, the form of electricity employed was, 
 with one exception, that elicited by means of the common electrical 
 machine ; being made use of either by taking sparks, in the course 
 of the spine ; or in the form of shocks, passed through the pelvis. 
 
 " In the former case, the patient was seated on an insulated stool, 
 and a metallic connection made between the prime conductor of the 
 machine and the body of the patient : a brass ball, furnished with a 
 wire or chain, in connection with the earth, was then passed upwards 
 and downwards, in the direction of the spine, at a distance of about 
 un inch from the surface. The machine being at this time excited, 
 the patient became charged, and the electricity continued to pass off, 
 accompanied by sparks, to the brass ball, and thence escaping, 
 through the medium of the wire or chain, to the earth : in this 
 manner a rapid succession of sparks could be maintained; and
 
 IN CERTAIN CONA'ULSIVE AND SPASMODIC DISEASES. 197 
 
 which, in the present instances, was continued until an eruption 
 followed, which assumed very much the appearance of lichen urti- 
 catus ; the time necessary for its production varying, in different 
 patients, from five to ten minutes. 
 
 " For the purpose of passing the shocks, the following method 
 was had recourse to. A large-sized Leyden jar was so placed, that 
 a communication was established between its inside coating and the 
 prime conductor : a " Lane's electrometer" was then fixed into one 
 end of the conductor, so as to admit of the insulated ball of the 
 former instrument being either in contact with, or at any required 
 distance from, the latter : a chain was placed in contact with the 
 outside coating of the jar, and another was attached to the ball of 
 the electrometer ; the ends of both of which were furnished with 
 directors, for convenience of application. 
 
 " One of the directors was then held upon the syrnphysis pubis, 
 whilst the other was placed upon the sacrum ; l by which means the 
 electric current, in performing its circuit, was made to pass through 
 the pelvis. The ball of the electrometer being then placed at a 
 certain distance (generally gths of an inch) from the prime con- 
 ductor, motion was given to the machine, and the charging of the 
 jar commenced ; and upon a sufficient quantity of electricity being 
 accumulated to enable its discharge to take place by means of the 
 electrometer, the shock was felt. By adopting the use of an elec- 
 trometer of this kind, the violence of the shocks is made to depend 
 upon the distance of its insulated ball from the conductor of the 
 machine, and not upon the capacity of the jar : hence, it is only 
 necessary to place the ball at a greater or less distance from the 
 conductor, in order to proportion the intensity of the discharge to 
 the nature of the disease or powers of the patient. 
 
 " In one case, that of Jessie AYick, the magnetic-electrical machine 
 was made use of, the patient's strength not being sufficient to admit 
 of the ordinary and more powerful form of electricity. The larger 
 helix having been adjusted to the machine, one of the two con- 
 ducting wires, furnished with a brass disc, was placed over the 
 cervical portion of the spine ; whilst the remaining wire, which was 
 a so provided with a disc, was fixed over the lumbar vertebrae : the 
 helix being then slowly revolved, a succession of shocks was ob- 
 
 1 There is a female in attendance for the purpose of adjusting that part of 
 the apparatus more immediately connected \vith the person of the patient.
 
 198 OX THE INFLUENCE OF ELECTRICITY 
 
 tained, which were thus made to traverse the course of the spinal 
 column." 
 
 The following cases were taken from the Hospital Books, by my 
 pupils, Messrs. Brereton and Aspland. 
 
 CASE i. 
 
 JESSIE WICK, aged 17, admitted May I4th, 1837, under Dr. 
 Addison; a stout, intelligent, well-developed girl, of rather nervous 
 temperament. Her health seems to have been generally very good 
 till the age of 14 ; at which time, being of remarkably forward 
 sexual development, she began to menstruate. The catamenial 
 discharge immediately became irregular, occurring every fortnight, 
 lasting three days, and accompanied by acute pains in the loins and 
 genital organs. She does not appear, however, to have suffered 
 materially in her health from this irregularity. Two months since, 
 while menstruating, she suffered violent fright ; which was imme- 
 diately succeeded by cessation of the discharge, hysterical fits, and 
 continued trembling of the limbs, much increased by excitement. 
 Bleeding, with blisters and purgatives, was tried: but no relief 
 appearing, she was admitted into Miriam Ward, under Dr. Addison ; 
 her condition being as follows : She is utterly unable to remain in 
 a state of rest for a moment : her limbs, especially the upper ex- 
 tremities, are violently agitated : the mouth is from time to time 
 ludicrously distorted. The most unvarying motion is, a rolling of 
 her clenched hands quickly round each other, with a thrusting for- 
 ward of the right in a very systematic manner, it occurring after 
 every third revolution. Deglutition and speech but slightly affected. 
 Occasional pain in the head, back, and loins, and under the left 
 mamma : palpitation of the heart, but no abnormal sound. Her 
 spirits are good, but she is fatigued from the continued action of 
 her muscles. The catamenial discharge is expected in two or three 
 days. 
 
 The bowels, which had been obstinately costive, having been, 
 by strong purgatives, freed from much highly offensive matter, 
 creosote, in niij doses, was exhibited thrice daily; but violent 
 retching following the seventh dose, it was discontinued. Her 
 spasmodic twitchings, palpitation, and restlessness, were aggravated. 
 Purgatives were continued ; and camphor mixture with hydrocyanic 
 acid, and sulphate of zinc, with hyoscyamus and camphor, pre-
 
 IN CERTAIN CONVULSIVE AND SPASMODIC DISEASES. 199 
 
 scribed. In spite of these remedies, not the slightest abatement 
 occurred in her symptoms : her nights were sleepless, and her irri- 
 tability excessive. On the 2oth of May the catamenial discharge 
 re-appeared, being somewhat after its proper period, scanty, and 
 accompanied by severe bearing-down pains in the back and loins. 
 It ceased again at 2 a.m. of the 2ist. From this date, till June 
 1 4th, she continued the use of purgatives; with occasional cupping 
 over the loins, blisters along the spine, the above-named mixture, 
 and increasing doses of zinc, reaching at last thirty-six grains daily. 
 Once, on the 23rd of May, the catamenia returned, but in a few 
 hours disappeared again ; and at the next and succeeding periods 
 were absent. Not the slightest abatement in her unpleasant symp- 
 toms took place : the arms were, perhaps, a little less violently 
 agitated, but the lower extremities, which till late in May had been 
 comparatively quiet, now became much disturbed, and kept up a 
 continued clapping of the feet against the floor : the mouth and 
 eyes, too, were more severely affected than formerly. On the 28th 
 of May, in addition to the other remedies, dashing of cold water 
 on the head, and along the spinal column, was introduced : but this 
 was necessarily omitted for a time, in consequence of the increasing 
 violence of a cough, which had long troubled her, and which was 
 now accompanied by copious bronchial secretion, deeply tinged with 
 blood. She now stated, that some time previous to admission she 
 had been similarly affected. Under depletion and mercurials, this 
 soon yielded; and the former remedies were vigorously applied 
 till June i5th; when the zinc producing constant nausea, the car- 
 bonate of iron, in 5ss doses, thrice daily, was substituted for it. 
 On the 23rd of June, the sulphate of iron was substituted in in- 
 creasing doses, reaching thirty-two grains daily, till August I4th. 
 A very great improvement evidently followed the exhibition of sul- 
 phate of iron, assisted by purgatives, chiefly, of calomel and com- 
 pound extract of colocynth, or aloes and myrrh, and the use of the 
 shower-bath. She was enabled, under this treatment, to sit nearly 
 still in a chair, unless talked to, or otherwise excited ; and, with 
 assistance, she could walk pretty well about the ward : there was, 
 however, always a dragging of one or the other of the feet. The 
 squinting, and distortion of the face, had very much subsided, and 
 the peculiar revolving and thrusting forward of the hands dimin- 
 ished : the least excitement, however, would speedily aggravate con- 
 siderably all her unpleasant symptoms. August I5th, having then
 
 200 ON THE INFLUENCE OF ELECTRICITY 
 
 been in the hospital exactly three months, she quitted with an inten- 
 tion of going to Ramsgate. For two months from her departure 
 we heard but little of her; but on October ijth she presented her- 
 self at Guy's Hospital, among the out-patients, in a much worse 
 condition than she had ever yet been. It is true, there was less 
 agitation of the limbs, but it had only given place to more alarming 
 symptoms. Prom her friends' statement it appeared, that before 
 reaching her destination she had been seized with epileptic fits, 
 which she had never experienced before. They were represented to 
 have been severe, and, in spite of remedies, had left her in the state in 
 which she appeared : on their approach, the chorea had subsided. 
 She had a foolish imbecile stare, the face dull, she appeared to be 
 almost regardless of surrounding objects, articulation was lost, and 
 she made no attempt, even by signs, to express her feelings. The 
 twitchings of the upper extremities, mouth, and eyes, were less : 
 the inferior extremities appeared paralytic, at least she made no 
 attempt to move them, nor was she able to stand ; her bowels were 
 said to be regular ; there had been no return of the catamenia. 
 She was immediately put upon 5j doses of carbonate of iron, and 
 used the shower-bath ; and a blister was applied to the spine, along 
 which there seemed to be pain on pressure. The bowels becoming 
 costive, drastic purgatives were again necessary, and croton-oil was 
 given. On the 2oth of October the sulphate was substituted for 
 the carbonate of iron ; but under this treatment no amendment was 
 produced. After one of her fits, she lay perfectly comatose, scarcely 
 seeming to breathe ; and it was not till repeated assafcetida injec- 
 tions had brought away large quantities of faecal matter, deeply 
 tinged with iron, and stimulating remedies had been used, that her 
 consciousness, and with it articulation, were regained. October 
 25th, sulphate of zinc in grain doses thrice a day was used, together 
 with a mixture composed of camphor mixture, and ammoniated 
 tincture of valerian ; and occasional blisters along the spine. The 
 zinc was rapidly increased, almost | gr. daily, till she took 36 grs. 
 per diem, added to which was the Ferri Sulph. But to no purpose : 
 her chorea returned almost as severely as ever ; the epileptic fits 
 were frequent, two or three daily, the longest interval between them 
 being three or four days. She could seldom leave her bed ; and to 
 guard against her falling from it, side- and foot-boards were neces- 
 sary. She had now, also, constant headache, which was always 
 aggravated on the approach of a fit ; and her spirits became low and
 
 IN CERTAIN CONVULSIVE AND SPASMODIC DISEASES. 201 
 
 desponding. During the epileptic paroxysm, she had violent opis- 
 thotonos, the superior part of the occiput almost meeting the heels ; 
 firm contraction of the flexors of the fingers and toes, with equally 
 firm contraction of the extensors of the fore-arms and legs ; much 
 thick foam from the mouth ; stertor ; largely-dilated pupil ; the 
 heart's action was quick and tumultuous ; with a sound resembling 
 that observed in chlorosis, distinctly heard at its apex. In this 
 condition she would remain from ten to twenty-five minutes ; after 
 which, a quick squinting of the eyes, with frequent relaxation and 
 contraction of the flexor muscles of the fingers and toes, would 
 occur : she would then sink into a deep sleep and awake from it 
 after many hours, pale, languid, and perfectly unconscious of all 
 that had happened. It was remarkable, that the slightest touch, 
 when the violence of the paroxysm was subsiding, would instantly 
 reproduce it. In this state she continued many months, with, 
 perhaps, some alleviation of the epileptic attacks, but no improve- 
 ment in her chorea. The symptoms of the latter were the same as 
 during her former attack clapping of the feet against the floor, 
 contortions of the mouth, squinting, with revolving and thrusting 
 forward of the hands. 
 
 As a last resource, Dr. Addison ordered electricity. Her strength 
 not allowing of the severer application, electro -magnetism was 
 commenced. It caused continued spasm of the flexor-muscles of 
 the arm ; so that, till the current was discontinued, she could not 
 relax her grasp of the brass handles. This was commenced on the 
 2oth of April ; and on the loth of the following month she was so 
 far improved, that she could use her needle with tolerable precision : 
 her general health improved ; and the fits became slighter, though 
 as frequent as before. Sparks were now drawn from the spine 
 every other day ; each exhibition continuing till a vivid eruption 
 was produced. Her improvement was most marked : at the end of 
 a week she was able to walk across the room without assistance : 
 her countenance gradually became less anxious, and the fits declined 
 in frequency. 
 
 June i. Twelve shocks, through the pelvis, every other day, were 
 ordered. The first administration, at the distance of three- eighths 
 of an inch from the conductor, was followed by severe abdominal 
 and pelvic pains, the immediate precursors of the catamenia. The 
 secretion continued for four hours. Shocks to be discontinued. 
 
 July 3. Improvement uninterrupted : occasional twitchings are
 
 202 ON THE INFLUENCE OF ELECTRICITY 
 
 the only indications of chorea. The catamenia have not appeared 
 this month. 
 
 A second exhibition of the shocks again occasioned the develop- 
 ment of the catamenial function : in six hours it became arrested ; 
 after which, she vomited a small quantity of blood. 
 
 July 15. She left the hospital entirely free from chorea; though 
 still subject to fits of diminished force and frequency. 
 
 CASE 2. Chorea. 
 
 EMMA HILLIER, aged 14, stout, plethoric, of dark hair and eyes, 
 admitted June I4th. Her mother states, that, from an early age, 
 she has been subject to epileptic seizures ; and four years ago was 
 brought into the hospital with a severe attack of chorea. She was 
 cured at the end of ten weeks ; and since then has had periodical 
 returns, the attacks generally observing the recurrence of spring 
 and autumn. The present attack is not severe ; but interferes with 
 progression, and slightly with speech. She complains of severe 
 headache ; and her temper is irritable. 
 
 Elic. Scintilla Electricse spina dorsi. 
 . Rhei c. Cal. gr. xij, p. r. n. 
 
 The sparks were drawn off, at the distance of three-eighths of an 
 inch, till the peculiar eruption was produced. After the fourth or 
 fifth trial, the articulation became distinct, and the walk almost 
 quite steady : there were still, however, twitchings in the arms, 
 shoulders, and muscles of the face. At the end of the third week 
 they had all entirely ceased, in the order above enumerated. Two 
 doses of the rhubarb and calomel had been administered during this 
 period. 
 
 CASE 3. 
 
 WILLIAM SUTTON, aged 14, a healthy looking, but rather small 
 boy, admitted into Lazarus' Ward, under Dr. Cholmley, on May 
 loth. He states, that he has been thrice affected with chorea; the 
 first attack occurring upon fright, caused by a vicious horse pur- 
 suing him. For this attack he was admitted into this hospital, 
 under Dr. Back ; and having remained under treatment six weeks,
 
 IN CERTAIN CONVULSIVE AND SPASMODIC DISEASES. 203 
 
 left, cured. Twelve months subsequently he again became the 
 subject of chorea; which, although of longer duration than the 
 former attack, was much less violent. He was then placed under 
 Dr. Bright ; and again left the hospital, apparently quite well. In 
 the commencement of the present year, he suffered from a third 
 invasion of the complaint, which he describes as of a more serious 
 character than either of the former. At present, he is unable to 
 remain quiet a moment : he can walk, but his legs bend about fre- 
 quently while he is doing so. He is continually thrusting his 
 hand along his side. The face is more violently affected than other 
 portions of the body. 
 
 Zinc, with purgatives, was administered, but with little benefit, 
 till June 1 9th ; when, upon his coming under Dr. Addison's care, 
 electricity was ordered to be applied daily along the spinal column. 
 This plan was persevered in till July nth, when, every symptom 
 of chorea having disappeared, and his general health being good, 
 he was presented. 
 
 CASE 4. Hysterical Paralysis. 
 
 MATILDA SIMMONS, aged 16, of delicate appearance, light brown 
 hair and eyes, mammae well developed; has been at service in 
 London ; and previous to the appearance of the catamenia, a twelve- 
 month ago, she experienced the ordinary symptoms attending a 
 delay of that function headache, palpitation, shooting pains, &c. 
 
 1'or six months, the catamenia appeared regularly ; cold then 
 occasioned their arrest; and the former symptoms recurred, and 
 were soon accompanied with numbness and coldness of the whole of 
 the left side. This was immediately preceded by a tit ; which, from 
 the account of the friends, appears to have been of the truly hyste- 
 rical character. Ten days before admission, the face, which had 
 hitherto escaped, became numb on the left side, the sight of the left 
 eye became dim, and there was a slight pain in the globe. On the 
 third day there was perfect amaurosis and ptosis. At the time of 
 admission, there was numbness, coldness, and deficient muscular 
 power over the whole of the left side, including the lining membrane 
 of the mouth, nostril, and conjunctiva : in the latter she perceived a 
 burning sensation, but could not appreciate a touch : the pupil was 
 contracted, and not at all obedient to light : she could not raise the
 
 204 ON THE INFLUENCE OP ELECTRICITY 
 
 upper eyelid. She complained of pain in the head, and giddiness. 
 Bowels torpid. 
 
 C. C. Nucbae. Emp. Lyltse postea. 
 
 Mist. Magnes. c. Magnes. Sulph. et Tinct. Jalapse, 5J t. d. 
 
 This treatment was continued for some time, without the slightest 
 benefit. 
 
 April 24. Dr. Addison ordered electricity, in the shape of sparks 
 down the spinal column. On the same evening she could bend her 
 fingers : and the 2/th recovered, to a certain extent, power over the 
 muscles of the arm. 
 
 29th. The third application was made yesterday, with the result 
 of restoring vision, and the power of elevating the upper eyelid, 
 increasing the power of the arm, and improving, to a certain extent, 
 motion and sensation in the leg. 
 
 May 4. Improvement continues : she can walk without difficulty ; 
 experiences no numbness, but complains of tingling in the fingers 
 of the left hand : the left eye remains as when she was admitted. 
 
 June 12. The form of electricity has, during the last ten days, 
 been changed ; sparks being drawn from the left eyelid, and shocks 
 passed through the uterus. There is no improvement in the eye, 
 which remains perfectly amaurotic ; but the catamenial function was 
 restored yesterday morning, not preceded or accompanied by any 
 particular symptoms. Her general health being good, she has left 
 the hospital at her own desire. 
 
 CASE 5. 
 
 ANNE BOSHER, aged 21, a stout, short girl, of rather heavy ex- 
 pression, with dark hair and eyes. Her own health, previous to her 
 present illness, had been always good : her family, however, is not a 
 sound one, cerebral diseases afflicting several members of it : a sister 
 has had chorea, but she has no recollection of it. At the age of 
 1 6, she lost her mother, which affected her seriously; and about 
 that time a large abscess formed under the left inferior maxilla, 
 which remained some time open, and discharged freely. The cata- 
 menia then appeared; and continued regular, in their recurrence 
 and quantity, till the age of 19, when she was suddenly seized with 
 severe pain at the posterior part of the head, accompanied by loss of 
 recollection. A medical man was called in, who used very large
 
 IN CERTAIN CONVULSIVE AND SPASMODIC DISEASES. 205 
 
 depletion. After confinement to bed for six weeks, this attack 
 yielded ; but she was left excessively languid, with severe pains in 
 the loins and right leg, irregularity in the catamenial discharge, and 
 diminished muscular power. Some weeks subsequently her right 
 hand became affected with involuntary twitchings, which gradually 
 extended themselves to the whole body, but more particularly to the 
 right side ; and at length her agitation was so violent, that straps 
 were required to keep her in bed. Speech and deglutition were 
 greatly impaired, and the muscles of the face and eyelids were in 
 constant action. She had no fit during this period, but the head- 
 ache was distracting. Medical aid was procured, but to no purpose. 
 She was then admitted into St. Thomas's Hospital ; and while there, 
 experienced some sharp epileptic attacks. She remained in that 
 hospital nearly ten months ; and then quitted, not much benefited ; 
 although at one time she had greatly improved. She was imme- 
 diately afterwards admitted into Charity Ward, at which time she 
 could with difficulty be retained in bed : she could not walk or, 
 indeed, even stand ; neither could she remain quiet for a moment. 
 Her epileptic seizures were frequent and severe : recollection im- 
 paired : deglutition and articulation imperfect : the right side is now, 
 and has been always, more seriously affected than the left : head- 
 ache, with pain in the back and loins. In this state she continued, 
 with very slight improvement, in spite of a host of remedies, com- 
 prising cold to the head, blisters and cupping to the spine, drastic 
 purgatives, iron, zinc, and many others. 
 
 June 12. Electricity daily, over the spine, was prescribed; the 
 bowels to be regulated by occasional purgatives. 
 
 This treatment has been steadily persevered in (being only once 
 or twice interrupted by her fits), and with very evident benefit. 
 The catamenia have re-appeared, although only for a few hours ; 
 her headache has considerably decreased, and her memory improved : 
 the fits seldom trouble her, and her muscular power is so much re- 
 stored, that she can not only walk about the ward without assist- 
 ance, and without much difficulty, but can carry, without spilling 
 the smallest quantity, a cup pretty full of liquid. There is still, 
 however, a little twitching of the extremities ; and the right side 
 remains yet more agitated than the left. The treatment is ordered 
 to be continued.
 
 206 ON THE INFLUENCE OV ELECTRICITY 
 
 CASE 6. Chorea. 
 
 SARAH KIDD, aged 16, tall, of slight make, dark hair and eyes, 
 swarthy complexion, prominent eyes, and fatuous aspect, admitted 
 Feb. 1 8th, 1837, into Miriam "Ward. 
 
 Her family are all suffering from derangement of the nervous 
 centres. One is blind, two epileptic; another, both idiotic and 
 blind. She has always been weakly. The catarnenia appeared 
 twelve months ago, preceded by considerable pain; but were 
 arrested in about two hours, by some one in disguise alarming her. 
 They have never appeared since, either naturally or vicariously. 
 Immediately after their cessation, symptoms of .chorea came on. 
 The irregular and involuntary motions chiefly affected the neck and 
 face. These increased, so that the strait-jacket was employed, 
 to keep her in bed. Violent muscular agitation, frequent head- 
 aches, loss of articulation, and impairment of deglutition, continued 
 for five months, in spite of medical treatment, which chiefly consisted 
 of leeches to the temples and spine, and the use of the shower-bath. 
 Twice during this period she had severe aggravations, lasting three 
 or four hours ; during which it was with difficulty that three or 
 four persons kept her in bed. At the end of five months she could 
 walk about, but the twitchings never ceased. The shower-bath 
 was persisted in, till the occurrence of an attack of acute rheu- 
 matism. 
 
 A fortnight ago, without any assignable cause, the twitchings 
 became more vigorous. At present, the aspect is fatuous, though 
 occasionally wild, and almost maniacal; the symptoms of chorea 
 are well marked and severe ; the pupils are dilated ; eyesight dim ; 
 sweating profuse. 
 
 Pulv. Rhei c. Cal. 9j, statim. 
 
 Zinci Sulph. gr.j, t. d. 
 
 Pil. Aloes c. Myrrba, 9j, alt. noctibus. 
 
 The symptoms remained obstinate. Colchicum in powder was 
 given as a purgative, and continued for some days after the peculiar 
 pea-soup motions had been induced. Valerian and iodide of iron 
 were not more successful. 
 
 April 20. Electricity was commenced. Sparks were drawn from 
 the spine, and shocks passed through the pelvis.
 
 IN CERTAIN CONVULSIVE AND SPASMODIC DISEASES. 207 
 
 29. The sparks induce a variegated eruption, without papulae, 
 her skin being thick. There is much less twitching of the shoulders, 
 and the hands are more steady. Muscae volitantes still flat before 
 the eyes. She looks more cheerful, and feels, generally, better. 
 
 May 2. Is rapidly improving. She can now walk several steps 
 without falling. Each electric shock produces intense muscular 
 spasm. 
 
 Within a day or two from this date, all traces of involuntary 
 muscular action disappeared : her gait, however, remained stiff and 
 . ungainly. This was explained by the anatomy of her knees ; the 
 patellae being ill developed, not above a third of their natural size, 
 and seated several inches above their natural position. Yery slight 
 flexion is possible ; and the attempt causes pain. The dimness of 
 vision and muscae volitautes have quite disappeared. 
 
 20. Presented, quite cured. 
 
 t 
 
 CASE 7. Chorea treated by Electricity. 
 
 PRANCES SHEAD, aged 12, an active and intelligent girl, of 
 moderate height and stoutness, admitted April 12, 1837, into 
 Miriam AVard. 
 
 She has undergone most of the ordinary diseases of child- 
 hood : and, without any very apparent cause, has frequently suffered 
 from headache, chiefly confined to the occipital region. During the 
 last three months, this symptom has increased ; and she has like- 
 wise experienced nocturnal pains in the eyes disturbing her rest, 
 dimness of vision, and muscae volitantes. The catamenial function 
 is not developed. 
 
 On the 24th of March, she was much alarmed by a cat flying at 
 her ; and from this period her friends can date slight irregular 
 movements of the hands. These continued for about a week : a 
 paroxysm of pain in the head then occurred, confined to its old 
 spot, and so excessive, that she threw herself down and screamed 
 violently. This ushered in increased muscular agitation, not con- 
 fined to the arms, but affecting the whole body ; progression became 
 difficult ; articulation and deglutition much impaired ; respiration 
 difficult and laborious ; the expiration being attended with a 
 snorting sound. 
 
 At present, these symptoms are in full force. The countenance 
 is vacant ; there is headache, pain in the right ankle and wrist,
 
 208 ON THE INFLUENCE OF ELECTRICITY. 
 
 general and continued muscular spasm, affecting both sides equally, 
 but most intense in the arms, shoulders, and face. The tongue is 
 broad, slightly furred; its muscles under no control. Pulse 100, 
 feeble : appetite good. A slight " bellows' sound" is audible over 
 the root of the aorta. Upon the neck and back a number of 
 furunculi are forming, apparently owing to stimulating applications 
 which have been used before her admission. 
 
 Scammon. gr. v, Hydr. Submur. Sacchar. aa gr.iiss. stat. et alt. auror. 
 Zinc. Sulph. gr. j, Ext. Conii gr. ij, t. d. in forma pil. 
 
 April 17. It was necessary to administer the zinc in solution, 
 owing to her inability to swallow anything solid. Articulation is 
 now quite inaudible. The furunculi continue to form ; and, when 
 opened, discharge pus, and sloughing cellular membrane. During 
 sleep, which is not much disturbed, there is slight twitching of the 
 fingers. Increased pain and convulsion come on in paroxysms. 
 
 20. The zinc has been increased to eight grams thrice a day, 
 without the slightest benefit. Dr. Addison now ordered electric 
 sparks down the spine, every other day. 
 
 28. The electricity has been administered four times, and with 
 marked benefit. It is continued each time for about ten minutes, 
 until a vivid eruption appears, closely resembling lichen urticatus, 
 though scarcely so much raised. She can now project the tongue, 
 though only for an instant, and articulate audibly; deglutition is 
 more comfortably performed ; she can sit in a chair, and even stand 
 for a short period. The pain in the head is diminished. 
 
 May 6. She can now walk without difficulty, and stand on one 
 leg for a short time. The shoulders, arms, and tongue are now 
 the most affected. 
 
 12. The electricity is still continued, and the improvement is 
 uninterrupted. She can now walk, without exhibiting any irregular 
 movements. The countenance has entirely lost its fatuous expres- 
 sion. She cannot keep the tongue protruded. 
 
 31. Presented quite free from all traces of chorea. 
 
 August. Again admitted under Dr. Bright, with a very mild 
 attack of the disease, not sufficient to interfere with her ordinary 
 pursuits. The sulphate of zinc was ordered ; and she left, cured, 
 in less than twenty days.
 
 PREFATORY REMARKS 
 
 ON 
 
 DISEASE OF THE SUPRA-RENAL CAPSULES, 
 
 THE brevity of Addison's treatise on " Disease of 
 the Supra-renal Capsules" may excite surprise in the 
 minds of some of our readers unacquainted with its 
 origin and the process of its production. We may, 
 therefore, state that the author contented himself with 
 giving, more suo, a brief, lucid, and masterly description 
 of the malady, illustrated by a few cases. It may also 
 interest them to know that, in obedience to the true 
 scientific modesty to which we have before adverted, 
 he had, some years before the publication of his mono- 
 graph, introduced the subject to a local medical society, 
 and an allusion to the discussion of it which then 
 occurred appears to us of sufficient importance for 
 remarks. 
 
 It will be seen from the paper that an attempt to 
 elucidate the nature of a malady which he had styled 
 " IdiopatJiic ancemia," from an inability to associate it 
 with any exact pathological condition, led Addison to 
 the discovery of the diseased state of the supra-renal 
 capsules ; he had repeatedly observed an ailment which 
 terminated in fatal exhaustion without any evidence of 
 organic disease; the clinical features of the malady, 
 however, whilst under observation, were prominently 
 bloodlessness, a sense of extreme prostration, and 
 various shades of alteration in the colour of the skin. 
 
 It thus necessarily happened that when, in the absence 
 of any other explanatory pathological condition, the 
 supra-renal capsules presented an abnormal state, the 
 association between it and the symptoms exhibited 
 during life took possession of the author's mind, he 
 correlating them as cause and effect ; and subsequent 
 writers have spoken of them in the same sense.
 
 ii PREFATORY REMARKS. 
 
 We must, however, remind our readers that anaemia 
 and " morbus Addisonii" are not pathologically con- 
 nected ; for whilst in the one case the patient is pale, 
 flabby, breathless, and, perhaps, fat, he is in the other 
 spare, of a brownish hue, manifesting a good colour in 
 his lips and muscles, so that his condition is one rather 
 of asthenia than anasmia. 
 
 There is another important point to which the atten- 
 tion of the reader should be attracted ; that in tran- 
 scribing, as we are bound to do, all the pages of 
 Addison's treatise, we necessarily include some para- 
 graphs which the author, had a more extended obser- 
 vation been accorded to him, would have been the first 
 to expunge, under the belief that he was supplying an 
 impulse to the further investigation of the disease. 
 Addison unfortunately inserted some paragraphs im- 
 plying that if the supra-renal organs were involved in 
 cancer or tubercle, symptoms corresponding to those 
 which he had described would result. All subse- 
 quent experience has shown that on this point he was 
 unquestionably in error. He had given an exact and 
 perfect narration of the symptoms attendant upon the 
 disease which now bears his name, but he does not 
 appear to have recognised that the true morbus 
 Addisonii has essential peculiarities of its own; that 
 no other disease or degeneration of the organ is capable 
 of producing the same associated train of symptoms ; 
 indeed, that no other primary disease of the organ has 
 been seen. Like most other great discoveries, the full 
 recognition of its importance has been slowly adopted, 
 and the progressive investigation of its clinical nature 
 languidly prosecuted ; for nearly a quarter of a century 
 has elapsed since the original paper was read before 
 the South London Medical Society ; yet even now it 
 does not find a place in the nosology of some writers, 
 although the evidence of its distinct and essential 
 nature as a malady sui generis is conclusive, whether it 
 be deduced from observations made in this country or 
 throughout the continent of Europe.
 
 ON THE 
 
 CONSTITUTIONAL AND LOCAL EFFECTS 
 OP 
 
 DISEASE OF THE SUPKA-RENAL CAPSULES. 
 
 PREFACE. 
 
 IF pathology be to disease what physiology is to 
 health, it appears reasonable to conclude that, in any 
 given structure or organ, the laws of the former will 
 be as fixed and significant as those of the latter, and 
 that the peculiar characters of any structure or organ 
 may be as certainly recognised in the phenomena of 
 disease as in the phenomena of health. 
 
 When investigating the pathology of the lungs, I 
 was led by the results of inflammation affecting the 
 lung-tissue to infer, contrary to general belief, that the 
 lining of the air-cells was not identical and continuous 
 with that of the bronchi, and microscopic investigation 
 has since demonstrated in a very striking manner the 
 correctness of that inference, an inference, be it ob- 
 served, drawn entirely from the indication furnished 
 by pathology. 
 
 Although pathology, therefore, as a branch of medi- 
 cal science, is necessarily founded on physiology, 
 questions may, nevertheless, arise regarding the true 
 character of a structure or organ, to which occasionally 
 the pathologist may be able to return a more satisfac- 
 tory and decisive reply than the physiologist these 
 
 14
 
 210 PREFACE. 
 
 two branches of medical knowledge being thus found 
 mutually to advance and illustrate each other. 
 
 Indeed, as regards the functions of individual organs, 
 the mutual aids of these two branches of knowledge are 
 probably much more nearly balanced than many may 
 be disposed to admit ; for in estimating, we are very 
 apt to forget how large an amount of our present phy- 
 siological knowledge respecting the functions of these 
 organs has been the immediate result of casual obser- 
 vations made on the effects of disease. Most of the 
 important organs of the body, however, are so amenable 
 to direct observation and experiment, that in respect to 
 them the modern physiologist may fairly lay claim to a 
 large preponderance of importance, not only in estab- 
 lishing the solid foundation, but in raising and 
 greatly strengthening the superstructure of a rational 
 pathology. 
 
 There are still, however, certain organs of the body 
 the actual functions and influence of which have hitherto 
 entirely eluded the researches, and bid defiance to the 
 united efforts of both physiologist and pathologist. 
 
 Of these, not the least remarkable are the " supra- 
 renal capsules," the atrabiliary capsules of Casper Bar- 
 tholinus ; and it is as a first and feeble step towards 
 inquiry into the functions and influence of these organs 
 suggested by pathology, that I now put forth the 
 following pages. 
 
 T. A. 
 
 24, NEW STKEET, SPRING GARDENS ; 
 May 2ist, 1855.
 
 ON THE 
 CONSTITUTIONAL AND LOCAL EFFECTS 
 
 OF 
 
 DISEASE OF THE SUPRA-RENAL CAPSULES. 
 
 IT will hardly be disputed that at the present moment the functions 
 of the supra-renal capsules, and the influence they exercise in the 
 general economy, are almost or altogether unknown. The large 
 supply of blood, which they receive from three separate sources; 
 their numerous nerves, derived immediately from the semilunar 
 ganglia and solar plexus; their early development in the foetus; 
 their unimpaired integrity to the latest period of life; and their 
 peculiar gland-like structure all point to the performance of some 
 important office : nevertheless, beyond an ill-defined impression, 
 founded on a consideration of their ultimate organization, that, in 
 common with the spleen, thymus, and thyroid body, they in some 
 way or other minister to the elaboration of the blood, I am not 
 aware that any modern authority has ventured to assign to them 
 any special function or influence whatever. 
 
 To the physiologist and to the scientific anatomist, therefore, they 
 continue to be objects of deep interest; and doubtless both the phy- 
 siologist and anatomist will be inclined to welcome and regard with 
 indulgence the smallest contribution calculated to open out any new 
 source of inquiry respecting them. But if the obscurity which at 
 present so entirely conceals from us the uses of these organs justify 
 the feeblest attempt to add to our scanty stock of knowledge, it is 
 not less true, on the other hand, that any one presuming to make 
 such an attempt ought to take care that he do not, by hasty preten- 
 sions, or by partial and prejudiced observation, or by an over-
 
 212 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 statement of facts, incur the just rebuke of those possessing a 
 sounder and more dispassionate judgment than himself. 
 
 Under the influence of these considerations I have for a consider- 
 able period withheld, and now venture to publish, the few facts 
 bearing upon the subject that have fallen within my own knowledge, 
 believing, as I now do, that these concurring facts, in relation to 
 each other, are not merely casual coincidences, but are such as 
 admit of a fair and logical inference an inference that, where these 
 concurring facts are observed, we may pronounce with considerable 
 confidence the existence of diseased supra-renal capsules. 
 
 As a preface to my subject, it may not be altogether without 
 interest or unprofitable to give a brief narrative of the circum- 
 stances and observations by which I have been led to my present 
 convictions. 
 
 Tor a long period I had from time to time met with a very remark- 
 able form of general anaemia, occurring without any discoverable 
 cause whatever cases in which there had been no previous loss of 
 blood, no exhausting diarrhrea, no chlorosis, no purpura, no renal, 
 splenic, miasmatic, glandular, strumous, or malignant disease. 
 
 Accordingly, in speaking of this form in clinical lecture, I perhaps 
 with little propriety applied to it the term " idiopathic," to distin- 
 guish it from cases in which there existed more or less evidence of 
 some of the usual causes or concomitants of the anaemic state. 
 
 The disease presented in every instance the same general charac- 
 ter, pursued a similar course, and, with scarcely a single exception, 
 was followed, after a variable period, by the same fatal result. 
 
 It occurs in both sexes generally, but not exclusively, beyond the 
 middle period of life, and, so far as I at present know, chiefly in 
 persons of a somewhat large and bulky frame, and with a strongly - 
 marked tendency to the formation of fat. 
 
 It makes its approach in so slow and insidious a manner that the 
 patient can hardly fix a date to his earliest feeling of that languor 
 which is shortly to become so extreme. The countenance gets pale, 
 the whites of the eyes become pearly, the general frame flabby rather 
 than wasted; the pulse, perhaps, large, but remarkably soft and 
 compressible, and occasionally with a slight jerk, especially under 
 the slightest excitement; there is an increasing indisposition to 
 exertion, with an uncomfortable feeling of faintness or breathless- 
 ness on attempting it ; the heart is readily made to palpitate ; the 
 whole surface of the body presents a blanched, smooth, and waxy
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 213 
 
 appearance ; the lips, gums, and tongue seem bloodless ; the flabbi- 
 ness of the solids increases; the appetite fails; extreme languor 
 and faintness supervene, breathlessness and palpitations being pro- 
 duced by the most trifling exertion or emotion ; some slight oedema 
 is probably perceived about the ankles ; the debility becomes extreme. 
 The patient can no longer rise from his bed, the mind occasionally 
 wanders, he falls into a prostrate and half-torpid state, and at length 
 expires. Nevertheless, to the very last, and after a sickness of, 
 perhaps, several months' duration, the bulkiness of the general frame 
 and the obesity often present a most striking contrast to the failure 
 and exhaustion observable in every other respect. 
 
 With perhaps a single exception the disease, in my own expe- 
 rience, resisted all remedial efforts, and sooner or later terminated 
 fatally. 
 
 On examining the bodies of such patients after death I have 
 failed to discover any organic lesion that could properly or reason- 
 ably be assigned as an adequate cause of such serious consequences ; 
 nevertheless, from the disease having uniformly occurred in fat 
 people, I was naturally led to entertain a suspicion that some form 
 of fatty degeneration might have a share, at least, in its production ; 
 and I may observe that, in the case last examined, the heart had un- 
 dergone such a change, and that a portion of the semilunar ganglion 
 and solar plexus, on being subjected to microscopic examination, 
 was pronounced by Mr. Quekett to have passed into a correspond- 
 ing condition. 
 
 Whether any or all of these morbid changes are essentially con- 
 cerned as I believe^they are in giving rise to this very remarkable 
 disease, future observation will probably decide. 
 
 The cases having occurred prior to the publication of Dr. Bennett's 
 interesting essay on " Leucocythaemia," it was not determined by 
 microscopic examination whether there did or did not exist an 
 excess of white corpuscles in the blood of such patients. 
 
 It was whilst seeking in vain to throw some additional light upon 
 this form of anaemia that I stumbled upon the curious facts which 
 it is my more immediate object to make known to the profession ; 
 and however unimportant or unsatisfactory they may at first sight 
 appear, I cannot but indulge the hope that, by attracting the atten- 
 tion and enlisting the co-operation of the profession at large, they 
 may lead to the subject being properly examined and sifted, and the
 
 214 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 inquiry so extended as to suggest, at least, some interesting physio- 
 logical speculation, if not still more important practical indications. 
 
 The leading and characteristic features of the morbid state to 
 which I would direct attention are, anaemia, general languor and 
 debility, remarkable feebleness of the heart's action, irritability of 
 the stomach, and a peculiar change of colour in the skin, occurring 
 in connection with a diseased condition of the " supra-renal 
 capsules." 
 
 As has been observed in other forms of anasmic disease, this 
 singular disorder usually commences in such a manner that the in- 
 dividual has considerable difficulty in assigning the number of weeks, 
 or even months, that have elapsed since he first experienced indica- 
 tions of failing health and strength; the rapidity, however, with 
 which the morbid change takes place varies in different instances. 
 
 In some cases that rapidity is very great, a few weeks proving 
 sufficient to break up the powers of the constitution, or even to 
 destroy life, the result, I believe, being determined by the extent, 
 and by the more or less speedy development of the organic lesion. 
 
 The patient, in most of the cases I have seen, has been observed 
 gradually to fall off in general health; he becomes languid and 
 weak, indisposed to either bodily or mental exertion ; the appetite 
 is impaired or entirely lost ; the whites of the eyes become pearly ; 
 the pulse small and feeble, or perhaps somewhat large, but excessively 
 soft and compressible ; the body wastes, without, however, present- 
 ing the dry and shrivelled skin and extreme emaciation usually 
 attendant on protracted malignant disease ; slight pain or uneasi- 
 ness is from time to time referred to the region of the stomach, and 
 there is occasionally actual vomiting, which in one instance was both 
 urgent and distressing; and it is by no means uncommon for the 
 patient to manifest indications of disturbed cerebral circulation. 
 
 Notwithstanding these unequivocal signs of feeble circulation, 
 anemia and general prostration, neither the most diligent inquiry 
 nor the most careful physical examination tend to throw the 
 slightest gleam of light upon the precise nature of the patient's 
 malady ; nor do we succeed in fixing upon any special lesion as the 
 cause of this gradual and extraordinary constitutional change. 
 
 We may, indeed, suspect some malignant or strumous disease 
 we may be led to inquire into the condition of the so-called blood- 
 inaking organs but we discover no proof of organic change any- 
 where no enlargement of spleen, thyroid, thymus, or lymphatic
 
 OF DISEASE OP THE SUPRA-RENAL CAPSULES. 215 
 
 glands no evidence of renal disease, of purpura, of previous ex- 
 hausting diarrhoea, or ague, or any long-continued exposure to 
 miasmatic influences ; but with a more or less manifestation of the 
 symptoms already enumerated we discover a most remarkable and, 
 so far as I know, characteristic discoloration taking place in the 
 skin sufficiently marked, indeed, as generally to have attracted 
 the attention of the patient himself or of the patient's friends. 
 
 This discoloration pervades the whole surface of the body, but is 
 commonly most strongly manifested on the face, neck, superior ex- 
 tremities, penis, and scrotum, and in the flexures of the axillae and 
 around the navel. 
 
 It may be said to present a dingy or smoky appearance, or various 
 tints or shades of deep amber or chesnut-brown ; and in one 
 instance the skin was so universally and so deeply darkened that 
 but for the features the patient might have been mistaken for a 
 mulatto. 
 
 In some cases the discoloration occurs in patches, or perhaps 
 rather certain parts are so much darker than others as to impart to 
 the surface a mottled or somewhat chequered appearance ; and in one 
 instance there were, in the midst of this dark mottling, certain in- 
 sular portions of the integument presenting a blanched or morbidly 
 white appearance, either in consequence of these portions having 
 remained altogether unaffected by the disease, and thereby contrast- 
 ing strongly with the surrounding skin, or, as I believe, from an 
 actual defect of colouring matter in these parts. Indeed, as will 
 appear in the subsequent cases, this irregular distribution of pigment- 
 cells is by no means limited to the integument, but is occasionally 
 also made manifest on some of the internal structures. 
 
 We have seen it in the form of small black spots, beneath the 
 peritoneum of the mesentery and omentum a form which in one 
 instance presented itself on the skin of the abdomen. 
 
 This singular discoloration usually increases with the advance of 
 the disease ; the anaemia, languor, failure of appetite, and feebleness 
 of the heart, become aggravated ; a darkish streak usually appears 
 on the commissure of the lips : the body wastes, but without the 
 emaciation and dry, harsh condition of the surface, so commonly 
 observed in ordinary malignant diseases ; the pulse becomes smaller 
 and weaker; and without any special complaint of pain or uneasiness 
 the patient at length gradually sinks and expires. 
 
 In one case, which may be said to have been acute in its develop-
 
 216 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 meat, as well as rapid in its course, and in which both capsules 
 were found universally diseased after death, the mottled or chequered 
 discoloration was very manifest, the anaemic condition strongly 
 marked, and the sickness and vomiting urgent; but the pulse, 
 instead of being small and feeble, as usual, was large, soft, and 
 extremely compressible, and jerking on the slightest exertion or 
 emotion, and the patient speedily died. 
 
 My experience, though necessarily limited, leads to the belief that 
 the disease is by no means of very rare occurrence, and that were we 
 better acquainted with its symptoms and progress, we should pro- 
 bably succeed in detecting many cases which in the present state of 
 our knowledge, may be entirely overlooked or misunderstood ; and, 
 I think I may with some confidence affirm, that although partial 
 disease of the capsules may give rise to symptoms, and to a condi- 
 tion of the general system extremely equivocal and inconclusive, yet 
 that a more extensive lesion will be found to produce a state which 
 may not only create a suspicion, but be announced with some con- 
 fidence to arise from the lesion in question. When the lesion is 
 acute and rapid, I believe the anaemic prostration and peculiar con- 
 dition of the skin will present a corresponding character, and that 
 whether acute or chronic, provided the lesion involve the entire 
 structure of both organs, death will inevitably be the consequence. 
 
 If this statement be correct and I quite believe it to be so the 
 chief difficulty that remains to be surmounted by further experience 
 in this, I fear, irremediable disease, is a correct and certain diagnosis 
 how we may at the earliest possible period detect the existence of 
 this form of anaemia, and how it is to be distinguished from other 
 forms anaemic of disorder. 
 
 As I have already observed, the great distinctive mark of this 
 form of anaemia is the singular dingy or dark discoloration of the 
 skin ; nevertheless, at a very early period of the disorder, and when 
 the capsules are less extensively diseased, the discoloration may, 
 doubtless, be so slight and equivocal as to render the source of the 
 anaemic condition uncertain. 
 
 Our doubts, in such cases, will have reference to the sallow 
 anaemic conditions resulting from miasmatic poisoning or malignant 
 visceral disease ; but a searching inquiry into the history of the case, 
 and a careful examination of the several parts or organs usually 
 involved in anaemic disease, will furnish a considerable amount of 
 at least negative evidence ; and when we fail to discover any of the
 
 OF DISEASE OP THE SUPRA-RENAL CAPSULES. 217 
 
 other well-known sources of that condition, when the attendant 
 symptoms resemble those enumerated as accompanying disease of 
 the capsules, and when to all this is superadded a dark, dingy, or 
 smoky-looking discoloration of the integument, we shall be justified 
 at least in entertaining a strong suspicion in some instances, a 
 suspicion almost amounting to certainty in others. 
 
 It must, however, be observed, that every tinge of yellow, or 
 mere sallowness, throws a still greater doubt over the true nature of 
 the case, and that the more decidedly the discoloration partakes of 
 the character described, the stronger ought to be our impression as 
 to the capsular origin of the disorder. The morbid appearances 
 discovered after death will be described with the cases in which they 
 occurred ; but I may remark that a recent direction (March, 1 855) 
 has shown that even malignant disease may exist in both capsules, 
 without giving rise to any marked discoloration of the skin ; but, 
 in the case alluded to, the deposit in each capsule was exceedingly 
 minute, and could not have seriously interfered with the functions 
 of the organs ; extensive and fatal malignant disease had, however, 
 affected other parts. 
 
 It may be observed in conclusion, that on subjecting the blood of 
 a patient who recently died from a well-marked attack of this 
 singular disease to microscopic examination, a considerable excess 
 of white corpuscles was found to be present. 
 
 CASE i.* Reported by Mr. Thomas Fuller. 
 
 James Wootten, set. 32, admitted into Guy's Hospital, under 
 Dr. Golding Bird, Feb. 6, 1850, has been residing in Long Alley, 
 Moorfields, and is by occupation a baker. 
 
 States that he was attacked with cough three years since, which 
 he was unable to get rid of by ordinary remedies, and was finally 
 cured at St. Bartholomew's, after taking pills for one week. 
 
 From this time his skin, previously white, began to assume a 
 darker hue, which has been gradually increasing. Twelve months 
 after leaving the above hospital he was laid up from excessive 
 weakness, the result of his cough, which had again appeared, and 
 incapacitated him for his work. He now became an out-patient of 
 
 * The cases generally are given in the language and style of their respective 
 reporters.
 
 218 ON THE CONSTITUTIONAL AND LOCAL EFFECTS. 
 
 St. Thomas's, under Dr. Goolden, who cured his cough, and think- 
 ing that the colour of his skin depended on jaundice, treated him 
 for that disease, but to no purpose. 
 
 He left the hospital in tolerable health, but subsequently lost 
 flesh, and became so excessively weak, the colour of his skin at the 
 same time getting rapidly darker, that he applied for admission here, 
 which was granted him. 
 
 Present appearances. The whole of the skin of the body is now 
 of a dark hue, and he has just the appearance of having descended 
 from coloured parents, which he assured me is not the case, nor 
 have any of his family for generations, that he can answer for, mani- 
 fested this peculiarity. 
 
 The colour of the skin does not at all resemble that produced by 
 the absorption of the nitrate of silver, but has more the appearance 
 of the pigment of the choroid of the eye ; it seems to have affected 
 some parts of the body more than others, the scrotum and penis 
 being the darkest, the soles of the feet and palms of the hands the 
 lightest ; the cheeks are a little sunken ; the nose is pointed ; the 
 conjunctiva are of a pearly whiteness ; the voice is puny and puerile, 
 the patient speaking with a kind of indescribable whine, and his 
 whole demeanour is childish. 
 
 He complains of a sense of soreness in the chest about the 
 scrobiculus cordis. 
 
 The chest is well-formed and perfectly resonant ; the sounds of 
 the heart are also healthy ; there is some slight fulness in the region 
 of the stomach. 
 
 The urine is of a proper colour, and he has passed in twelve 
 hours one and a half pints, which has a specific gravity 1008, an 
 acid reaction, and contains neither albumen nor sugar ; there is also 
 some pain on pressure in the left lumbar region. 
 
 Feb. 8. Dr. Bird wished a likeness to be taken, so as to be able 
 to watch any alterations in his colour; and considering the case 
 one of anaemia, ordered Lyn. Ferri lodidi ^j, ter die; and middle 
 diet. 
 
 These he took the whole of the time he was in the hospital, and 
 was discharged in April, rather stronger, but the colour remaining 
 precisely the same. 
 
 Shortly after his discharge from the hospital he was seized with 
 acute pericarditis and pulmonic inflammation, under which he 
 speedily sank and died.
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 219 
 
 The following is a report of the post-mortem examination 
 Lungs universally adherent, the adhesions being very old. The 
 upper lobe of the right lung contained some small denned patches 
 of recent pneumonia, about the size of a crown piece, surrounded 
 by tolerably healthy structure. 
 
 The lower lobe was extremely fleshy and without air. The left 
 lung was bound down by old pleuritic adhesions, which were very 
 tough and difficult to be torn through. The substance of this lung 
 was fleshy, and contained but little air. 
 
 There was no tubercle or cavity. 
 
 The mucous membrane of the bronchial tubes were considerably 
 injected, and, I believe, rather thickened. 
 
 The pericardium was distended with a fluid of a deep brown 
 colour, amounting to about half a pint; recent lymph was effused 
 over the whole serous surface. 
 
 The liver and spleen were both of weak texture, and easily broken 
 down ; the structure of the liver rather coarse. 
 
 The gall-ducts pervious. 
 
 The gall bladder contained the usual quantity of bile, which 
 was thin, watery, and clear. 
 
 The thoracic duct was pervious throughout ; and there was no 
 obstruction to any of the veins or arteries that I could discover. 
 
 The colour of the blood in the arteries had an unusually dark 
 appearance. 
 
 The kidneys were quite healthy and of full size. 
 
 The supra-renal capsules were diseased on both sides, the left 
 about the size of a hen's egg, with the head of the pancreas firmly 
 tied down to it by adhesions. Both capsules were as hard as stones. 
 Intestines pale. Lumbar glands natural. No tubercular deposit 
 was discovered in any organ. The head was not examined. 
 
 In some of the cases about to be given the capsules merely par- 
 ticipated in disease affecting other organs, either of a strumous or 
 malignant character, and it might consequently be doubtful whether 
 the peculiar symptoms depended upon such complications, or upon 
 the special disease of the capsules. In the above instance, how- 
 ever, no such doubt could reasonably be entertained, inasmuch as 
 there was found no abnormal condition whatever of any other organ 
 to which the peculiar symptoms could by any means be attributed. 
 The slow and gradual inroads of the disease, and the remarkable 
 excess of pigment, were sufficiently accounted for by the universality
 
 2.20 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 of the change that had taken place in the structure of both capsules ; 
 at least, such would be the legitimate conclusion to be drawn from 
 a comparison of the present with other cases about to be related. 
 
 CASE 2. James Jackson, set. 35. The subject of this case was 
 admitted into the clinical ward, under my own care, November nth, 
 1851, and died December 7th, 1851. For the particulars of its 
 history and result I am indebted to my former pupil and present 
 distinguished colleague, Dr. Gull, who was the first to suspect the 
 true nature of the malady during the life of the patient. 
 
 A married man, residing at Gravesend, and occupied as a tide- 
 waiter in the customs. 
 
 Of a bilious temperament, dark hair, and sallow complexion, 
 which since his illness has much deepened, so that now it is of dark 
 olive-brown. His wife says, " This obvious change in his com- 
 plexion has been from the begiuning of his illness, and gradually 
 came on at that time." There can be no doubt as to this change 
 in the complexion depending upon increase of pigment ; for if the 
 lips be turned down the mucous membrane is seen to be mottled by 
 a deposit of pigment, and a closer examination shows that the dark 
 colour of the lips, which at first had the appearance of sordes, is 
 dependent upon the presence of a black pigment, which is not move- 
 able by moistening or washing the lips. There is an expression of 
 anxiety in the face, and the brow is contracted. He gives the fol- 
 lowing history of himself : 
 
 His occupation subjects him to much anxiety ; he is exposed to 
 ah 1 the vicissitudes of the weather, both night and day ; and some- 
 times his food for weeks together consists of salt provisions. 
 
 Eight years ago he had rheumatism, accompanied with great 
 nervous depression; since that time he has enjoyed general good 
 health, with the exception of some attacks of bilious vomiting. 
 
 His present illness came on six months ago with headache, vomit- 
 ing, and constipation. About the sixth day of his illness he became 
 delirious, and was insensible for twenty-four hours. On recovering 
 his consciousness, he was unable to move the fingers of either hand, 
 nor could he move the legs below the knees ; the same parts were 
 numb, as was also the tip of the tongue. He continued weak 
 during the whole summer. 
 
 Two months ago he resumed his occupation, and remained at it
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 221 
 
 until ten days back, when the old symptoms of headache, vomiting 
 and constipation returned. 
 
 Dr. McWilliam saw him at this time, and found his symptoms to 
 have an intermittent character, and regarded the case as one of mias- 
 matic poisoning, not only from his general symptoms, but also from 
 the dark, poisoned look of his face, not altogether unlike that presented 
 on the approach of the asphyxic stage of cholera. On his admission 
 into the hospital the pulse was extremely small and feeble, the 
 expression of the face pinched, the brows knitted. 
 
 He vomited mucus containing altered blood of a dark-brown 
 colour : tongue clean; epigastric region full, especially towards the 
 left side, where he had some twitching pain and slight tenderness on 
 pressure ; urine natural in colour and quantity, of a light brown 
 colour, not coagulable by heat. He went on, day by day, with but 
 slight symptoms of change. Skin cool ; pulse moderate in frequency, 
 but extremely feeble, so as scarcely to be felt at the wrist. On several 
 occasions the depression was so great as to require the exhibition of 
 decided stimulants. There was a continued tendency to sickness. 
 The abdomen soft, with marked aortic pulsation. Bowels con- 
 stipated; chest everywhere resonant; heart's sound normal ; extent 
 of dulness on percussion not increased. Slight traces of intermittence 
 in the symptoms ; the surface in the evening being cool, or even 
 cold, and the following morning warm, as if from reaction. 
 
 Probable diagnosis. The epigastric tenderness and pulsation, with 
 frequent vomiting, and the ejected mucus and altered blood, point 
 to an inflammatory condition of the gastric mucous membrane. But 
 what condition of system is it which favours the production of black 
 pigment ? Is it some affection of the liver ; or is it, as Dr. Addison 
 supposes, disease of the supra-renal capsules ? 
 
 Sectio-cadaveris. The lining membrane of the stomach was finely 
 injected into minute puncta and stellae of a bright red colour, with 
 two or three spots of ecchymosis. The structure of the membrane 
 was thickened and pulpy, and the surface covered with tenacious 
 mucus. In some parts there were irregular superficial abrasions ; 
 these appearances of the mucous membrane becoming very distinct by 
 examining it under water by the aid of sunlight, and seeming, more- 
 over, unequivocally to demonstrate the existence of a gastritis. The 
 brain, lungs, heart, spleen, liver, and kidneys were normal. 
 
 The supra-renal capsules contained, both of them, compact fibrinous 
 concretions, seated in the structure of the organ; superficially examined,
 
 222 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 they were not unlike some forms of strumous tubercle. The slow and 
 insidious approach and progress of the constitutional loss of strength, 
 the extreme feebleness of the pulse, the absence of all evidence of 
 any lesion sufficient to account for the patient's declining condition, 
 the loss of appetite, the uneasiness and irritability of the stomach, 
 and the indications of disturbed cerebral circulation, were all so 
 strongly marked, and so exactly corresponded in kind with what 
 have been observed to accompany the most extensive disease of the 
 capsules, that, coupled with the excess of dark pigment in the 
 integument, we did not hesitate to anticipate, with much confidence, 
 an extensively diseased condition of these organs. ^ 
 
 CASE 3. Reported by Mr. Williams. 
 
 Henry Patten set. 26, a carpenter and window blind maker, 
 residing at 13, Brandon Street, Walworth, was admitted Nov. 9, 
 1854, having been for some time an out-patient under Dr. Rees. 
 
 His habits have been somewhat intemperate; his drink chiefly 
 malt liquor and spirits. 
 
 With the exception of a sister, who died of phthisis, all his rela- 
 tions are healthy. He has been married four years. The patient 
 states that up to six months ago he enjoyed very good health, but 
 then began to be troubled with what he calls " rheumatic" pain in the 
 right leg, which, without laying him up, gradually extended to his hips 
 and side, and thence to the bottom of the spine. His back latterly 
 has been very tender, a jerk or jarring movement giving him great 
 pain at that part. He has noticed his hips to have become dark- 
 coloured for the last three months, and more lately his face to be 
 similarly discoloured in patches. Eor the last month he has dis- 
 continued work on account of attacks of giddiness and dimness of 
 sight, accompanied by a peculiar pain at the back of the head and 
 partial loss of consciousness. These attacks would occur several 
 times in the course of the day, upon any unusual exertion, always 
 while in the standing posture, and were instantly relieved by sitting 
 or lying down. Since he has discontinued his employment they 
 have only occurred on getting out of bed in the morning. It is for 
 the pains and tenderness at the back, and occasional attacks, as above 
 described, with general debility, that he has been attending this 
 hospital as an out-patient.
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 223 
 
 Present condition. The patient presents a highly strumous 
 appearance, being thin, pale, and the hair dark and dry. Over the 
 face and forehead, which are of a general yellowish hue, are several 
 patches of darkened skin, and similar black patches on the lips. 
 There is angular curvature at the second, and great tenderness on 
 pressure over the upper three lumbar vertebrae ; he complains also 
 of pain at this part upon moving in bed. There is no paralysis, 
 but considerable general debility. His bowels are regular, and the 
 tongue clean, but the appetite is impaired ; the urine is clear, mode- 
 rate in quantity, and not albuminous. Heart-sounds normal, but 
 the impulse feeble. 
 
 Pulse 80, small and weak. 
 
 Nov. loth. $> Quinae Disulph. gr. iss. 
 Aquae distill, ^j. 
 Syr. Rhoeodos, 5ss. 
 Acid. Sulph. dil. n\v. 
 Ft. Haustus ter die s., Vin. Alb. $iv. 
 
 "With these medicines and middle diet he continued with no 
 appreciable change until the 24th, when he had a kind of fainting 
 fit upon rising to have his bed made, contrary to an order that he 
 should keep in the recumbent posture. This day his diet was 
 changed to milk at his own request. He has been once or twice 
 sick after taking his food. 
 
 a8th. The sickness has continued, and he to-day has a trouble- 
 some hiccough, for which he was ordered 
 Jul. Ammon., p. r. n. 
 
 29th. He has had little sleep, the hiccough, unrelieved by the 
 Julep. Ammon., annoying him much. Dr. Barlow, who now took 
 the ward, ordered him 
 
 JSther. Chlor. Vt\\. 
 
 Vini Opii, TT\v. 
 
 ex Mist. Camph. t. d. a. 
 
 3oth. He is to-day about the same. Has been sick this morn- 
 ing, the vomited matter consisting of food and drink, the hic- 
 cough occasionally ceasing. 
 
 Dec. ist. Hiccough still very harassing. 
 
 9> Vini Opii n\x. 
 
 Tinct. Cautorei fl\x. 
 
 ex Julep. Pimentse p. r. n.' 
 
 This was found to relieve the hiccough somewhat.
 
 224 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 2nd. He seems considerably weaker, and upon approaching him, 
 his eyelids half closed, allowed the lower sclerotic of the raised 
 eyeballs to be seen. The tongue was moist and clean, and pulse 80, 
 very weak. On speaking to him he roused up and appeared quite 
 as usual, but soon relapsed into the torpid state again. His blood 
 under the quarter inch object-glass presented from forty to sixty 
 white corpuscles in each field, mostly scattered about, but some in 
 patches of two or three and six or eight together. 
 
 3rd. Slept better, although the hiccough did not cease. He 
 complains of a constricting pain about the waist ; he is tender on 
 pressure over the spleen, where no tumour is to be felt. The 
 tongue to-day is dry, and beginning to be sordid ; teeth dirty ; pulse 
 week. He presents the same typhoid appearances. 
 
 4th. Pulse weaker, dicrotic 96; roused from the torpid state 
 with more difficulty than yesterday. He talks very sensibly, but 
 his wife, who watches by his bedside, states that he wanders in the 
 
 night. 
 
 Jul. Ammon. c. Tinct. Castorei TT|v. p. r. n. 
 
 The blood presented the same appearances under the microscope 
 as before. 
 
 5th. Hiccough continues, is more feeble, pulse scarcely percep- 
 tible, lies in a torpid and typhoid state. When roused, said he was 
 sore all over the body. Tongue and teeth sordid. 
 
 6th. Died quietly at 5 a.m. 
 
 Sectio-cadaveris. Nine and a half hours after death in cold wet 
 weather. Rigor mortis, but no decomposition. There was not 
 much emaciation, and the axillae were slightly discoloured. The 
 countenance was paler than in life, but presented the same olive hue, 
 with the dark patches on the face, forehead, and lips. There was a 
 psoas abscess on the right side, extending from Poupart's ligament 
 to the diseased vertebrae, and holding about a pint of flaky pus. 
 The disease was between the first and the second vertebrae, com- 
 mencing in the cartilage, and nearly destroying the neighbouring 
 vertebras at their centres. 
 
 The bone surrounding the cavity was red, soft, and infiltrated 
 with strumous matter. 
 
 Pleura and bronchi healthy. 
 
 Both lungs contained hard masses of grey strumous pneumonic 
 deposit, mostly in the apices, but also in the lower lobes ; these 
 masses presented the appearance of a conglomeration of tubercles,
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 225 
 
 held together by inflammatory matter. Heart and pericardium 
 healthy. Heart's weight seven ounces and a half. 
 
 The blood on microscopic examination contained the same excess 
 of white corpuscles observed in life. Stomach healthy, slightly ad - 
 herent to the left supra-renal capsule ; its structure was not affected . 
 Spleen large, firm, seven ounces and a half in weight. 
 
 Corpuscles visible. The pancreas and all other abdominal organs 
 were healthy. The head was not examined. 
 
 Each supra-renal capsule was completely destroyed and con- 
 verted into a mass of strumous disease, the latter of all degrees 
 of consistency. The left supra-renal capsule had formed at 
 the upper part a close connection with the outer coat of the 
 stomach. The upper part of this capsule seemed fluid, and of the 
 colour of pus ; the lower firmer, and of the consistency of putty. 
 The right capsule had all degrees of consistency from the bottom to 
 the top ; the lower part almost fluid and resembling pus, the centre 
 putty-like, and above this the matter could be detached in flakes ; 
 and at the top it was quite earthy, separate angular pieces being 
 easily detached. Although this patient was known to be suffering 
 under a serious affection of the spine, the ordinary indications of 
 the disease of the supra-renal capsules were sufficiently prominent 
 to justify the prediction, which was so satisfactorily confirmed by 
 the post-mortem examination. It is also worthy of remark that, 
 although the patient, as usual, suffered considerably from irritability 
 of stomach, there was but little change observable in that organ after 
 death. 
 
 CASE 4. Eeported by the Ward Clerk. 
 
 John Iveson, set. 21, admitted into Guy's Hospital, March 20, 
 1854, and died the following day. A stonemason, residing at 
 Lambeth. Last winter he had pain in the stomach and vomiting. 
 He slightly improved, but the day after Christmas was confined to 
 his bed with great pain and vomiting ; he vomited matter consisting 
 of a watery fluid. At that time he had "tic douloureux." On 
 admission, his extremities were cold, he was almost pulseless; his 
 hands were blue : he had not had any diarrhcea ; he had slight pain, 
 or rather soreness in the hypogastric region ; he was quite sensible; 
 the pupils were much dilated. He rallied a little after his admis- 
 
 15
 
 226 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 sion ; had no purging, but vomited bilious matter ; had no diabetes 
 or albuminuri. He appeared to die from syncope. 
 
 Sectio-cadaveris. Seventeen hours after death; weather cold; 
 limbs rigid, body tolerably nourished, face of a dingy colour, also the 
 axillae and hands. Abdomen not distended. 
 
 Head. The dura mater and sinuses were found to be healthy, the 
 membranes injected, and the veins full. There was slight sub- 
 arachnoid effusion. The grey matter of the cerebrum was rather 
 deep in colour. The brain was in other respects normal. 
 
 Chest. Trachea granular and congested. The right pleura 
 adherent at the posterior and lower parts; on the left side there 
 were firm adhesions at the apex ; the bronchi granular ; the left apex 
 was a little puckered, and presented several lobules, with iron-grey 
 consolidation and calcareous deposit. The right lung was healthy, 
 with the exception of a single iron-grey consolidation at the apex. 
 The bronchial and mediastinal glands were healthy. 
 
 Heart. Pericardium healthy. There was a white patch on the 
 right ventricle. The right side of the heart was moderately dis- 
 tended with clot, the left entirely and firmly contracted. The valves 
 were hsalthy, and the muscular fibre, though flaccid, appeared 
 healthy. No fat was found about the heart. Weight seven 
 ounces. 
 
 Abdomen. Peritoneum healthy viscera moderately contracted. 
 Stomach not distended; at the cardiac extremity there was post- 
 mortem solution of the mucous membrane ; towards the lesser cur- 
 vature it was granular, in some parts destroyed, ulcerated; quite 
 superficially there was arborescent injection. On microscopical ex- 
 amination, mucus- and granule-cells were observed. Brunner's 
 glands were very prominent. Ileum with much mucous congestion. 
 Peyer's and solitary glands very distinct, but only hypertrophied. 
 The mesenteric glands were enlarged, firm, and white, full of nuclei, 
 hypertrophied. 
 
 Large intestines were healthy. 
 
 Liver was of normal form and condition; there was a small 
 amount ^ of fat in the cells; weight two pounds fourteen ounces, 
 containing no arsenic. Gall-bladder healthy; ducts free, but not 
 enlarged. Spleen enlarged weight six ounces. Pancreas was 
 healthy. 
 
 The two supra-renal capsules together weighed forty-nine grains ; 
 they appeared exceedingly small and atrophied ; the right one was
 
 OF DISEASE OP THE SUPRA-RENAL CAPSULES. 227 
 
 natural, firm ; the left deformed by contraction ; each adherent to 
 surrounding parts by dense areolar tissue ; the section gave a pale 
 and homogeneous aspect ; it presented a fibrous tissue, fat, and cells 
 about the size of white blood-corpuseles. The lumbar glands were 
 enlarged. The kidneys coarse, weighing ten ounces. The bladder 
 and prostate were healthy. 
 
 The history of this man's case renders it probable that his disease 
 commenced several months prior to his admission into the hospital ; 
 and it is not a little remarkable that his earliest complaint was of 
 sickness, vomiting, and pain in the region of the stomach symptoms 
 which have constituted a more or less prominent feature in every 
 case that has fallen under my notice, and which, in the present 
 instance, were so urgent as to suggest a suspicion of some acrid 
 poison having been received into the stomach. 
 
 How far these gastric symptoms, when present, are referable to 
 sympathy existing between diseased capsules and the stomach 
 how far they depend upon disturbed circulation within the head 
 how far they are attributable to accidental or essential gastric inflam- 
 mation and how far the inflammatory aspect of the gastric mucous 
 membrane is the mere result of severe and repeated vomiting a 
 more extended observation will probaby determine hereafter. 
 
 It was from the presence of these gastric symptoms, the extreme 
 and peculiar prostration of the patient's strength, the great feeble- 
 ness and smallness of the pulse, the anaemiated eye, the absence of 
 any discoverable lesion to account for the patient's condition, 
 and more especially the dingy discoloration of the face, that led 
 before death to a belief that we should on post-mortem examination 
 find disease of the supra-renal capsules. 
 
 It is, moreover, of some significance and importance to observe 
 that, in the present instance, the diseased condition of the supra- 
 renal capsules did not result, as usual, from a deposit either of a 
 strumous or malignant character, but appears rather to have been 
 occasioned by an actual inflammation, that inflammation having 
 destroyed the integrity of the organs, and finally led to their 
 contraction and atrophy. 
 
 CASE 5. The Mowing, taken from Dr. Bright's reports of 
 medical cases, presents, according to my belief, a very good 
 illustration of the disease under consideration, and is headed: 
 " Serous Effusion under the Arachnoid and into the Ventricles in
 
 228 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 a Case of Emaciation, with Bilious Vomiting and diseased Renal 
 Capsules/' Ann Roots was admitted in July, 1829, under one of 
 the surgeons, into Guy's Hospital, on account of a tumour in the 
 left breast and a swelling in the right parotid ; but as it was per- 
 ceived that she was greatly emaciated and apparently sinking, and 
 therefore quite unfit to undergo any operation, she was transferred 
 to the care of the physician. Her complexion was very dark her 
 whole person emaciated ; she had no cough, and neither tension 
 nor tenderness of abdomen ; she had great difficulty in opening her 
 jaw, owing to the glandular swelling, and could not protrude her 
 tongue. There was no indication but to support the strength. Her 
 stomach soon became irritable ; she had bilious vomiting, which 
 reduced her strength, and for a day or two before her death, which 
 took place on the 18th of August, she became drowsy, yet capable 
 of being roused, complaining of some pain over the forehead, and 
 occasionally wandering a little in her intellects. 
 
 In the absence of all positive symptoms, I concluded that it was 
 possible some glandular disease, similar to that which had shown 
 itself below the mammae and under the jaw, might exist internally, 
 giving rise to emaciation and vomiting ; and it appeared probable 
 that serous effusion had been going on in the head for the last few 
 days. 
 
 Sectio-cadaveris. Considerable emaciation ; and on removing the 
 integuments the scalpel opened into an abscess, containing an ounce 
 or two of pus, situated beneath the mamma of the left side. The 
 dura mater was firmly attached to the skull at the vertex, where the 
 bone was remarkably thin and indented by the glandulse Pacchioni, 
 and the ordinary opaque deposit which surrounds them. On raising 
 the dura mater several small opacities were observable on the arach- 
 noid ; and a very considerable quantity of serous fluid was effused 
 under the arachnoid, raising it into bladders, as well as filling up 
 the hollows between the convolutions. The whole brain was soft 
 and watery, and many vessels showed themselves where horizontal 
 sections were made. In the ventricles about half an ounce of fluid 
 was collected. The choroid plexus was quite exsanguine. Slight 
 adhesions of the pleura pulmonalis and pleura costalis were found, 
 but not sufficient to prevent the lungs from collapsing pretty com- 
 pletely when the air was admitted into the chest. The upper lobe 
 of each lung was in an unhealthy state, looking puckered, and con- 
 taining one or two masses of earthy matter, besides several small
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 229 
 
 incipient tubercles ; the greater part of the lungs, however, was in a 
 very healthy condition. Heart small, but healthy. In the abdomen 
 slight old adhesions had taken place in various parts, but they were 
 composed of the finest transparent cellular tissue ; even the omentum, 
 which was glued by them to various parts, both of the intestines and 
 the parietes, had lost none of its delicacy and transparency. 
 
 The intestines were healthy, but stained with bile; the mucous 
 membrane healthy ; the liver healthy and the gall-bladder full of 
 bile; the pancreas healthy and the spleen also, but just between the 
 pancreas and the spleen a few absorbent glands were enlarged. The 
 glands of the mesentery were also slightly enlarged. The only 
 marked disease was in the renal capsules, both of which were en- 
 larged, tabulated, and the seat of morbid deposits, apparently of a 
 scrofulous character; they were at least four times their natural 
 thickness, feeling solid and hard ; on the left side one part had gone 
 into suppuration, containing two drachms of yellow pus. The 
 kidneys themselves healthy. The uterus held down by adhesions in 
 the pelvis. 
 
 It does not appear that Dr. Bright either entertained a suspicion 
 of the disease of the capsules before death, or was led at any period 
 to associate the colour of the skin with the diseased condition of 
 these organs, although his well-known sagacity induced him to 
 suggest the probable existence of some internal malignant disease. 
 In this, as in most other cases, we have the same remarkable pros- 
 tration, the usual gastric symptoms, the same absence of any very 
 obvious and adequate cause of the patient's actual condition, together 
 with a discoloration of the skin, sufficiently striking to have arrested 
 Dr. Bright's attention, even during the life of the patient. 
 
 CASE 6. E. H , Esq., was a member of the bar, somewhere 
 about middle age. I had the satisfaction of attending him in con- 
 sultation with Dr. Watson and Mr. Barker, when I was informed 
 that he had been getting thin and emaciated during a period of 
 about twelve months. His appearance and symptoms were very 
 remarkable. He was certainly thin, but not strikingly emaciated, 
 and the surface was soft, loose, and supple. He was greatly anae- 
 miated ; his eyes were pearly ; he complained of extreme languor 
 and faintness ; his pulse, contrary to what is usual in capsular 
 disease, was of good size, but exquisitely soft and compressible; 
 the impulse of the heart was feeble, and palpitation or throbbing
 
 230 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 with scrobicular pulsation was immediately produced by the slightest 
 exertion ; without pain, the stomach was extremely irritable, and 
 vomiting was both urgent and distressing. With these symptoms 
 the surface generally presented a dark, dingy aspect, and there were 
 observed, chiefly on the face, neck, and arms, patches of a rather 
 deep chesnut-brown colour; these chesnut-brown patches were of 
 various sizes and shapes, and were associated here and there 
 with others presenting a singularly white or blanched appearance, 
 arising either in consequence of the latter portions of the integu- 
 ment having remained unaffected, and so contrasting with the sur- 
 rounding discoloration, or, what is more probable, from their having 
 received a less supply of pigment than natural. A patient inquiry 
 and most careful examination failed to elicit any information, or to 
 detect any lesion, sufficient to afford even a plausible explanation of 
 the patient's singular condition. The violent vomiting pointed to 
 organic, perhaps carcinomatous disease of the stomach ; nevertheless 
 the general condition and symptoms did not in other respects seem 
 to warrant such a conclusion ; and coupling the existing condition 
 and symptoms with the irregular deposition of dark pigment in the 
 skin, a suspicion was entertained that the whole might arise from 
 disease of the supra-renal capsules. To the last, however, consider- 
 able doubt prevailed amongst us as to the true nature of the case 
 chiefly in consequence of the severity and persistence of the vomiting 
 and from the vomited mucous matters having been occasionally 
 tinged with blood. 
 
 The patient speedily sank, and the following report of the morbid 
 appearances discovered after death was furnished, I believe, by my 
 distinguished friend, Dr. Hodgkin. 
 
 " The morbid specimens consisted of part of the stomach and 
 duodenum the termination of the small, and the commencement of 
 the large intestines, with the appendix vermiformis, and the renal 
 capsules, with a small portion of the kidney. They were taken from 
 a man rather beyond middle life, who, for a considerable time, had 
 suffered from obstinate derangement of the stomach. ' ' The coats 
 of the stomach taken unitedly did not produce any preternatural 
 thickness, but rather the reverse ; yet there might be a little 
 thickening or increased development of the mucous membrane. The 
 peculiarity of its appearance consisted in a spotted character, not 
 very easily described. Near the pylorus it seemed to consist of a 
 very slight degree of that irregularity which Louis has described as
 
 OF DISEASE 0V THE SUPRA-RENAL CAPSULES. 231 
 
 the etat mamelonne, and which appears to be nothing more than the 
 increased development of a natural structure; but in this instance 
 the elevatiops were smaller in size, and consequently more numerous, 
 though less prominent than those generally seen towards the middle 
 of the stomach, where this appearance is most frequently noticed. 
 Further from the pylorus, in the direction of the smaller curvature, 
 smaller spots were seen more scattered and distant from each other, 
 and apparently consisting of opaque light-coloured matter, within 
 the semi-transparent substance of the mucous membrane itself, 
 which was generally of a faint dusky-reddish colour. It could not 
 be decided whether these spots depended on any glandular apparatus, 
 yet the idea suggested itself that they might be connected with the 
 follicles of Lieberkiihn. Immersion under water, with the intention 
 of facilitating the examination with the microscope, rendered these 
 spots less conspicuous. The largest might equal a small pin's 
 head ; the smaller ones scarcely a quarter so large. The duodenum 
 appeared healthy. The portion of small and large intestine, of 
 which the next specimen consisted, offered nothing remarkable in 
 texture. The mucous membrane was tinged with the dingy olive 
 green of the faecal contents, and ileo-colic valve was rather more 
 prominent than usual in the caecum. The appendix vermiformis was 
 about three inches in length, but much distended, being about an 
 inch in diameter at its commencement, and becoming gradually less 
 towards the free extremity, where it but little exceeded the normal 
 size. Its peritoneal coat was quite healthy ; its general thickness 
 was very little increased ; its mucous membrane apparently healthy, 
 of greyish colour, from a little black pigment towards the upper 
 part. Its follicular apparatus was nearly or quite imperceptible. It 
 was completely cut off from the interior of the intestine, the mucous 
 membrane forming a cul-de-sac at both extremities, although there 
 was no apparent want of continuity on the exterior, the septum 
 between the two cavities being merely composed of the two mucous 
 membranes united by cellular tissue. No appearance of cicatrix 
 was discovered, indicating that the separation was of long standing, 
 if not congenital. The contents of the appendix consisted prin- 
 cipally of a transparent colloid or thick mucoid secretion, partly of 
 a light straw colour, partly tinged with blood. Interspersed through 
 it, but especially towards the upper part, was an opaque white 
 substance, of the same consistence, resembling coagulated milk or 
 ground white lead. A few points were blackened by pigments.
 
 232 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 Examined with the microscope, the transparent portion exhibited 
 no determinate structure, but a slight tendency to filamentous 
 arrangement. The whole portion was made up of a congeries of 
 oil-globules, varying in size, but all very minute. The black pigment 
 appeared to pervade some of the oil-globules, rather than itself to 
 compose distinct corpuscles. The basis of this collection was un- 
 doubtedly the mucus of the appendix itself, retained by the want of 
 any excretory passage. " The small fragment of kidney appeared to 
 be of healthy structure, but both the renal capsules were enlarged 
 (the united weight of the two being one and a half ounce), of rather 
 irregular surface, and considerably indurated. When cut into, 
 instead of exhibiting the ordinary appearance of combination of dark 
 and yellow substances, they seemed to consist of a firm, slightly 
 transparent reddish basis, interspersed with irregular spots of opaque 
 yellow matter, the whole bearing a strong resemblance to an enlarged 
 mesenteric gland, mottled with tubercular deposit. Such was pro- 
 bably the nature of the change which the organ had undergone. The 
 naked eye could discover no trace of cystiform arrangement, and the 
 opaque matter, when examined with the microscope, exhibited a 
 copious amount of fatty matter, but no nucleated cells." 
 
 It was to me a matter of much regret that I had not an oppor- 
 tunity of employing an artist to make an exact representation of the 
 singular discoloration observed upon the skin, and the more so 
 because, although agreeing in general character with those observed 
 in other cases, there was a manifest peculiarity, as well in the in- 
 tensity as in the mode of distribution of these discolorations. With 
 universal dinginess of the surface there were, especially about the 
 neck, hands, and arms, several well-defined patches of a deeper or 
 somewhat chesnut-brown hue, interspersed here and there with 
 blanched or almost dead-white portions of integument, contrasting 
 in a very remarkable manner with both the general dinginess and 
 deep brown patches ; and what is very remarkable, wherever the 
 integument presented the blanched or dead-white appearance, the 
 hairs upon its surface were observed to have turned completely 
 white. The superiority of a coloured drawing over the most elabo- 
 rate verbal description, in conveying a correct idea of any morbid 
 appearance, is so universally felt and acknowledged, that I have 
 great satisfaction in being now able to furnish one, which may most 
 fairly and faithfully be applied to the above case. Very recently 
 (March, 1855) I was requested to visit a patient (Mr. S ), about
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 233 
 
 sixty years of age, who presented, in a strongly marked degree, the 
 indications of diseased renal capsules. The history, mode of attack, 
 the progress, the anaemia, the extreme feebleness of the heart's 
 action, the uneasiness and irritability of the stomach, and the dis- 
 coloration of the skin, were all such as characterise the disease gene- 
 rally, and bore the closest resemblance to the above case in par- 
 ticular. My belief was that the capsules were affected with malig- 
 nant disease, and that probably some other structures about the 
 posterior mediastinum might have been in a similar condition, as the 
 patient had slight oedema of both the upper extremities, whilst the 
 lower limbs remained free. Anxious as I was to procure a post- 
 mortem examination, it was most firmly and peremptorily refused ; 
 and it was only through the kind and persevering efforts of my 
 friend, Mr. Parrott, of Clapham, that I succeeded in gaining per- 
 mission to have a sketch taken of the discoloured integument. Of 
 course, this representation does not carry along with it such authority 
 and conviction as one taken from a subject actually proved to have 
 had diseased capsules. Nevertheless, I entertain no doubt what- 
 ever that the capsules were diseased ; and even if they were not, I 
 hold myself answerable for the most perfect resemblance between 
 the two cases, so far as the infection of the integument was con- 
 cerned. 
 
 CASE 7. The following case having been under the care of 
 one of the surgeons for " carcinoma " of the mamma, I have not 
 been able to furnish any record of the symptoms during life. The 
 corpse, however, presented appearances sufficiently striking to arrest 
 the attention, and call forth the correct prediction of Dr. Lloyd, the 
 inspector, who kindly furnished me with the following report. 
 
 " Sectio-cadaveris. M. T , set. 60, cancerous disease of the 
 mamma, with cancerous disease of the supra-renal capsules. 
 Sixteen hours after death. Body extremely emaciated; the left 
 mamma presented a very extensive ulcerated phagedsenic, ma- 
 lignant tumour, occupying the whole of the upper part of 
 the left side of the chest, infiltrating the cellular tissue, the skin 
 and intercostal muscles with carcinomatous material. The colour 
 of the skin covering the face, arm*, and chest was of a peculiar 
 light brown swarthy hue. Chest. On raising the sternum and 
 cartilages it was found that the malignant growth had passed 
 through the pleura and invaded the lung on the left side, for a space
 
 234 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 of the size of the palm of the hand, by direct continuity of structure. 
 The pleural cavity of the side contained about sixteen ounces of 
 dark-coloured fluid. The lower lobe of the left lung was compressed 
 and sank in water. The upper lobe was healthy. The right lung 
 *was healthy. Heart was small and flabby. Abdomen. The liver 
 was contracted, irregular on its surface, of yellow colour, containing 
 abundance of fat, burning brilliantly in the spirit lamp ; upon its 
 surface were several nodules of cancerous development. The gall- 
 bladder was occupied in its entire extent by a calculus, and did not 
 contain any bile. Both supra-renal capsules contained a consider- 
 able amount of cancerous deposit, invading their entire structure, 
 and almost obliterating their cavities. The kidneys were contracted 
 and granular. The uterus healthy, but atrophied." I have already 
 expressed my belief that the urgency of the symptoms, and the 
 quick or slow progress of the disease, are determined by the activity 
 or rapidity of the morbid change going on in the capsules, and by 
 the actual amount or degree of that change; and that universal 
 disease of both capsules will, in all probability, be found to prove 
 uniformly fatal. These views appear to be countenanced by the 
 character, progress, and termination of the cases already given, and 
 receive additional confirmation from the history of the following, in 
 which the morbid change was limited to a single capsule, and in 
 which the constitutional and local consequences indicate a corres- 
 ponding result. 
 
 CASE 8. Reported by the "Ward Clerk. 
 
 Elizabeth Hannah Lawrence, set. 53, was admitted into Guy's 
 Hospital under Dr. Babington, March 30, 1853. 
 
 Appearance. A short woman, emaciated and feeble, skin harsh 
 and dry, and of a darkish hue. The folds of the axilla were 
 remarkably dark; coloured patches, about the size of the palm 
 of the hand, were observed raised in wrinkles, and resembling a 
 slight ichthyosis ; also a very dark-brown areola around the um- 
 bilicus. Hair grey ; much long hair on lips and chin. 
 
 Previous history. Is a single woman, and has always been a 
 servant ; has been living of late in Trinity Street, Borough. Was 
 always thin, but yet always enjoyed good health. 
 
 Present history. Four months ago an eruption appeared on 
 her body, for the cure of which she went to the Cutaneous Infir- 
 mary at Blackfriars. In a short time she was cured, and just as the
 
 OP DISEASE OP THE SUPRA-RENAL CAPSULES. 235 
 
 eruption disappeared the present stomach symptoms began. For 
 three months she has had vomiting, with pain in the abdomen and 
 back, particularly in the latter. She has thrown up no blood. 
 She was sent to the hospital as a case of malignant disease of the 
 stomach. The stomach can be felt as a hard tumour in the abdomen ; 
 no remains of eruption on the skin. The vomiting continued after 
 admission, and in three days she died from exhaustion. 
 
 Sectio-cadaveris. External appearance. The body that of a 
 small emaciated woman, with a fair skin and dark hair, presenting 
 certain peculiar discolorations. On either side of the neck there 
 was a tawny appearance, which would not have been remarked had 
 it not been for three 1 " still more marked tawny patches, one on the 
 centre of the sternum, the other two under either axilla. The skin 
 also, besides presenting this yellowish-brown appearance, was some- 
 what raised and wrinkled or corrugated. These marks led me to 
 prognosticate disease of the supra-renal capsules before opening the 
 body, believing them to be the marks pointed out by Dr. Addisou. 
 Thorax. The lungs were congested, exuding a frothy serum, and 
 easily lacerable. Heart. Small and lacerable. The mediastinal 
 glands in one or two instances carcinomatous. Abdomen. Was 
 shrunk and contracted. Stomach. The walls of the stomach from 
 the pylorus through the lesser curvature were thickened, present- 
 ing on the stomach externally a peculiar network appearance, con- 
 taining a transparent stroma ; beneath this another layer with its 
 fibres longitudinally arranged, of strong cellular material ; within 
 this, the mucous membrane whole and intact ; the entire thickness 
 being about three quarters of an inch at the pylorus, gradually 
 decreasing to a quarter at the commencement of the cardia. The 
 mucous membrane lower down was here and there destroyed by 
 ulceration, and this ulceration in one instance of an eighth of an inch 
 in size. The stomach was contracted and empty ; externally to the 
 stomach several of the glands were affected, even to the head of the 
 pancreas, but the pancreas itself was not affected. Several of the 
 lumbar glands were enlarged. The left supra-renal capsule was 
 infiltrated with malignant material, and closely adherent to the 
 vessels of the kidney. The kidney itself was healthy. The uterus 
 contained three fibrous tumours the size of walnuts. 
 
 Although this woman only survived four days after her admission 
 into the hospital, we were led by the partial discoloration of the skin 
 to anticipate disease of the capsules, one only of which, however,
 
 236 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 was found to be implicated. It will have been perceived that in a cer- 
 tain number of the cases already given, either strumous or malignant 
 disease existed in other parts or organs, as well as in the capsules, 
 and of course, in the midst of such complications, there is often 
 more or less difficulty in satisfactorily unravelling the case in all its 
 details during life ; nevertheless, as we know that without any such 
 complication whatever, mere disease of the capsules themselves has 
 proved sufficient to produce such alarming symptoms and such 
 serious consequences, it cannot with any show of reason be alleged 
 that these peculiar symptoms, when present, arise exclusively from 
 the accidental complication of other organs. 
 
 In the present instance, as in some others, the immediate cause of 
 death, as well as of many of the most distressing symptoms during 
 life, was unquestionably carcinomatous disease of the stomach. 
 
 CASE 9. Thomas Clouston, set. 58, admitted into Guy's Hospital 
 February nth, 1852, under Dr. Barlow. A muscular and strong- 
 built man, of a sanguine temperament, and dark complexion. He 
 has been a married man, but his wife died about twenty years ago. 
 His occupation has been that of a sailor, and according to his own 
 statement, he has led a very sober life. His general health has been 
 very good. About five years since he had a hernia in the left in- 
 guinal region, for which he has since worn a truss. This has never 
 given him any difficulty to return. About two months ago he came 
 from Liverpool, in which place he had settled, not intending to go 
 to sea again ; and was taken on board the " Dreadnought " for 
 stricture. His general health was quite good at this time, but 
 while in the " Dreadnought " he began to lose his appetite and to 
 feel generally unwell ; he had likewise some affection of the left eye, 
 in which he is now nearly blind. 
 
 On Saturday the 8th, he left the ship at his own request, think- 
 ing that he might be better on land ; after waiting two or three 
 days he found that he got no better, and his friends advised him to 
 come to the hospital. 
 
 Present symptoms. He complains of a sensation of sickness 
 without actual vomiting ; and tightness over the epigastrium. His 
 countenance is anxious. He has no pain in any part. He has 
 rigors followed by mild sweats, every five or six hours, the rigors 
 usually lasting about an hour. The abdomen is tense and tympa- 
 nitic ; not tender to the touch, excepting over the upper part. The
 
 OF DISEASE OF THE SUPRA-RENAL CAPSULES. 237 
 
 liver does not appear enlarged. His chest is broad and well formed ; 
 the motion of the ribs moderate, resonant on the percussion ; and 
 the lungs are apparently sound. The heart's sounds are normal. 
 Pulse rather feeble, 80. Tongue injected at the tip and edges, 
 coated with a light-brown fur, very dry. Urine of about average 
 quantity, rather large than otherwise ; of a high colour, acid, and does 
 not coagulate by heat. The bowels have been regular. After he had 
 been in a few hours, he brought up a lage quantity of beer. Ordered 
 Mixt. Efferves. 4tis horis. 
 
 Feb. 1 2th. The sickness has not returned, but he is without any 
 appetite. He slept but little. 
 
 1 3th. He is much the same ; but has a more sallow and sunken 
 expression of countenance. He complains of nothing but loss of 
 appetite and general debility. His tongue continues dry and coated 
 with a brownish fur. His bowels have been relaxed, and passed his 
 motions partly involuntarily. 
 
 1 4th. No special change. 
 
 i yth. He seems rather better; he had a little breakfast, and 
 enjoyed it. 
 
 1 8th. He has relapsed into his former state, having no appetite, 
 and complaining of great debility and thirst. He has ^iv of sherry 
 daily. 
 
 aoth. There is but little change in him, his countenance appears 
 to grow darker, and his strength seems gradually failing. His bowels 
 are rather irritable. Ordered 
 
 Enema Amyli c. Syr. Jss ; 
 Inf. Cusparise, iss, t. d. 
 
 25th. He has been getting gradually weaker, without showing 
 any special symptoms in addition to those mentioned. He died this 
 morning. 
 
 Sectio-cadaveris. None was allowed beyond the brain and abdo- 
 men. Of the former there was considerable softening, and a large 
 amount of subarachnoid fluid. The kidneys were slightly enlarged, 
 mottled, and in some parts the cortical substance was entirely 
 degenerated into fat. A few tubercles were observed on the surface. 
 The tunic was very easily taken from the surface ; tubercles were 
 also observed in the spleen, and on the peritoneum covering the ter- 
 mination of the ileum. Tubercular deposit was likewise found in 
 one of the supra-renal capsules.
 
 238 ON THE CONSTITUTIONAL AND LOCAL EFFECTS 
 
 The development of tubercles on various parts, as well as in 
 one of the supra-renal capsules, sufficiently attests the strumous 
 character of the patient's disease ; and it is difficult to divest oneself 
 of the notion that the disease in the supra-renal capsule had some 
 share in producing the peculiar symptoms which immediately pre- 
 ceded the fatal result, whatever importance may be attached to the 
 state of the kidneys and cerebral complications. At all events, the 
 discoloration of the skin indicated before death the existence of cap- 
 sular disease ; and it is worthy of remark that in this instance the 
 deposition of pigment-cells was not limited to the integument, but 
 was found scattered in small masses over the omentum, the mesentery, 
 and the cellular tissue on the interior of the abdominal parietes. 
 
 CASE 10. Jane Koff, set. 28. This person was admitted into the 
 Obstetric Ward, labouring under cancer of the uterus, February 4th, 
 1852. She died February 8th, and on the 9th the body was placed 
 on the table for inspection. When proceeding to perform this duty, 
 Dr. Lloyd was struck with the peculiar dingy appearance of the 
 skin, and in consequence, prior to commencing, sought me to look 
 at it. The appearance, though not very strongly marked, was cer- 
 tainly such as to create a strong suspicion that something was 
 wrong with the capsules. On exposing the organ on the right side 
 it presented a perfectly healthy appearance, and we felt disposed to 
 conclude that our anticipation would turn out to be erroneous. On 
 proceeding to examine the left capsule, however, we were much sur- 
 prised to find a very extraordinary, and, I suspect, an extremely rare 
 condition of parts. A malignant tubercle had been developed at 
 that precise point where the large vein escapes from the organ ; this 
 tubercle projected into the interior of the vein, so as almost or 
 entirely to obstruct it, and had, moreover, led to rupture and effusion 
 into or a sort of apoplexy of the capsule itself. This case would 
 render it probable that the excess of dark pigment, so characteristic 
 of renal capsular disease, depended rather upon an interruption of 
 some special function than upon the nature of the organic change ; 
 for, with the exception of the manifestly recent sanguineous effusion 
 into its tissue, the capsule itself did not appear to have undergone 
 any considerable deterioration. 
 
 CA.SE ii. I may observe, in conclusion, that very recently there 
 was examined, at Guy's Hospital, the body of a person William
 
 OF DISEASE OP THE SUPRA-RENAL CAPSULES. 239 
 
 Godfrey who had died of cancer, affecting the thoracic parietes, 
 and extending through the lungs. Quite unexpectedly there was 
 found extensive disease of one of the supra-renal capsules, the organ 
 being very much enlarged, and converted into a hard mass of appa- 
 rently carcinomatous disease. On referring to the notes of the 
 case, as taken by the clinical clerk, I found it stated that the patient's 
 face presented a dingy hue, although he was naturally of a fair com- 
 plexion, with reddish or sandy hair in the pubes ; and, moreover, the 
 face of the corpse was ascertained to present a freckled and dingy 
 appearance, with a slight brown discoloration at the root of the nose 
 and at each angle of the lips. 
 
 THE END. 
 
 PBINTKD BT 1. I. ADLAKD, BARTHOLOMEW CLOSE.
 
 INDEX. 
 
 Abdominal friction sound, 89 
 
 Abscess of lung following pneumonia, 
 
 2,23 
 Addison's disease of capsules, 211 
 
 keloid, 177 
 
 Adelon, on pulmonary vein, 3 
 Air-cells, serous character of, 20 
 Albuminization in inflammation, 22 
 Albuminous induration of lung, 27 
 Alibert's keloid, 158, 170 
 Amaurosis, with hysterical paralysis, 
 
 204 
 
 Anasarca, with fatty liver, 105 
 Anatomy of air-cells, 19 
 
 of the lungs, 1 
 
 Apoplexy of lung leading to gangrene, 
 3 
 
 Babington, Dr., case of Addison's dis- 
 ease, 234 
 
 Barlow, Dr., case of Addison's disease, 
 236 
 
 Bateman, on vitiligo, 157 
 
 Bichat, on anatomy of pulmonary vein, 
 3 
 
 Bile, analysis of, in fatty degeneration 
 of liver, 100 
 
 Bird, Dr. Golding, analysis of bile in 
 fatty liver, 100 
 
 Brain disease simulated by pneumonia, 
 14 
 
 disorders of, with kidney disease, 
 187 
 
 Bright, Dr., case of Addison's disease, 
 
 228 
 Bronchial tubes, dilatation of, 44 
 
 mistaken for tubercle, 61 
 
 Capsules, supra-renal, disease of, 211 
 Carnification of lung (Laennec), 25 
 Chest, physical examination in diseases 
 
 of, 65 
 Chorea, use of electricity in, 202, 206, 
 
 207 
 Cloquet, on anatomy of pulmonary 
 
 vein, 3 
 
 Convulsive diseases, use of electricity 
 
 in, 195 
 Cough in pneumonia dependent on 
 
 bronchitis, 15 
 Cyst, ovarian, accidental rupture of, 15 
 
 Dieburg, Dr., on keloid, 175 
 Dropsy, ovarian, with rupture of cyst, 
 155 
 
 with fatty liver, 105 
 
 Electricity, use of, in convulsive dis- 
 eases, 195 
 
 Fatty degeneration of the liver, 99 
 Females, disorders of, connected with 
 
 uterine irritation, 109 
 Fever, continued, simulated by pneu- 
 monia, 13 
 
 Gull, Dr., case of Addison's disease, 220 
 
 Haemoptysis, slight, importance of, 72 
 Hodgkin, Dr., case of Addison's dis- 
 ease, 230 
 
 Hysterical paralysis, use of electricity 
 in, 203 
 
 Inflammation, albuminizing tendency 
 
 of, 22 
 Iodine, use of, in true keloid, 179 
 
 Jaundice, with vitiligoidea, 163 
 
 Keloid, of Alibert, 158, 170 
 
 spurious, 173 
 
 true, use of iodine in, 177, 179 
 Kidney disease, brain disorders with, 
 
 187 
 
 Lebert, on keloid, 176 
 Liver, derangement of, with vitiligoidea, 
 163 
 
 fatty degeneration of, 99 
 
 auasarca with, 105 
 
 condition of skin with disease of, 101 
 
 16
 
 242 
 
 INDEX. 
 
 Lloyd, Dr., case of Addison's disease, 
 238 
 
 Lung, abscess of, as result of pneu- 
 monia, 2 
 
 air-cells of, anatomy of, 19 
 
 albuminous induration of, 27 
 
 anatomy of the, 1 
 
 apoplexy of, a cause of gangrene, 3 
 
 changes in apex of, 37 
 
 carnification of, 25 
 
 circumscribed gangrene of, 23 
 
 diffuse gangrene of, 23 
 
 granular induration of, 27 
 
 grey hepatization of, 22 
 
 grey induration of, 28 
 
 oedema of, seat of, 21 
 
 red hepatization of, 21 
 
 tubercle of, analagous to that of 
 serous membranes, 30 
 
 uniform albuminous induration of, 
 35 
 
 Meek el, on anatomy of pulmonary vein, 
 3 
 
 (Edema of lungs, seat of, 21 
 
 Ollivier, on anatomy of pulmonary vein, 
 
 3 
 Ovarian dropsy, case of, with rupture 
 
 of cyst, 155 
 
 Paralysis, hysterical, use of electricity 
 
 in, 203 
 Phthisis, pathology of, 39 
 
 pneumonic, 48 
 
 tubercular, 56 
 
 tuberculo-pneumonic, 49 
 Pneumonia and its consequences, 17 
 
 absence of pain in, 16 
 
 cough in, dependent on bronchitis, 
 15 
 
 diagnosis of, 7 
 
 effects of, 19 
 
 giving rise to abscess, 2 
 
 identical with inflammatory tubercle, 
 2 
 
 lobnlar, 24 
 
 ordinary changes in, 33 
 
 Pneumonia, permanent effects of, 27 
 ' rarely terminates in abscess, 23 
 
 seat of, 8, 18 
 
 simulating brain disease, 14 
 
 simulating fever, 13 
 
 simulating hydrocephalus, 14 
 
 suffocative, 54 
 Pneumonic phthisis, 48 
 
 Preface to papers on diseases of lung, 
 
 xix 
 Pulmonary tubercle analogous to that 
 
 of serous membranes, 30 
 
 artery, anatomy of, 2 
 
 vein, anatomy of, 3 
 
 Rayer, on keloid, 158 
 Reissessen, on anatomy of air-cells, 19 
 Renal capsules, supra-, diseases of, 
 211 
 
 Serous character of air-cells, 20 
 Skin, bronzing of, in Addison's disease, 
 215 
 
 condition of, with fatty liver, 101 
 
 keloid of, 169 
 
 vitiligoidea of, 157 
 Supra-renal capsules, disease of, 211 
 
 Tubercle, asthenic, 50 
 
 compound, 50 
 
 inflammatory, identical with pneu- 
 monia, 2, 28 
 
 of serous membranes analogous to 
 pulmonary, 30 
 
 stheiiic, 49 
 
 with fatty liver, 102 
 Tubercular phthisis, 56 
 Tuberculo-pneumonic phthisis, 49 
 
 Uterine irritation, disorders connected 
 with, 109 
 
 Vein pulmonary, anatomy of, 3 
 Vitiligo (Willau), 157 
 Vitiligoidea plana, 157 
 
 tuberosa, 157 
 
 Willan, description of vitiligo, 157 
 
 ERRATA. 
 
 Page 24, 12th line from top, for "these" read " those." 
 99, 5th line from top,/or " accept" read " except." 
 159, 17th line from top,/or "hypochondria" read " hypochondrium." 
 170, 2nd line from bottom, for " from far as" read "far from."
 
 A 000 040 250 3