KXBMAM Ut THE Name of Book and Volume, Division Range ih'^Af^*'M, * Received i §7 A ^• ■.* 11 >x, ' University of California. THE MEDICAL LIBRARY i ■ \' . .1 . I ■< ) r n ci i: A r 1 ). m . J >. Of San Fmniisc',-. i PEESENTED BY MRS. AND MISS rOURGEAUD. ' I nun i /,• J . is;.-. vm A C . '^ "^ '•-*>^Qa??6PS«'*' wm'^ AA ^^^^^\f^M0^ 1 '( v-y ^^A^A/ ^O^nf{fy\' •^A^^A' S^^^^^Sc^^^^ >>m>^tf/0WMA/^^r'^:?^ Digitized by tine Internet Arciiive in 2008 witii funding from IVIicrosoft Corporation littp://www.arcliive.org/details/clinicallecturesOObennricli ^^r-t-^-X^ CLINICAL LECTURES PRINCIPLES AND PRACTICE OF MEDICINE. BY JOHN HUGHES BENNETT, M.D, r.I{.S.E. PROFESSOR OP THE INSTITUTES OF MEDICINE, AND SENIOR PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OP EDINBURGH. Formerly Lecturer on the Practice of Physic, Physician to the Fever Hospital, Director of the Poli-Clinic at the Koyal Dispensary, and Pathologist to the Eoyal Infirmary, Edinburgh ; Member of various Scientific and Medical Societies in Edinburgh, St. Andrews, Philadelphia, New York, Paris, Vienna, Berlin, Jena, Stockholm, Copenhagen, Amsterdam, etc., etc. FROM THE LAST EDINBURGH EDITION. iLMitlj JilJC ?i1untirrB illustrations on tLJUooU. NEW YORK: SAMUEL S. & WILLIAM WOOD, 389 BROADWAY. 1860. ^" R. CEAIGHEAD, PRINTER, Caiton ISuirtiing, 81, 83, and 85 Centre Street, N. T. PREFACE. Ix consequence of tlie rapid exhaustion of a second edition of this work, I have been called upon to prepare a new one much sooner than I could have anticipated. The whole of it, not- withstanding, has been most carefully revised, and the volume extended by the addition of fifty pages, with twenty-one new cases and thirty-four new wood-cuts, I have endeavoured throughout, by reference to indisputable facts, to demonstrate the correctness of the principles which have guided my prac- tice, and have, therefore, authenticated every case with the name of its reporter in the hospital books. I have availed myself of numerous illustrations engraved on wood, having long been persuaded that mere description of morbid appearances, and especially of those that are made visible by means of the microscope, communicates only feeble or imper- fect ideas to others. Of these illustrations, such as are borrowed have the names of their authors apj^ended ; such as have no name attached are original. I have again to ex|)ress my warmest thanks to numero.us friends for aid rendered to me in various wa^'s, but more espe- cially to Dr. Markham of London and to Dr. John Glen, now Medical Superintendent of the Eoyal Infirmary, Dundee. Dr. Markham has done me the honour to make a most careful study and critical analysis of the book, and has favoured me wiih numerous valuable remarks and suggestions, of which I have iv PEEFACE. gladly taken advantage. Dr. Glen, by correcting tlie sheets during their progress through the press, has not only added to the obligations I formerly owed him, but has enabled me to produce the present edition long before it would have been possible for me, otherwise, to have completed the undertaking. I am still, however, deeply sensible of the many imperfections with which this work is chargeable, and for which I must solicit the kind indulgence of my medical brethren. To exemplify the entire subject of practical medicine by means of cases in a work of moderate compass, is obviously impossible. But sufl&- cient examples, I trust, have been given to illustrate the more important modifications, which the advanced state of diagnosis and pathology has effected in the treatment of diseases. The flattering manner in which it has been received by the profes- sion, and noticed by the press, confirms the conviction I formerly ventured to state, viz., that such modifications will be shown by further experience to be not merely temporary changes, but permanent improvements in the practice of the art. J. HUGHES BENNETT. Edixburgh, April, 1859. CONTENTS. List of iLLrsTRAxioxs .... Introductiox, . . . • • The relation of the science to the art of medicine Mode of conducting the cUnical course The political state of the medical profession The social state of the medical profession . The present state of practical medicine Page xvi 1 2 6 9 12 13 SECTION I. EXAMINATION OF THE PATIENT Arrangement of symptoms, etc. Inspection of the dead body Relative position of internal organs Ikspection .... Inspection of the general posture . of the countenance of the chest of the abdomen Palpation* . . • • Increased or diminished sensibility of parts Altered form, size, density, and elasticity Alterations of movement . Mensuration . . . • Percussion .... Of the different sounds produced by percussion Of the sense of resistance produced by percussion General rules to be followed in the practice of mediate percussion Special rules to be followed in percussing particular organs in percussing the lungs in percussing the heart in percussing tlie liver in percussing the spleen 18 19 24 26 28 28 29 29 30 30 30 31 31 32 35 37 38 38 40 40 43 44 46 VI CONTENTS. Special rules to be followed in percussing the stomach and intestines in percussing the kidneys in percussing the bladder AUSCUXTATION" ....... General rules to be followed in the practice of auscultation Special rules to be followed during auscultation of the pulmonarv organs Of the sounds produced by the pulmonary organs in health and in disease . Special rules to be followed during auscultation of the circulatory organs Of the sounds produced by the circulatory organs in health and disease ...... Auscultation of the abdomen Auscultation of the large vessels . Use of the Microscope ..... Description of the Microscope Mensuration and demonstration How to observe with a microscope Peixcipal Applications of the Microscope to Diagxosis Saliva MOk The Blood . Pus Sputum Vomited matters Foeces Uterine and vaginal discharges Mucus Dropsical fluids Urine Cutaneous eruptions and ulcers Use of Chemical Tests To detect albumen in the urine To detect bile in the urine . To detect sugar in the urine To detect chlorides in the urine Page 46 48 48 49 49 51 51 55 55 5S 5S 59 61 67 69 71 72 74 75 78 78 81 83 85 86 87 88 91 94 94 94 95 96 SECTIOX 11. PREs'CIPLES OF MEDICINE Ox the General Laws of Nctritiox ix Health axd Disease Function of nutrition . . . . , Function of innervation . . . . , 97 99 99 108 CONTENTS. Vll Page General anatomy and physiology of the nervous system . . lOS General pathology of the nervous system .... 115 Simple, Caxcerous, axd Tubercular Exudatioxs — their Pathology axd General Treatment . . . . , . 123 Production of exudation ...... 123 Theory of exudation . , , . . . 126 Yital transformations of the exudation . . . . 128 Simple exudation . . . . . . 128 Cancerous exudation ...... 133 Tubercular exudation . . . . . . 137 Pathologj' of the three kinds of exudation . . . 138 Death of the exudation . . , . . . 141 Mortification or moist gangrene .... 141 Ulceration ....... 144 General treatment of exudation ..... 146 Morbid Growths of Texture — their General Pathology and Treat- ment ......... 148 Classification ....... 149 Fibrous growths . . . . . . 151 Patty growths . . . . . . 159 Cystic growths . . . , . . 161 Glandular growths . . .. . . . 170 Epithelial growths . . . . . . 173 Vascular growths . . . . . . 181 Cartilaginous growths ...... 186 Osseous growths ...... 190 Cancerous growths ...... 196 General pathology of morbid groAvths .... 197 General treatment of morbid growths . . . , 208 Morbid Degenerations of Texture ..... 210 Albuminous degeneration . . . . . . 210 Fatty degeneration ...... 216 Pigmentary degeneration . , , . . . 227 Mineral degeneration ...... 234 Concretions ........ 237 Albuminous concretions ...... 238 Fatty concretions ....... 238 Pigmentary concretions ...... 239 Mineral concretions ...... 239 Urinary concretions . . ' . . . , 240 Prostatic concretions ...... 244 Hairy concretions ....... 244 Vegetable fibrous concretions ..... 245 Amyloid and amylaceous concretions .... 247 VIU CONTENTS. SECTION III. Pathology ..... Cerebral Hemorrhage— Cases XVIII. to XXVIII. Pathology and treatment . Page ON THE RECENT CHANGES IN THERAPEUTICS, OCCASIONED BY AN ADVANCED KNOWLEDGE OF DIAGNOSIS AND PATHOLOGY .250 The Diminished Employment of Blood-lettixo and other Antiphlo- gistic Remedies in the Treatment of Acute Inflammations . 251 Proposition 1. — That little reliance can be placed on the experience of those who, lilve Cullen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations . 252 Proposition 2. — That inflammation is the same now as it has ever been, and that the analogy sought to be established between it and tlie varying types of fevers is fallacious .... 254 Proposition 3. — That the principles on whicii blood-letting and anti- phlogistic remedies have hitherto been practised are opposed to a sound pathology . . . . . . . 257 Proposition 4. — That an inflammation once establislied cannot be cut short, and that the object of judicious medical treatment is to con- duct it to a favourable termination .... 264 Proposition 5. — That all positive knowledge of the experience of the past, as well as the more exact observation of the present day, alike establish the truth of the preceding principles as guides for the future ....... 269 The Influence of Predominant Ideas on the Healthy and Disordered Functions of the Body ...... 292 SECTION IV. DISEASES OF THE NERVOUS SYSTEM . 303 On the I'ATnoLoaY of Cerebral and Spinal Softenings, and on the Necessity of employing the Microscope to ascertain their nature 305 Acute Hydrocephalus — ^Cases I. to III. . . . . 312 Pathology and treatment ...... 316 Cerebral Meningitis, Acute — Cases IV. to VI. . . . 319 Pathology and treatment ...... 323 Chronic — Cases VIL and VIII. . . ' . . 325 Cerebritis, Acute — Cases IX. and X. . . . . . 329 Chronic— Cases XL to XIV. .... 333 Pathology and treatment of cerebritis .... 343 Cerebral Disease from Obstruction of Arteries — Cases XV. to XVII. 345 354 356 373 CONTENTS. IX Cancer op the Brain — Case XXIX. Dropsy of the Brain — Case XXX. Structural Diseases of the Spinal Cord — Cases XXXI Treatment . . . . ' Pathology . . . . • Functional Disorders of the Nervous System — Case Classification of functional nervous disorders Pathology of functional nervous disorders Treatment of functional nervous disorders Delirium tremens —Cases XXXIX. to XLII. Poisoning by opium — Case XLIII. Poisoning by hemlock — Case XLIV. Poisoning by lead — Case XLY. Page . 378 381 U. to XXXVII. 385 391 397 XXXVIII. 399 ^ 402 404 408 410 ^ 413 413 ^ . . 418 SECTION V. DISEASES OF THE DIGESTIVE SYSTEM Diseases op the Mouth, Pharyns, and (Esophagus — Cases XLVI. to L. Functional Disorders of the Stomach — Cases LI. to LIII. General pathology and treatment of dyspepsia Vomiting of sarcinas — Cases LIV. and LV. Organic Diseases of the Stomach Chronic ulcer of the stomach— Cases LVI. and LVII. Chronic ulcer of the stomach, with perforation — Cases LVIII. and LIX. Pathology and treatment . Cancer of stomacli — Cases LX. and LXI. Diseases op the Liver . Acute congestion — Case LXII. Jaundice— Cases LXIIL and LXIY. Jaundice from cancer compressing the ducts — Cases LXV. and LXVI. Enlargement of the liver — Case LXVII. Fatty enlargement — Case LXVIII. Cirrhosis — Cases LXIX. and LXX. Cancer of the liver — Case LXXI. Diseases of the Intestines Diarrhoea — Cases LXXII. and LXXIII. Dysentery— Cases LXXIV. to LXXVI. Pathology and treatment of diarrhoea and dysentery Obstruction of large intestine from Cancer — Case LXXVII. Strangulation of small intestine from inguinal hernia — Case LXXVIII Intestinal "Worms — Cases LXXIX. to LXXXII. Peritonitis— Cases LXXXIIL to LXXXVL 421 421 429 432 435 438 438 440 446 448 4.53 454 454 458 463 464 467 472 476 476 479 483 486 488 492 499 CONTENTS. SECTION TL DISEASES OF THE CIRCULATORY SYSTEM Pericarditis — Cases LXXXTII. to XCII. Pathology and treatment .... Valvular Diseases of the Heart — Cases XCUI. to CIII. Enlarged foramen ovale — Case CIY. Pathology of valvular and organic diseases of the heart Treatment of valvular and organic diseases of the heart Fuxctioxal Diseases of the Heart Aneurism — Cases CY. to CXIII. General diagnosis of thoracic aneurisms Physical phenomena of abdominal aneurisms Pathology and treatment of aneurisms [Page 512 514 527 532 548 550 555 556 557 587 590 590 SECTION VII. DISEASES OF THE RESPIRATORY SYSTEM 592 Laryngitis — Cases CXIY. to CXYIL Treatment by topical applications Diagnosis of laryngitis .... Bronchitis— Cases CXYIII. to CXXII . Pathology and treatment .... On injections into the bronchi in pulmonary diseases Pleuritis— Cases CXXIII. to CXXYIL Pathology, diagnosis, and treatment of Pleuritis . Empyema— Case CXXYIII. Pneumonia— Cases CXXIX. to CXLIII On the diagnostic value of the absence of chlorides from the urine in pneumonia — Case CXXXYIIL Chronic pneumonia and gangrene of the lung — Cases CXXXIX. toCXLHI General pathology and treatment . Phthisis Pcliionalis — Cases CXLIY. to CL. On the natural progress of phthisis pulmonalis — the tendency to ulceration — the modes of arrestment Pathology and general treatment of phthisis pulmonalis Special treatment of phthisis pulmonalis . Cancer of the Lung — Case CLII. Carbonaceous Lungs— Cases CLIII. and CLIV . Pathology and treatment .... 593 59* 600 602 607 611 613 618 625 630 643 645 646 658 675 684 691 696 699 702 CONTENTS. XI SECTION VIII. DISEASES OF THE GENITO-URINARY SYSTEM Page 706 Ovarian Dropsy — Cases CLV. to CLVII. Pathology of ovarian dropsy .... Treatment of ovarian dropsy .... Nephritis and Pyelitis — Cases CLYIII. and CLIX. Desquamative nephritis — Case GLX. to CLXII. Suppurative nephritis — Case CLXIII. Scrofulous nephritis — Case CLXIV. Calculous nephritis — Case CLXV. .... Chronic pyelitis — Case CLXVI. .... Pathology of cystic kidney .... Persistent Albujiinuria, or Bright's Disease — Cases GLXVII. CLXXVI Pathology of Bright's disease .... Diagnosis of Bright's disease .... Treatment of Bright's disease .... to •706 721 724 72G 730 737 740 742 745 747 748 765 769 772 SECTION IX. DISEASES OP THE INTEGUMENTARY SYSTEM 774 Classification op Skin Diseases 775 Diagnosis of Skin Diseases 779 Porrigo ..... 782 The Treatment op Skin Diseases 783 Dermatozoa ..... 789 Acarus scabiei .... 789 Entozoon foUiculorum 792 Dermatophyta ..... 794 Favus— Cases GLXXVII. to CLXXXII. . 794 History of favus as a vegetable parasite 798 Mode of development and symptoms of favus 798 Causes ..... 801 Pathology ..... 803 Treatment ..... 810 Xll CONTENTS. SECTION X. DISEASES OF THE BLOOD Leucocythemia— Cases CLXXXIII. to CLXXXV. Pathology and treatment . Discovery of leucocythemia Chlorosis Ain> Anaemia — Case CLXXXVI. ICHOR^MiA OR (so-called) Pt^mia — Case CLXXXVII Pathology ..... Glucoblemia— Cases CLXXXVII I. and CLXXXIX. Pathology and treatment . Continued Fever .... Febricula— Cases CXC. to CXCIH. Relapsing fever — Case CXCIV. Typhoid fever treated by quinine— Cases CXCV. to CXCVII. Typhus fever treated by quinine— Cases CXCVIII. to CCIL Typhus fever treated without quinine — Cases CCIII. to CCXYIII Diagnosis of continued fevers Morbid anatomy of the Edinburgh fever during the winter 1 846-7 Propagation of fever in hospitals . Treatment of continued fever Remittent Fever — Can it be separated from Acute Hydrocephalus ? — Case CCIX. .... Intermittent Fever — Case CCX. Pathology and treatment . Eruptive Fevers .... Scarlatina— Cases CCXI. and CCXII. Treatment of scarlatina — Case CCXVI. Erysipelas— Cases CCXYII. and CCXVIU. Yariola— Cases CCXIX. and CCXX. The Ectrotic treatment of variola . Yaecination ! . . . Pathology of variola Syphilis and Mercurial Poisoning — Cases CCXXII. and CCXXIII. Forms of syphilis .... Diagnosis of syphilis Propagation of syphilis Pathology of sjqibilis Treatment of syphilis Rheumatism and Gout .... General pathology and treatment . Treatment of rheumatism by nitrate of potash — Cases CCXXY. and CCXXVI Treatment of rheumatism by lemon juice . Page 813 814 827 840 844 847 849 852 854 856 859 860 862 866 869 870 872 875 876 880 882 883 884 885 887 892 893 894 897 897 899 902 903 904 905 906 909 909 910 914 CONTENTS. XIU Rheumatic iritis — Case CCXXXIV. Chronic gout — Case CCXXXY. Scorbutus— Cases CCXXXTI. and CCXXXYII.. Pathology and treatment . . Polydipsia— Cases CCXXXVIII. and CCXXXIX. POLTSARCiA OR Obesity — Case CCXL CoxcLusiON — The ethics of medicine Table of Cases ..... General Index ..... Page 917 919 920 921 923 926 929 935 945 LIST OF ILLUSTEATIONS. Fig. Page 1. View of internal organs after removal of the thoracic and abdominal parietes 26 2. Deep-seated view of same ......... 26 3. Remarkable displacement of organs, in consequence of intestinal obstruction 27 4. The stethometer of Dr. Quain, half the real size 32 5. Mode of applying the instrument when the string is used ... 32 6. The chest-measurer of Dr. Sibson, natural size 33 7. Mode of applying the chest-measurer 33 8. Mode of application of the chest-measurer 34 9. Stetho-goniometer, for measuring the inclination of the walls of the thorax 35 10. The Plexmieter 35 1 1. The percussion hammer of Winterich 36 12. Anterior view of the limits and intensity of dulness on percussion in health 41 13. Posterior view of same 41 14. View of percussion in phthisis, atrophied heart and liver, and abstinence 42 15. View of percussion in pleurisy ........ 43 1 6. View of percussion in pericarditis, pneumonia, and loaded rectum . . 43 17. View of percussion in hypertrophy of Uver and heart .... 44 18. View of percussion in hypertrophied liver and spleen — Enlarged heart . 45 19. View of percussion in enlarged spleen — pushed somewhat upwards . 46 20. View of percussion in dropsy of the abdomen, enlarged heart, and aneurism 48 21. Oberhfeuser's microscope made for medical men 62 22. Grubj''s compound pocket microscope ....... 64 23. The same microscope mounted, ready for use ...... 64 24. Spaces equal to 1-lOOOth and 1-500 of an inch magnified 250 diameters linear 68 25. SaUvary corpuscles, epitheUal scales, etc., as seen in a drop of saliva . 72 26. Minute coufervoid filaments springing from an altered epithelial scale . 73 27. Confervoid filaments and sporules, in exudation on the mouth and gums 73 28. Fringe-like epithelium, from the surface of an ulcer on the tongue . . 73 29. Globules of cow's milk 74 30. Colostrum of the human female, containing mDk globules greatly varying in size 74 31. Blood-corpuscles, drawn from the extremity of the finger ... 75 32. Blood-corpuscles altered in shape from exosmosis . . . . .75 33. Blood-corpuscles altered in form, and aggregated together, in thickened blood 76 34. Altered blood-corpuscles in the fluid of an ha^matocele . . . . 76 35. Appearance of blood once observed in a case of cholera . . . . 77 LIST OF ILLUSTRATIOXS. XV 77 77 78 78 78 78 Fig. P^« 36. Appearance of a drop of blood in leucocythemia 77 37. The same, after the addition of acetic acid .... 38. The same, after the blood has stood 24 hours .... 39. Pus corpuscles, as seen in healtliy pus 40. The same, after the addition of acetic acid .... 41. Pus corpuscles, surrounded by a delicate cell-wall . 42. Irregular-shaped pus corpuscles, in scrofulous pus . 43. Mass, consisting of minute molecules, frequently seen in disintegrated tubercle 79 44 and 45. Masses composed of molecules and oily granules varymg in size 79 46. Mass partly composed of the debris of a fibrous structure ... 79 47. Mass composed of tubercle corpuscles ''9 48. Fragments of phosphate of lime occasionally found in the sputum . . 79 49. Fragment of elastic tissue of the lung, in phthisical sputum ... 80 50. Fragment of areolar and elastic tissue, from phthisical sputum . . 80 51. Another fragment ........... 80 53. Fibrinous coagula in sputum, exhibiting moulds of the bronchi . . 80 53. Fibres, with corpuscles, in a fibrinous coagulum from a bronchus . . SO 54. Epithelial cells, embedded in mucus, expectorated from the fauces . . 81 5.5. Another portion of expectorated mucus from the fauces, acted on by acetic acid 81 56 and 57. Cells loaded with pigment in the sputum of a collier ... 81 58. Appearance of starch corpuscles after partial digestion in the stomach . 82 59. Flake in the rice-water vomiting of a cholera patient .... 82 60. Structures observed in certain rice-water vomitings from a cholera patient 82 61. Sarcina Yentricuh 83 62. Portions of the urcdo in bread partly digested and disintegrated . . S3 63. Structure of confervoid mass passed from the bowels .... 83 64. The same magnified 500 diameters linear 83 65. Bounded masses of earthy matter 84 66. Structure of flakes in a rice-water stool, from a cholera patient . . 84 67. Corpuscles seen in a chronic leucorrhoeal discharge .... 85 68. Structure of gelatinous mucus from the os uteri 85 69. The same, after the addition of acetic acid 85 70 and 71. Two specimens of cancerous juice squeezed from the uterus . 86 72. Tiscid greyish yellow sputa of pneumonia, treated with dilute acetic acid 87 73. Spermatozoa as observed in the fluid of Spermatocele . . . . 87 74. Cells in fluid, removed from an ovarian dropsy 88 75. Lozenge-shaped and rhomboidal crystals of uric acid .... 88 76. Aggregated and flat striated crystals of uric acid 88 77. Urate of ammonia, in a granular membranous form, and in spicular masses 89 78. Triple phosphate, with various forms of urate of ammonia ... 89 79. Octahedral and dumb-beU shaped crystals of oxalate of lime ... 89 80. Flat and rosette-like crystals of cystine 89 81. Bodies observed in the urine of a scarlatina patient, 24hours after being passed 90 82. Cast of a uriniferous tube 90 83. Fatty casts, at an early period of formation 90 84. Fragments of faXXy and waxy casts 90 85. Epidermic cells from crust of Psoriasis 91 86. Thalli of the fungus found in the ear by Mr. Grove .... 92 87. The fungus {Achorion Sclionleini) from a favus crust .... 92 88. The same magnified 500 diameters linear 92 89. Epithelial cells, from the surface of an ulcer ^of the lip .... 92 Xvi LIST OF ILLUSTRATIONS. rig. , ^««« 90. The same, after the addition of acetic acid .....'. 92 91. Epidermic cells from the edge of a softened epitheUoma . ... 93 92. Other cells from the centre of the softened portion 93 93 Appearance of section of cancerous ulcer of the skin .... 93 94. Transverse section of the spinal cord of the iSatoio saJa?- . . . .109 95. Longitudinal section of the spinal cord of the inal cord and nerves — Pain in back ; general sensibility, increased, diminished, or absent; special sensibility — sight, hearing, smell, taste, touch, their 20 EXAMINATION OF THE PATIENT. increase, perversion, or diminution ; spinal irritation, as determined by percussion ; motion, natural or perverted, fatigue, pain on movement ; trembling, convulsions, contractions, rigidity, paralysis. IV. Digestive System. — Mouth — Lips, teeth, and gums; taste in tbe mouth. Tongue — Mode of protrusion, colour, furred, coated, fis- sured, condition of papillae, moist or dry. Fauces, tonsils, jyharynx and oesophagus — Deglutition — if impeded, examine the pharynx with a spatula, the cervical glands, neck, etc.; regurgitation. Stomach — Appetite, thirst, epigastric uneasiness or pain, swelling, nausea, vomit- ing, character of matters vomited, flatulence, eructations. Abdomen — Its measurement and palpation ; pain, distension or collapse, borborygmi, tumours, constipation, diarrhciea, character of dejections, hemorrhoids. Liver — Size, as determined by percussion, pain, jaundice, results of pal- pation, etc. Spleen — Size, as determined by percussion. If enlarged, examine blood microscopically. V. Genito-Urinary System. — Uterus — Condition of menstrual dis- charge, amenorrhoea, dysmenorrhoea, menorrhagia, leucorrhcea, etc. If pain, or much leucorrhoeal discharge, examine os uteri and vagina with speculum ; uterine or ovarian tumours ; pain in back ; difficulty in walking, or in defoecation ; functions of mammae. Kidney — Lumbar pain ; micturition ; quantity and quality of urine, colour, specific gra- vity ; precipitates, as determined by the microscope, and by chemical tests ; action of heat, nitric acid, etc. ; action on test papers ; strictures ; discharges from urethra; spermatorrhoea, etc. "VI. Integumentary System. — General posture; external surface; expression of countenance ; obesity ; emaciation ; colour ; rough or smooth ; dry or moist ; perspiration ; marks or cicatrices ; eruptions (see diagnosis of skin diseases) ; temperature ; morbid growths or swell- ing ; anasarca ; oedema ; emphysema ; etc, VII. Antecedent History. — Age; parentage; constitution; here- ditary disposition ; trade or profession ; place of residence ; mode of living as regards food and drink ; habits ; epidemics and endemics ; contagion and infection ; exposure to heat, cold, or moisture ; irregu- larities in diet ; excesses of any kind : fatigue ; commencement and progress of the disease; date of rigor or seizure; mode of invasion; previous treatment : in female cases whether married or single — have had children and miscarriages, previous diseases, etc. Such are the principal points to which your attention should be directed during the examination of a case. A little practice will soon impress them on your memory, and in this manner habit will insure that no very important circumstance shall be overlooked. At first, indeed, it inay appear to you that such a minute examination is unne- cessary ; but we shall have abundant opportunities of proving, that, whilst a little extra trouble never does harm, ignorance of a fact fre- quently leads to error. It is surprising, also, how rapidly one thoroughly conversant with the plan, is able to examine a patient so as to satisfy EXAMINATION OF THE PATIENT. 21 himself that all the organs and functions have been carefully interro- gated. Remember that the importance of particular symptoms is not known to the patient, and that, consequently, it is not in his power voluntarily to inform you of the necessary particulars. It is always your duty to discover them. In carrying out the examination, the following hints may be attended to:— 1. It sliould never be forgotten that you are examining a fellow- creature, who possesses the same sensitiveness to pain, and the same . feelings as you do, and that everything that can increase the one or wound the other should be most carefully avoided. Prudence, kindness, and delicacy, are especially enjoined upon those who treat the sick. 2. The questions should be precise, simple, and readily compre- hended. When an individual has a limited intelligence, or is accus- tomed to a particular dialect, you will not arrive at your object by becoming impatient, or talking in a loud voice, but by putting your interrogations in a clear manner, and in language proportioned to the inteUigence of the individual. 3. it is often necessary, after asking the first question, "Where do you feel pain?" to tell the patient to put his or her hand on the part. An Irish peasant applies the term "heart" to an indefinite region, extending over great part of the chest and abdomen ; and a woman, in speaking of pain in the stomach, often means the lower part of the abdomen. 4. When pain is referred to any circumscribed part of the surface, the place should always be examined by palpation, and, if possible, seen. Rostan relates very instructive cases where the omission of one or the other of these rules has led to curious errors in diagnosis.^ 5. Although the question, "How long have you been ill?" is suffi- ciently plain, it is often difficult to determine the period of commence- ment of many diseases. In acute inflammatory or febrile disorders, we generally count from the first rigor. In chronic affections, a lengthened cross-examination is frequently necessary to arrive at the truth. 6. A state of fever may be said to exist when we find the pulse accelerated, the skin hot, the tongue furred, unusual thirst, and head- ache. These symptoms are commonly preceded by a period of indis- position, varying in duration, and ushered in by a rigor or sensation of cold. Such a febrile state may be idiopathic, when the case is called one of fever, or symptomatic of some local disease, when the nature of the case is determined by the organ affected and lesion present. 1. In endeavouring to ascertain the cause of the disease, great tact and skill in examination are necessary. We must guard ourselves against the preconceived views of the patient on the one hand, and be aUve to the possibility of imposition on the other. Sometimes, with all our endeavours, no appreciable cause can be discovered, and at others we find a variety of circumstances, any one of which would be sufficient to occasion the malady. 8. In forming our diagnosis — that is, in framing a theory deduced from the facts elicited by examination — we should be guided by all the circumstances of the case, and be very careful that these are fully knowui before we hazard an opinion. Even then it is not always possible to 22 EXAMINATIOX OF THE PATIENT. come to a satisfactory conclusion, and in sucli cases the diagnosis should be deferred until further observation has thrown new light upon the nature of the disease. 9. In recording a case, it is, for the most part, only necessary to put down, under each head, the symptoms or signs present. If any system be quite health}-, it should be said that it is normal. In many cases, however, it is necessary to state what are called negative symptoms. This demands great tact, and exhibits a high degree of medical informa- tion. For instance, an attack of epilepsy generally commences with a cry or scream ; but sometimes there is none — in which case this should be stated. Again, no expectoration is a rare negative symptom in pneu- monia. Symptoms which are usually present in the disease, but are absent in the particular case, constitute negative symptoms. 10. All mention of size should be, according to its exact measure- ment, in feet and inches. Situation is often referrred to certain regions, into which the surface has been arbitrarily divided, such as subscapular, cardiac, epigastric, etc., but it is always better to refer at once to ana- tomical parts, such as the clavicle, particular rib, nipple, umbilicus, angle of scapula, and so on. Extent should also be determined by proximity to well-known fixed points. All vague statements, such as large, great, small, little, etc., should be carefully avoided ; and in recording cases, dates and references should always be given in the day of the month or of the disease, and not in the day of the week. 11. In conversing on, or discussing, the circumstances of the case at the bed-side, we should always use technical language. Thus instead of saying, a man has a cavern at the top of the lung, we should speak of a vomica under the clavicle ; instead of saying, a man has diseased heart, we should speak of cardiac hypertrophy, or of insufficiency of the mitral or aortic valves, etc. Having formed a diagnosis, and prescribed for the patient, the further examination should be conducted at intervals, varying, as regards time, according to the gravity of the case. In addition to the changes which may occur in the signs and symptoms previously noticed, the effects of remedies should be carefully inquired into, and care taken to ascertain whether the medicine and diet ordered have been administered. If the case prove fatal, the symptoms ushering in death, and the manner in which it occurs, should be especially observed. "Whenever a record of the case is to be kept, I cannot too strongly impress upon you the impor- tance of noting these down in a book at the time, rather than trusting to the memory. For a long series of years the reports of cases, dictated aloud by the professor, and written down at the bed-side by the clerk, have formed a leading feature of the Edinburgh system of clinical instruction, and such is the only trustworthy method of recording cases with accuracy. When a patient dies, the examination is not completed. The time has now arrived when an inspection of the dead body confirms or nulli- fies the diagnosis of the observer. You should consider this as a most important part of the clinical course. It is invariably regarded with the greatest interest by those who practise their profession with skill. It is only in this manner, that any errors they may have committed can be corrected ; that the value of physical diagnosis can be demonstiated EXAMINATION OF THE PATIENT. 23 and properly appreciated, and the true nature or pathology of diseases, and the mode of treating them rationally, can ever be discovered. But here, again, method and order are as necessary in the examina- tion of the dead as of the living, and it is of equal importance that no viscus be overlooked. The three great cavities should always be inves- tigated. Nothing is more injurious to the scientific progress of medicine than the habit of inspecting only one of them, to satisfy the curiosity of the practitioner, or to determine his doubts on this or that point. Many medical men direct their attention to a certain class of diseases, and are apt to attribute too much importance to a particular lesion. It fre- quently happened to me, -when pathologist to this institution, after the physician had examined this or that organ, to which he attributed the death of his patient, and had left the theatre, that further examination, according to the routine I always practised, revealed important lesions that were never suspected. Thus, a person supposed to have died of Bright's disease of the kidney, may have had a pneumonia latent and overlooked. Large caverns and tubercular deposits in the lungs may satisfy the physician, and he may leave the body, when intense peritoni- tis may be subsequently found, arising from intestinal perforation. A man has hypertrophy, with valvular disease of the heart ; he dies sud- denly, and everything is referred to the cai'diac lesion. On opening the head, an apoplectic extravasation or yellow softening may be discovered. I cannot too strongly, therefore, impress upon you the necessity of always making a thorough jmst-mortem examination, and for this pur- pose you should, if possible, obtain permission to inspect the whole body, and not any particular cavity. The object of a post-mortem examination is threefold, — 1st, To ascer- tain the cause of death ; 2d, To obtain a just appreciation of the signs and symptoms ; 3d, To learn the nature of the disease. These inquiries are very distinct, but practitioners generally have only in view the two first. It frequently happens that, on the discovery of a lesion that seems to explain the fatal termination, they feel satistied, and there is an end to the investigation. In medico-legal cases, this is the only object. But even here it is necessary to examine all the organs, to avoid a pos- sibility of error, for how can any conscientious man form an opinion, that an abdominal disease has been fatal, if he be not satistied by inspection that the chest and brain are healthy ? Again, it often occurs during life that a particular sign or symptom is unusual or mysterious, and that this, if explained by the examination, too often satisfies the practitioner. But it must be obvious that this throws no light upon the nature of the disease or its mode of cure. To do this, morbid changes must be sought for, not in that advanced stage where they cause death, or occasion prominent symptoms, but at the ver\' earliest period that can be detected. Hence we must call in the microscope to our assist- ance, and with its aid follow the lesion into the ultimate tissue of organs ; we must observe the circumstances which produced it, as well as the symptoms and physical signs to which it gave rise, the secondary disorders, and the order of their sequence ; their duration and mode of termination. This is the kind of extended investigation which can alone be serviceable to the advancement of medicine, and such, I trust, will be the object all of you will have in view in examining dead bodies. 24 EXAMESTATION OF THE PATIENT. At all events, sucli are the views that I shall constantly endeavour to place before you during this course of clinical instruction. The following is an arrangement of the organs, textures, etc., which demand your attention : — I. External Appearances. — Number of hours after death. Gene- ral aspect and condition of the body ; peculiarities of person ; marks on the surface; sugillation; amount of decomposition. In cases of sus- pected death by "violence, great minuteness in the external examination is necessary. II. Head. — Scalp; calvaria ; meninges; sinuses; choroid plexus; brain, its form and weight ; cerebellum, its weight ; cortical and medul- lary substance of brain ; ventricles, exact quantity of fluid in each, which should be removed with a pipette — its character; medulla oblongata ; nerves, and arteries at the base of the brain ; base of cranium ; sinuses. HI. Spinal Column. — Integuments over spine; vertebrae; meninges; cord ; nerves. IV. Xeck. — Thyroid gland; larynx and its appendages; trachsea ; tongue ; tonsils ; pharynx ; oesophagus. V. Chest. — Thymus gland ; lining membrane of bronchi ; bronchial glands ; pleurae ; contents of pleural cavity ; parenchyma of lungs ; large thoracic veins ; pericardium, its contents ; general aspect and position of the heart; its weight; amount of blood in its various cavities; right auricle ; coronary veins ; auricular septum ; right ventricle, size of its cavity ; thickness and degree of firmness of its walls ; endocardium ; tricuspid valve ; pulmonary artery, its calibre ; pulmonary veins ; left auricle; mitral valve; left ventricle; thickness and condition of its muscular tissue ; size of its cavity ; sigmoid valves ; coronary arteries ; aortic opening and arch ; large arteries of the neck ; thoracic aorta, its structure and calibre. VI. Abdomen. — Peritoneum and peritoneal cavity ; omentum ; posi- tion of abdominal viscera ; stomach ; duodenum ; small and large intes- tines ; liver, its weight, form, and structure — its artery, veins, and ducts ; o-all-bladder and its contents ; portal system ; pancreas and its duct ; mesenteric and other absorbent glands ; spleen ; its weight, size, and structure ; supra-renal capsules ; kidneys, weight of each ; secreting and excreting portions; pelvis; ureters; bladder; with the prostate and urethra in the male ; in the female, uterus, ovaries, Fallopian tubes, vao-ina ; abdominal aorta and vena cava ; large abdominal arteries and veins ; ganglia of the sympathetic system. VII. Blood. — Appearance in the cavities of the heart, in aorta, vena cava, vena portse, etc. ; coagulated and fluid portions — adhesion or not of the former. VIII. — Microscopic Examination of all the morbid structures and fluids, the blood, etc. etc. In carrying out the post-mortem examination, the following hints may be attended to : — i. As I have already said, the head, chest, and abdomen, should always be examined, but the spinal cord and neck need not be disturbed EXAMINATION OF THE PATIENT. 25 unless the symptoms indicate some lesion there. In special cases, par- ticularly judicial ones, however, every part should be carefully inspected, and it may be also necessary to investigate a variety of circumstances connected with external and surgical lesions, such as fractures, wounds, and burns; injury to the large vessels; alterations, of the organs of sense, etc. etc. 2. Great care should be taken not to disfigure the body. Incisions through the skin, therefore, should be made in such directions that when^the edges are afterwards sewn together, the necessary dissections below may not be visible. Neither should the body be exposed more than is needful, and delicacy demands that the genitals should always be kept covered. The wishes and feelings of friends and relations should invariably be held in consideration. 3. Before removing the stomach, or any portion of the intestines, a ligature should be placed above and below the tube, which should after- wards be opened with the greatest care, and the character of the con- tents, whether gaseous, Huid, mucous, bloody, fcecal, or containing foreign substances, should be observed before washing and inspecting the mucous surface. This rule should be especially followed in all medico-legal investigations, in which, from neglect of it, the ends of jus- tice have been frequently defeated. 4. You should seize every opportunity of opening dead bodies with your own hands, and acquiring dexterity in exposing the cavities, taking out the viscera, etc. Nothing is more annoying than to see the brain cut into or contused, in removing the calvarium ; or the large vessels at the root of the neck wounded in disarticulating the sternum, whereby the surrounding parts are deluged with blood ; or the cardiac valves cut through, instea^l of being simply exposed ; or awkward incisions made into the intestines, permitting the foecesto escape ; slipping of ligatures, etc. etc. Coolness, method, knowledge of anatomy, and skilfulness in dis- section, are as necessary when operating on the dead as on the living body. 5. In examinations made at private houses, it is not always neces- sary to remove the viscera. The heart, lungs, liver, kidneys, etc., maybe readily examined in situ. But in this Infirmary, where every facility exists,' the viscera are invariably taken out, and after describing the mor- bid alterations they present, I shall always pass them round, so that every one present may examine them. 6. It is a good rule never to omit the examination of a morbid tex- ture or product miscroscopically, until experience has made you perfectly familiar with its minute structure. 7. Notes of the examination should always be made at the time. If organs are healthy, this should be distinctly stated, so that hereafter all doubt as to their having been carefully examined may be removed. Here negative appearances are often of as much consequence as negative symptoms. 8. In describing morbid appearances, we should be careful to state the physical properties of an organ or texture, such as the size, form, weight', density, colour, position, etc. ; and avoid all theoretical language, such as its being inflamed, tubercular, or cancerous, as well as such inde- finite description as small and large, narrow and wide, increased or dimi- 26 EXAMIISrATION OF THE PATIENT. nislied, etc. etc. Size should always be stated in feet and inches, and the amount of fluid in quarts, pints, or ounces. 9. The amount of care and time bestowed on the examination of an individual body will vary according to circumstances. In some cases it may require continued investigation, involving microscopical and chemi- cal research for several days. I have never heard of a student regretting the employment of too much care in post-mortem investigation, although the occurrence of omissions from carelessness and unacquaintance with morbid anatomy, are unfortunately too often exhibited by medical men in courts of justice, to the detriment of our profession in the eyes of the public, and not unfrequently to the perversion or suppression of justice.* For the correct examination of the patient in the manner described, it will be found necessaiy to possess an accurate knowledge of the relative position of the various internal organs. This subject is not placed so carefully before the student as it deserves — a circumstance which may probably be attributed to the fact, that anatomy is for the most part taught by surgeons. But now that physical diagnosis constitutes so necessary a part of medical education, topographical, as distinguished from surgical anatomy, is every day felt to be more necessary. I would Fig. 1. * For an excellent guide to the examination of the dead body, I would recoiumend the practitioner and student to a work entitled, " "What to observe," published under the authority of the London Medical Society of Observation. Fig. 1. Superficial view of internal organs after the removal of the thoracic and abdominal parietes. Fig. 2. Deep view. — Sihson.) EXAMINATION OF THE PATIENT. 27 earnestly therefore recommend the student of Clinical Medicine to study the excellent work of Dr. Sibson on Medical Anatomy, in which this subject is admirably treated and illustrated. From his work I have bor- rowed the two accompanving figures, which exhibit at a glance the posi- tion of the internal organs in a healthy adult male after death. They also indicate the general relation of the viscera to the fixed parts of the trunk and thoracic walls, the study of which is far more useful than learning the contents of various artificial regions marked out by lines on the surface of the body. In studying all such relations of the viscera after death, it should be remembered that the organs do not occupy exactly the same position in the living body. " Expiration is the last act of life, and this last expira- tion is usually more extensive and forced than the expiration of tranquil life. In the dead body, the lungs shrink up within the position that they usually occupy during life ; at the same time the heart and its ves- sels retract, and the abdominal organs follow the diaphragm somewhat upwards." — ( Sibson.) The remaikable changes which occasionally occur in the natural posi- tion of the internal viscera may be judged of from a case which occurred to Professor Easton of Glasgow, in a pregnant female, aged twenty-seven. The enlargement of the uterus, co-operating with a gradually increasing tendency to accumulation of foeces in the lower end of the colon, at ifl -c Fic 8 length produced enormous distension of the sigmoid flexure, the ascend- ing portion of which measured thirteen, and the descending twenty-five Fig. 3. Remarkable displacement of organs, in consequence of intestinal obstruc- tion, a, Caput coli ; b, ascending portion of sigmoid flexure ; c, descending portion ; d, gravid uterus turned a little down. — {Eastmi.) 28 EXAMINATION OF THE PATIENT inches in circumfei'ence. The spleen and diaphragm were forced high up on the left side, compressing the hing, and displacing all the neighbour- ing organs, so that, on elevating the sternum and removing the ribs after death, the appearances represented Fig. 3 were exhibited.* Besides the method of general examination previously detailed, it is further essential to employ various special modes of investigation. These are inspection, palpation, mensuration, percussion, auscultation, the use of the microscope, and of chemical tests. To them we are indebted for that precision and certainty which characterise the results of physical science. Up to a comparatively recent period medical men formed their diagnosis and prognosis of internal diseases from an observation of func- tional symptoms. But as these — being often only the sensations of the patient — may vary from hour to hour according to accidental circum- stances, while the pathological lesions which occasion them remain the same, they are most uncertain. Formerly it was imagined that every morbid organic change gave rise to a certain train of symptoms, and that a knowledge of these was all-sufficient to determine the structural malady. But this idea is negatived by clinical observation, which teaches us that many ditferent lesions have the same symptoms ; and that, occasionally, most important and even fatal organic diseases have no symptoms at all. (See Cases LXXXIIL, LXXXVIL, OXX., CXXIII.) Cases of fatty heait, and atheromatous degeneration of the cerebral blood-vessels, often give rise to no symptoms whatever until death suddenly supervenes by syncope or coma. Hence, whenever phy- sical exploration is applicable, it should be had recourse to, in addition to an investigation of the symptoms. It is in a great measure owing to our superior knowledge in this respect that medicine has made such great advancement during the present century. INSPECTION. Inspection of a part or of the w^hole surface of the body in various posi- tions is often of the utmost importance. The latter is necessary in the examination of army recruits, but can seldom be carried out rigorously in hospital, and still less in private practice. Delicacy forbids it in females. The part affected, however, ought always to be seen, a neglect of which rule has led to numerous errors. The various eruptions which appear on the surface of the body are spoken of in another place. Here I shall only shortly allude to the inspection of the general posture, of the countenance, of the thorax, and of the abdomen. Inspection of the general jJosture of the patient in repose and in mo- tion is often highly diagnostic. Thus the position and attitude assumed by the body in cases of fever, in acute inflammations, in hemiplegia or paraplegia, in hydrothorax and asthma, in colic or spasmodic diseases, even in various forms of insanity, are very characteristic. The description of these, however, belongs to the consideration of individual diseases. As a general rule, the supine position denotes muscular de- bility — quick and forcible changes of position indicate excitement of the * Monthly Journal of Medical Science, Dec. 1850, p. 494. BY INSPECTION. 29 nervous system or spasm, — whilst fixed and restrained movements are dependent on paralysis or inflammatory pain. Inspection of the countenance is a matter of such importance as to be instinctively practised, with a view- of determining the amount of pain, disturbance of the feelings, or general mental and bodily con- dition of the patient. A thorough knowledge of the indications so presented to the physician is only to be attained by long experience in the observation of "^disease. The cuticular surface may be so altered as to give a peculiar appearance to the complexion, especially in chronic diseases of the digestive system. The changes in the blood- vessels and blood occasion pallor or flushing ; the sallow and yellow^ hue observed in some disorders ; the state of tumidity or shrinking, of heat or coldness, and of dryness or moisture. Alterations in the sub- cutaneous and muscular tissues produce emaciation, or oedema, languor, and various kinds of convulsion or paralysis. The individual features also require to be studied, especially the eye and mouth. Pain, if in the head, causes the brow to corrugate ; if in the chest, the nostrils to be drawn upwards ; if in the abdomen, the lips to be raised and stretched over the gums and teeth. These changes are more readily observed in children m whom they are not under the control of the will. Inspection of the Chest. — This refers to the form and confignration of the entire thorax, or its various parts, and to a careful comparison of the two sides wdaen at rest and when in motion. It is often difiicult, in cases where changes are not well marked, to determine thera by mere inspection. To "do so, a good light, and a proper position, both of the observer and of the patient, are necessary. The observer should, if possible, be directly in front of the patient, and whenever the case admits of it, the latter should be in the sitting posture. The chest may be so altered in disease as to be irregular or unsymmetrical, from distortions, congenital or acquired, in the bones of the vertebral column or of the thoracic w^alls. Various portions of it may be expanded or bulge out, as in cases of empyema or thoracic tumours; or it may be retracted and depressed, as occurs in chronic phthisis. A case pre- sented jtself to the late Dr. Spittal at the Royal Dispensary of this city, where the retraction was so great on one side, that the student in charge of it had placed compresses on the sound side, in the belief that the healthy prominence there was indicative of a tumour. The motions of the chest bear reference to inspiration and expiration,* which * " During inspiration, the clavicles, first ribs, and through them the sternum and all the annexed ribs, are raised ; the upper ribs converge, the lower diverge ; the upper cartilages form a right angle with the sternum, and the lower cartilages of opposite sides, from the seventh downwards, move further asunder, so as to widen the abdominal space between them, just below the ziphoid cartilage : the effect being to raise, widen, and deepen the whole chest, to shorten the neck, and apparently to lengthen the abdomen. During expiration, the position of the ribs and cartilages is reversed ; the sternum and ribs descend ; the upper ribs diverge, the lower con- verge ; the upper cartilages form a more obtuse angle with the sternum, and the lower cartilages of opposite sides approximate, so as to narrow the abdominal space between them, just below the ziphoid : the effect being to lower, narrow, and flatten the whole chest, to lengthen the neck, and apparently- to shorten the abdo- men. It is to be observed, that during inspiration, while the ribs and sternum are moving upwards, the lungs and heart, and the. abdominal organs, are moving down- wards, and that, consequently, viewed in relation to the ribs, the descent of the internal organs appears to be greater than it really is." — {Sibson.) 80 EXAMINATION OF THE PATIENT pass imperceptibly into one another, and can be made more rapid or prolonged voluntarily. A forced inspiration gives rise to more thoracic movement in the female than in the male, in whom it is more abdo- minal. In disease these motions are altered in various ways — 1st, By general excess or diminution, as in cases of spasmodic asthma or laryngeal obstruction. 2d, By partial immobility, as in pleurisy ; or by augmented expansion, as in the side not affected in a pneumonia or pleurisy. 3d, By increased rapidity, as in pericarditis ; or unusual slowness, as in coma. Insjyectioti of the Abdomen. — The abdomen in health is slightly convex, and marked by elevations and depressions, corresponding to the muscles in its walls, the umbilicus, and prominences of the viscera below. It varies according to age and sex — in youth being smoother and flatter than in the adult, and in females being broader inferiorly than in males, from the greater width of the pelvis. In disease it may be, 1st, enlarged generally and symmetrically, as in dropsies, or partially . and irregularly, from ovarian, hepatic, splenic, and other tumours ; 2d, it may be retracted — generally fi'om extreme emaciation, or partially, from local intestinal obstruction. The superficial abdo- minal veins are sometimes greatly enlarged, and at others distinct pulsations are visible, dependent on deep-seated cardiac, or arterial disease. The abdomen, like the chest, is in constant movement in connection with the act of respiration, being more prominent during inspiration, and flattened during expiration. These respiratory move- ments of the abdomen bear a certain relation to those of the chest, being often increased when the latter are arrested, and vice versa. Thus, in pleui'isy, the respiratory movements are mostly abdominal, whereas, in peritonitis, they are altogether thoracic. The variations observable in the disturbed relations of the respiratory movements in the thorax and abdomen are often highly instructive, especially in cases of dyspnoea from hydrothorax, spasmodic asthma, anaemia, ascites, abdo- minal tumours, etc. PALPATIOX. Palpation also is a necessary mode of examination, and is some- times practised by simply applying the tips of the fingers, at others, by placing the hand on the part affected, and not unfrequently by employ- ing both hands, and pressing with them alternately. This latter method is most applicable in endeavouring to judge of tumours, especially when large or deep seated, and situated in the abdomen. The position of the patient during palpation must be varied according to the part examined. Tlie horizontal posture is best to judge of deep-seated pulsations and vibrations, but sometimes the erect posture, or even leaning forward, becomes necessary, as when the heart is being examined. When feel- ing the abdominal organs through the integuments, these last should be relaxed, by causing some one to flex the inferior extremities on the abdomen, and push tlie head and neck forwards. In this manner palpa- tion aftbrds information — 1st, As to the increased or diminished sensi- bility of various parts ; 2d, Of their altered form, size, density, and BY PALPATION. 31 elasticity ; and, 3d, Of tlie different kinds of movement to which they may be subjected. 1. When pain is experienced in any part, it is generally increased by pressure and movement, if inflammatory, but relieved if neuralgic. Not unfrequently pressure causes pain or tenderness where otherwise neither are experienced. Thus deep pressure in the right iliac region causes pain in typhoid fever, which, however, must be judged of from the ex- pression of the countenance, rather than the statement of the patient. Again, over the vertebral column pressure or percussion may induce pain that is otherwise not felt. In paralytic cases the diminution of sen- sibility can only be ascertained by feeling or pinching the part, and the limitation of anaesthesia is best arrived at by pricking the surface with some pointed hard substance. 2. Alterations in external form and size may be judged of by inspec- tion, but with regard to internal organs, especially abdominal ones, we derive more exact information from palpation conjoined with percus- sion, as in cases of hypertrophied liver and spleen, or when some tumour exists. In such cases we can feel from the increased density and resist- ance the size and outline of the morbid growths, which will be more or less distinct, in proportion as they are near the surface, and circumscribed in form. Occasionallv organs are diminished in size, and cannot be felt in their normal positions, as when the inferior margin of the liver can- not be detected in this way, from atrophy. The natural elasticity of parts mav also be increased or diminished. Thus the abdomen is more elastic when air is in excess in the intestines, and less so when the peri- toneum contains liquid. The integuments also may be more rigid and indurated, as in chronic skin diseases, or, on the other hand, soft and doughy, as in oedema, when they pit on pressure, from diminished elas- ticity. 3. Certain motions in the thoracic and abdominal ca\-ities, as well as in other parts of the body, are best judged of by palpation. It is in this way that the character and situation of pulsation at the heart, root of the' neck, or elsewhere, are determined. The expansive motion of the thorax and abdomen during respiration is also thus ascertained. If we place the two hands, with the fingers spread out like a fan in the axillae or flanks, and bring the two thumbs towards each other, near the ster- num or umbilicus, we can judge by their approach and separation, of the amount of expansion or retraction that takes place. Application of the hand also allows us to detect undulatory motions below the integument, and to determine the existence of vibrations, frictions, gratings, and cre- pitations. Rostan relates a case where all the symptoms of acute inter- costal rheumatism were present (which disease was diagnosed), caused by a broken rib, that was overlooked from the diseased part not having been examined by palpation. There is a natural fremitus or thrill per- ceptible on placing the hand on the chest, when a person is speaking, which is increased in some diseases of the chest, and lessened in others. This sensation is also sometimes felt over the large blood-vessels. It resembles more or less the %nbration felt on placing the hand on the back of a cat while purring. Fluctuation is another sensation, caused by pressing on or percussing parts in such a way as to cause displace- ment of their contained fluids. A modification of it is known under 32 EXAMINATION" OF THE PATIENT the name of succussion, whicli is effected by shaking the patient- ceeding, however, which is seldom necessary. -apro- MEXSURATION. Tlie simplest way of measuring the circumference of parts, or the distance between any two fixed points, is by means of a graduated tape. In ascertaining the circular measurement of the chest or abdomen, that moment should be chosen when the patient holds his breath at the end of an ordinary expiration, great care being taken that the tape is carried evenly round the body. The relative mensuration of the two sides of the chest or abdomen, is best accomplished by choosing the spinous pro- cesses of the vertebrae as fixed points on the one hand, and a line drawn through the centre of the sternum and umbilicus on the other. The exact levels of the measurements should always be noted, such as at the nipples, margin of the lower ribs or umbilicus, which are those most deserving of observation. The diameter of the trunk in various direc- tions is best ascertained by means of a pair of callipers. The amount of motion in the chest and abdomen, and of its various parts, is capable of being accurately determined by means of the chest- measurer of Dr. Sibson ^Fig. 6), or the stethometer of Dr. Quain (Fig. 4). Both instruments are composed of a brass box, having a dial and Fl?.4 Fis. 6. an index, which is moved by a rack attached to a prolonged pinion or a string. One revolution of the index indicates an inch of motion in the chest ; the intervening space being graduated. It has been found neces- sary, when making observations on the respiratory movements, whether of the chest or the abdomen, to divert the patient's attention, and make him look straight forwards, otherwise these movements become so affected as to vitiate the results. The instruments may be applied in the sitting or recumbent posture. The method of applying them with a string attached is shewn (Fig. o), and the mode of using Dr. Sibson's Fig. 4. The stethometer of Dr. Quain, half the real size. Fig. 5. Mode of applying the instrument when the string is used. — {R. Quain.) BY MENSURATION. 83 chest-measurer by placing the pinion on the nail of the observer's finger, mo'v-ing with the chest, is seen (Fig. V), If held in the hand, as in Fio-s, 5 anil 7, great steadiness and care are requisite to arrive at exact results. Dr. Sibson's instrument may be attached to brass rods, -which are bent at right angles, so as to present the form of 3. The upper arm is move- able, and admits of elongation by means of a split tube, so tbat iu this way great steadiness is arrived at, while the instrument itself can be car- ried to any part of the chest or abdomen, without disturbing the position of the patient, as seen in Fig. 8. There is, however, considerable variation even in health in difi"erent persons. Some, for instance, can cause the second rib to advance two and a quarter inches during forced inspiration, whilst others can only cause it to advance three quarters of an inch. The motion of the whole left side, excepting that of the second rib, is somewhat less than on the right side. It should also be remembered that the motion of the tenth Fig. 6. The chest-measurer of Dr. Sibson, natural size. Fig. 7. Mode of applying the chest-measurer. — {Sibson.) 3 84 EXAMINATION OF THE PATIENT ribs indicates that of the diaphragm. Tlie pressure of the stars in the female exaggerates the thoracic and diminishes the abdominal movements. Fi2. S. According to the observations of Dr. Sibson, made with this instru- ment, the respiratory movements in health may be thus represented in lOOth's of an inch. Instrument applied to Side. Centre of sternum between 2d costal cartilages ! 2d Rib near the costal cartilage .... Lower end of sternum 5th Costal cartilages near the rib . . ight left 6th Rib at the side. 10th Rib (rio {let (rig |lef r Abdomen . ght left right left ( right j left centre ; i right i [left (boy I man Involuntary tranquil respiration. Voluntary forced respiration about 3 to 6 100 3 " 7 110 3 " 7 110 2 " 6 95 3 " 6 95 2 '^ 5 85 5 70 3 60 10 65 9 60 25 90 25 to 30 100 9 In disease it may be observed as a general rule, that if the respiratory movements are restrained in one place, they are increased elsewhere. We have already alluded to the relation existing between thoracic and abdominal movements (see Inspection). The amount of these may be exactly ascertained by the chest-measurer. In the same manner the diminished movements on one side of the chest in pleuritis, pneumonia, and incipient phthisis, can be determined and compared with the exag- gerated motion on the opposite. Thus in phthisis, instead of the indi- cator of the instrument placed over the second rib, on the affected side, moving between 1 and 110 on forced inspiration, as in health, it may only move between 1 and 30. In making observations with the chest- measurer, considerable practice and skill are necessary, as in the employ- ment of all other instruments. It enables us to arrive at great accuracy, Fig. 8. Mode of application of the cliest-measurer, attached to brass rods, bent at right angles, when the patient is in the horizontal posture. — (Sibsoa.) BY PERCUSSION. 85 and constitutes an extra means of exploration, without, however, being absolutely necessary for arriving at a correct diagnosis in every case. The expansibility of the lungs, and the amount of air expelled from the chest after full inspiration, may also be measured by the spirometer of Mr. Hutchinson. But the necessity of determining the height and weight of the individual, of teaching him how to inspire and expire, of pay- ing attention to the muscular force and other circumstances, so interferes with the correct conclusions to be derived from this mode of explora- tion, as to render it valueless in the examination of cases generally. As a means of physiological research in determining the vital capacity of the chest, Mr. Hutchinson's investigations are of the utmost importance. Dr. Scott Alison has lately invented an instrument for measuring the angles of the chest. It will also enable us to judge approximatively of the curves under various altered conditions. He calls it stetho-gonio- meter, a term derived from three Greek words, signifying chest, angle, and measure. Dr. S. Alison believes that it will afford data not to be Fi2. 9. obtained by other means, and assist in the diagnosis of disease in its earlv as well as in its later stages.* PERCUSSION. The object of percussion is to ascertain the resistance and size of organs. It may be practised directly, or through the medium of an interposed body (mediate percussion) — the last being the only satisfac- tory way. Without knowing how to strike, and to produce clear tones, we can never educate the ear, or the sense of resistance. This prelimi- Fig. 10. * Beale's Archives of Medicine, Vol. I., p. 60. Fig. 9. Stetho-goniometer, for measuring the incHnation of different parts of the walls of the thorax in cases of disease, aa, The arms; b, the arc of a circle gra- duated ; c, the vernier, with an arrow, also graduated ; d, vernier arm ; e, joint. — {Scott Alison.) 86 EXAMINATION OF THE PATIENT nary education in the art of percussion requires a certain dexterity, -which some find it very difficult to obtain. The difficulty seems to depend, in some cases, on an alteration in the proportions usually exist- ing between the length of the fingers. Thus, I have seen more than one person who had the index finger nearly an inch shorter than the middle one, and -who, consequently, found it impossible to strike the pleximeter fairly with the tips of two fingers at once. By far the most common cause of failure, however, is want of patience and perseverance in overcoming the first mechanical difficulties; and there is every reason to believe that could this be surmounted, accurate percussion would become more universal and better appreciated. With- out entering into the numerous discussions which have arisen as to the superior advantages of one plan as compared with another, or of using this or that instru- ment, I may mention, that for the last sixteen years I have employed a pleximeter and a hammer. These instruments I can confidently recommend to you as the readiest means of obtaining accurate results at the bed-side by means of percussion. The ivory pleximeter I use is that of M. Piorry, as modified by M. Mailliot. Its length is two inches, and breadth one. It possesses two handles, and an inch and half scale drawn upon the surface. It may be applied with great precision to every part of the chest, even in emaciated subjects (Fig. 10). The hammer is the invention of Dr. Winterich of "Wurzburgh. The advantages it possesses are, — 1st, That the tone produced by it, in clearness, penetra- tiveness, and quality, far surpasses that which the most practised percussor is able to occasion by other means. 2d, It is especially useful in clinical instraction, as the student most distant from the patient is enabled to distinguish the varieties of tone with the greatest ease. 3d, It at once enables those to percuss, who, from peculiar formation of the fingers, want of opportunity, time, practice, etc., are deficient in the necessary dex- terity (Fig. 11). "With Ae assistance of the instruments I now recommend to you, every student acquainted with the relative situations of the difterent thoracic and abdo- minal organs, is himself enabled, without other pre- liminary education, to detect the difterent degrees of sonoriety they possess in a state of health and disease. Yi2. 11. I may say, that by means of these instruments, after one hour's practice on a dead body, he is placed on a par (as regards the art of percussion) with the generality of experienced practitioners in BY PERCUSSION". 37 this country ; and any of you, after one mouth's employment of them, will be enabled to mark out accurately on the surface of the body, the size and form of the heart, liver, spleen, etc. Of the Diffkrent Sounds pkoduced by Percussion. The sounds produced by percussion arise from the vibrations occa- sioned in the solid textures of the organ percussed. The different density and elasticity of these textures will of course more or less modify the number and continuance of the vibrations, and give rise to different sounds. M. Piorry considers that nine elementary sounds are thus formed, which he has designated, from the organ or part which originates them, '■'■femoral, jecoral, cardial, 2}uli)ional, intestinal, stomacal, osteal, hiimo- rique, and hydatiquer I consider that all these sounds may be reduced to three elementary ones; that, in point of fact, there are only three tones occasioned by percussion, and that all the others are intermediate. These three tones are respectively dependent, — let. On the organ con- taining air ; 2d, On its containing fluid ; and 3d, On its being formed of a dense uniform parenchymatous tissue throughout. These tones, there- fore, may be termed the tympanitic, the humoral, and the jMrcnchytna- tous. Percussion over the empty stomach gives the best example of the first kind of sound ; over the distended bladder, of the second ; and over the liver, of the third. Certain modifications of these sounds occa- sion the metallic and the cracked-pot sound. The latter is made audible over the chest under a variety of circumstances, by percussing with the mouth open. The terms jecoral, cardial, pulmonal, intestinal, and stomacal, however, may be used to express those modifications of sound produced in percussing respectively the liver, heart, lungs, intestines, and stomach. No description will suffice to convey proper ideas of the various altera- tions of tone occasioned by percussing over the difterent thoracic and abdominal viscera. To become acquainted with these, it is absolutely necessary to apply the pleximeter to the body, and then half an hour's practice with this instrument and the hammer will be sufiicient to render any one conversant with those, which may be heard in a normal state. It must be remembered, however, that the tones even then may vary according to circumstances. Thus, immediately after a deep inspiration, the pulmonal sound will be rendered more tympanitic, and, after expira- tion, more parenchymatous. In the same manner the stomach and intestines may give out difterent sounds according to the nature of its contents. In the left or right iliac fossa a clear tympanitic sound will be heard when the intestine below is empty, and a dull parenchymatous sound when it is full of foeces. A study of the difterent modifications of sound, which various organs thus produce in a state of health, readily leads to the comprehension of the sounds which may be elicited in a morbid state. Thus, the lungs may occasion a dull or parenchymatous sound, from solidification, the result of exudation, or, on the other hand, become more tympanitic, from the presence of emphysema. The abdomen may give out a paren- 38 EXAMINATION OF THE PATIENT chTmatous sound, from enlargement of the uterus or an ovarian tumour ; or "a dull humoral sound, from the effusion of fluid into the cavity of the peritoneum. Of the Sense of Resistaxce pkoduced by Percussion. By the sense of resistance is understood the peculiar sensation resulting from those impressions which are communicated to the fingers on striking hard, soft, or elastic bodies. It is of the greatest service in determining the physical condition of the organ percussed. The sense of resistance bears relation to the density of the object struck, — hence, firm and solid textures offer more resistance than those which are soft or elastic. The thorax of the child is elastic, whilst that of the adult is unvielding. Of all the thoracic and abdominal organs, the liver pre- sents the greatest degree of resistance, and the stomach the least. The presence of fluid in the hollow viscera offers an amount of resistance between the parenchymatous organs on the one hand, and those con- tainino- air on the other. But air much condensed, or fluid contained within the rigid walls of the thorax, may oft'er a considerable degree of resistance. The sense of resistance should be as much educated by the physician as the sense of hearing, and it would be difficult for an indix^idual, prac- tised in the art of percussion, to say which of these two points is the more valuable to him. Both are only to be learnt by practice, and con- sidering it perfectly useless to describe that in words which may be learnt in half an hour, by the use of the plexi meter and hammer on a dead body, or the liWng subject, I shall now proceed to describe the General Ecles to be followed ix the Practice of Mediate Pekcussion, 1. Tlie pleximeter should be held by the projecting handles between the thumb and index finger of the left baud, and pressed firmly down upon the organ to be percussed. Much depends upon this rule being- followed, as the sound and sense of resistance are considerably modified according to the pressure made by the pleximeter. A very easy experi- ment will prove this. If, for instance, the pleximeter be struck while it rests lightly on the abdomen over the umbilicus, and again, when it is pressed firmly down amongst the viscera, the change in tone will be at once perceived. In the first case, a dull sound is produced, from the muscles and integuments being alone influenced by the force of the blow ; in the second case, a clear tympanitic sound is occasioned from the vibration of the walls of the intestine. In every instance, therefore, the pleximeter should be so held and pressed down, as to render it, so to speak, a part of the organ we wish to percuss. 2, Great care must be taken that no inequality exist between the inferior surface of the pleximeter and the skin. Firmly pressing it down will always obviate this when the abdomen is examined. As regards the thorax, the groove over the antenor mediastinum, the pro- BY PERCUSSION. 39 minence of the clavicles and of the ribs, in emaciated siibjects, may allow a hollow to exist iinder the instrument, by which a deceptive tympanitic sound is occasioned. By a little management, however, with the small and oval pleximeter I have recommended, this may readily be avoided. 3. The hammer should be held, as advised by Dr. Winterich, between the thumb and the first and third fingers, the extremities of which are to be placed in hollows prepared for "them in the handle of the instru- ment. By some these are considered useless ; but in all cases where slight differences in tone are to be appreciated, I have found this the best mode of employing it. Ordinarily, however, it will be sufiicient to hold it by the extremity of the handle, merely in such a manner as will enable the practitioner to strike the pleximeter lightly, or with force, as occasion may require. 4. Care must be taken to strike the pleximeter fairly and perpen- dicularly. Unless this be done, vibrations are communicated to tex- tures in the neighbourhood of the organ to be percussed, and fallacious results are the consequence. If in percussing the lungs, for example, the blow be made obliquely, we obtain the dull sound produced by the rib, and I have seen considerable error in the diagnosis thus occasioned. 5. A strong or gentle stroke with the hammer will modify the tone and sense of resistance, inasmuch as the impulse may be communicated by one or the other to a deep-seated or a superficial organ. Thus a gentle stroke will elicit a pulmonal tympanitic sound just below the fourth rib, where a thin layer of lung covers the liver, but a strong one will cause a jecoral parenchymatous sound. At the inferior margin of the liver, on the other hand, where a thin layer of the organ covers the intestines, the reverse of this takes place, a gentle stroke occasioning a dull, and a strong one a clear sound. 6. By withdrawing the hammer immediately after the blow, we are better able to judge of the sound ; by allowing it to remain a moment, we can judge better of the sense of resistance. 7. The integuments should not be stretched over the part percussed, as when the stethoscope is employed, for an unnatural degree of re- sistance is thus communicated to the hand of the operator from the muscular tension. In every case, especially where the abdomen is examined, the integuments and superficial muscles should be rendered as flaccid as possible. 8. It is always best to percuss on the naked skin. It is not absolutely essential, however ; and in cases where, from motives of delicacy, it is desirable that the chest or abdomen be not exposed, it only becomes necessary that the covering of linen or flannel be of equal thickness throughout, and not thrown into folds. 9. The position, in which the individual examined should be placed, will vary according to the organ explored. In percussing the tlioracic organs and the liver, a sitting position is most convenient. The stomach, intestines, uterus, bladder, and abdominal tumours or effusions, are best examined when the patient is lying on the back, with the knees flexed so as to relax the abdominal walls, and, if necessary, the head and neck bent forward, and supported by pillows. In percussing the spleen, the individual should lie on the right side ; and when the kidneys are 40 EXAMINATION OF THE PATIENT examined, lie should lie on the breast and abdomen. In cases of effu- sion into the serous cavities, a change of position furnishes most valu- able indications. 10. In percussing any particular organ, the pleximeter should be first applied over its centre, where the sound and sense of resistance it mav furnish are most characteristic. Two blows with the hammer are generally sufficient to determine this. From the centre, the pleximeter should be moved gradually towards the periphery, or margin of the organ, and struck as it proceeds with the hammer, now forcibly, now lio-htly, until the characteristic sound of the next organ be elicited. The pleximeter is then gradually to be returned towards the organ under examination, until the diiference of tone and sense of resistance become manifest. In this manner having first heard the two distinct sounds well characterised, we shall be better enabled to determine with accuracy the limit between the one and the other. This may be done exactlv, after having determined whereabouts the line of separation is, by placing the long diameter of the pleximeter transversely across it, and strikino-, first one end of the instrument, and then the other, till the pre- cise spot is determined. This spot should now be marked, by placing with a pen a dot of ink on the skin. The opposite and then other portions of the margin of the organ sliould be limited in the same man- ner, and these in turn should be marked with dots of ink, until the wdiole organ be completely examined. Then by uniting all these dots with a line of ink, we have the exact form of the organ drawn upon the skin. When it is thought necessary to render the first mark per- manent, in order to see if any subsequent change take place in the size of the organ, or extent of the dulness, it may be rendered so, by carry- ino- lightly a stick of nitrate of silver over the ink line, while it is still moist. Special Rules to be followed in Percussing Particular Organs. Before proceeding to percuss individual organs in persons labouring imder disease, you should obtain a general knowledge of the limits and intensity of dulness on percussing the thoracic and abdominal viscera in health. The accompanying figures convey this information with great accuracy, the depth of tint corresponding to the dulness of tone and amount'of resistance. The normal sonoriety and dulness exhibited (Figs. 12 and 13), will enable you to compare with readiness the alterations revealed by percussion under a variety of diseased conditions. Lungs. — Percussion of the lungs generally bears reference to a change in density, which is only to be detected by comparing the healthy with the morbid portions. The great practical rule here to be followed is, to apply the pleximeter with the same firmness, and exactly in the same situation, to each side of the chest in succession, and to let the blow with the hammer be given with an equal force. Care must be taken that the position of both arms be alike, as the contraction of the pectoral muscles on one side more than on the other may induce error. In short, every circumstance must be the same before it is possible to deter- mine, in delicate cases, either from the tone or sense of resistance, BY PERCUSSION. 41 wlietlier change of density exist in the hings. AVhen circumscribed alterations are discovered in the pulmonary tissue, their limits may be Fig. 12. Fig. 13. marked out on the surface of the skin, in the manner previously indi- cated. In this way I have frequently succeeded in determining with accuracy the size and form of circumscribed indurations, arising from partial pneumonia and pulmonary apoplexy. Under the clavicles, the pleximeter must be applied with great firmness. Inferiorly, a thin layer of lung lies over the superior surface of the liver ; and to deter- mine the exact place where its inferior border terminates, the blows with the hammer should be very slight. Posteriorly, also, the pleximeter must be firmly applied, and the force of the blows considerable ; but they should decrease in force inferiorly, where a thin layer of lung descends over the liver much deeper than anteriorly. In a healthy state, a distinct difference may be observed in the sonoriety of the lungs immediately after a full expiration and a full inspi- ration. This does not take place when the tissue becomes indurated from any cause; and thus we are furnished with a valuable diagnostic sign. Congestion of the lung, and pneumonia in its first stage, cause only slight dulness and increased resistance, which, however, may occasionally be detected by the practised percussor. In the second and third stage of pneumonia, and in apoplexy of the lung, this dulness and resistance are well marked, and even an impression of hardness and Fig. 12, anterior, and Fig. 13, posterior view of the nonnal limits and intensity of dulness on percussion. P, pulmonal sound ; C, cardiac sound ; H, hepatic sound ; S, splenic sound ; G-, gastric sound (here the stomach is moderately distended with air) ; E, enteric sound. In the anterior view the intestines are tolerabh' free from air, except CO, colic sound, from distended colon. The descending colon and rectum are filled, and sound dull. HU, humoral sound, over a distended bladder; M, mus- cular, and 0, osteal sounds. — i^P lorry.) 42 EXAMrS'ATIOX OF THE PATIENT Fis. 14. solidity communicated to the hand. "When, however, the lung is infil- trated with tubercle, the induration is most intense, and the greatest degree of resistance communicated. Partial indurations Irom apoplexy or simple cancerous and tubercular exudation, may be detected by per- cussion, even when deep-seated, and covered by healthy portions of the lungs. In this case, by pressing with the pleximeter, and striking lightly, a tympanitic sound only is heard ; but by pressing the plexi- meter down firmly, and striking with force, the dull sound may be elicited and circumscribed. When indura- tions, however, exist inferiorly in those portions of the lungs which overlap the liver, it requires great practice to detect them with cer- tainty. Caverns in the lungs, when large and filled with air, induce a tympanic sound (Fig. 14, 3); but ther are generally more or less full of viscous and fluid matters, and give rise to duiness. Two or three ounces of fluid may be detected in the pleural cavity, bv causing the patient to sit up. The height or level of the fluid is readily determined, and should be marked daily by a line made with nitrate of silver. If the eff"usion be only on one side, the increased duiness is more easily detected. It disappears on placing the patient in such a position as will cause the fluid to accumulate in another part of the pleural cavitv, when the space which was previously dull becomes clear (Fig. 15). When the eftusion entirely fills the pleural cavity, no limit, of course, can be detected ; but, even then, the duiness is distin- guished from that of the liver by the diminished feeling of resistance. When the lung is emphysematous, or if air be present in the pleura, the sound becomes unusually tympanitic ; this tympanitic note on per- cussion, however, may exist under a variety of circumstances, which it is of great importance to be acquainted with. Thus, condensation from pneumonia at the posterior part of the lung, or partial pleurisy, by causing the anterior portion of the organ to be over distended with air, or compressed and pushed forward, may give origin to this sound. The same occurs in chronic phthisis, over parts which were once dull, either from large dry cavities filled with air, or from the emphysema which accompanies cicatrices and partial condensation of pulmonary texture. On percussing the chest with the mouth open, there may fre- quently be elicited a sound, which Laennec first likened to gently Fig. 14. Phthisis — Atrophied heart and liver — Prolonged abstinence. 1, Atrophied hear?; 2, Infiltrated tubercle on left side ; 3, The same on right side with a cavity ; 4, Atrophied liver ; 5, Spleen : 6, Unusual duiness over abdomen, from prolonged aiistinence. — {Piarry.) BY PERCUSSIOlSr. •iS striking a cracked pot. It may be very closely imitated by crossing tlie palms of both hands, so as to leave a hollow between them, and then striking the knuckles of the inferior hand against the knee, so as to produce a clinking sound. I have produced it by percussing the chest in cases of pleurisy, pneu- monia, and phthisis ; of congest- ed, apoplectic, and emphysematous luncrs, and even when these organs were quite healthy, if, as in young subjects, the ribs are very elastic. The conditions which seem favour- able for the production of this sound, are, 1st, A certain amount of confined air rendering the tissue of the lung tense ; 2d, The sudden compression of this air by a solid body in its neighbourhood ; 3d, Communication of this air with the external atmosphere. Hence it is not diagnostic of any particular dis- order, or pathological state, such as a Fig- 15. pulmonary cavity, so much as of a physical condition, which, however, if rightly interpreted, is likely to be of ' ' the utmost advantage in our efforts at detecting the nature of disease.* Heart, — To mark out the precise limits of the heart constitutes the first difiicult lesson in the art of per- cussion. M. Piorry commences by determining the clear sound at the upper end of the sternum, and bring- ing the pleximeter gradually down- wards till the dull sound of the heart be heard. I have found it best to place the instrument first under and a little inside the left nipple, where the cardiac dulness is most intense ; then to carry it upwards, striking it continually with the hammer until the clear sound of the lung be elicited ; then, by bringing it down again to- wards the heart, we shall readily distinguish the line where cardial dulness * See the author's "Clinical Investigation into the diagnostic value of the cracked-pot-sound." — Edinburgh Medical Journal for March 1856. Fig. 15. Pleurisy. 1, On the right side when in the erect position ; 2, On the left side, when lying on the right: 3, Kidneys, the left enlarged; 4, Spleen. — (Piorry.) ^ Fig. 16. Pericarditis, pmuinonia, and loaded rectum. 1, Pericarditis; 2, Pneumonia separable from the extreme dulness of the Uver; 3, Loaded rectum.— (Picwr;/.) u EXAillXATIOX OF THE PATIENT commeBces, and thus limit the superior margin of the organ. Tlie same method is to be followed in determining the situation of the lateral margins, only carrying the pleximeter outwards or inwards, striking more and more forcibly with the hammer, until the clear tympanitic sound of the lung only be heard. It is more difBcult to determine the situation of the apex of the heart ; for as this rests on the diaphragm, and this again upon the left lobe of the liver, it cannot readily be distinguished fi-om them. The size of the heart, however, may be pretty accurately estimated, by limit- ing its superior and lateral margins. In females, the left mammary gland should be drawn upwards and outwards by an assistant. In the natural position of the organ (Figs. 1 and 2) it is well to remember that the auricles are on the right, and the ventricles on the left side. The normal size of the heart differs in different persons. As a gene- ral rule, however, it may be considered that, if the transverse diameter of the dulness measure more than two inches, it is abnormally enlarged. It has been known to measure seven inches. (Piorry.) In hydroperi- cardium, the dulness has been remarked to exist rather at the superior part of the sternum, than on one side or the other. (Piorry, Reynaud.) In pericarditis it bulges out interiorly (Fig. 16, 1). In hypertrophy and dilatation of the right auricle, the increased extent of the dulness stretches towards the median line, and sometimes passes over it (Fig. 17, 3). In similar hypertrophy of the left ventricle, the dulness extends on the left side more or less, according to the increased size of the heart (Fig. IT, 1, and Fig. IS). In concentric hypertrophy, there is little or no enlargement, but the density is greatly increased. The presence of tubercle in the lungs surrounding the heart ; aneu- risms or other tumoui-s pressing upon, or in the neighbourhood of, the organ ; hypertrophied liver, ex- tensive empyema, etc. etc., may render the mensuration of the ex- tent of its dulness diificult or im- possible. The changes in position of the heart produced by a pleurisy on one side pushing it towards the opposite one, or by the pregnant uterus, or an ovarian tumour or ascites thrusting it upwards, may also be determined by percussion, especially if the impulse can be distinguished by palpation or auscul- tation. Liver. — Limitation of the size of the liver should be commenced by Fig. 17. placing the pleximeter over the organ on the right side, where the dulness and resistance are greatest. It Fie n. Hypertrophy of liver and heart. 1, Hrpertropbied liver, which may be «tillftirther enlareed to the dotted Unes over the abdomen; 2, Distended gall-blad- der; 3, Hypertrophied right auricle— 1, Hypertrophied ventricles; 4, Loaded ceec'um'; 5, 'Loaded rectum and descending colon. — {Fiorry.) BY PERCUSSION. 45 should tlien be carried upwards, until tlie clear sound of tlie lung be distino-uished, when it ought again to be brought down, and the limit marked. This huiit, however, may indicate either the inferior margin of the lung, or superior convex surface of the liver. Now, as a thin layer of lung descends in front of the liver, it ■will be necessary to determine where the tympanitic sound ceases infe- riorlv, bv striking gently with the hammer, and where the parenchy- matous sound ceases superiorly, by striking forcibly, so that vibrations may be communicated to the organ through the layer of lung. The space between these two lines thus marked on the surface is wider in some in- dividuals than in others, and deeper and more extensive posteriorly than anteriorly. Bv carrying the pleximeter from the right side anteriorly, and then posteriorly towards the left of the patient, the whole superior margin may be thus detected, and marked with ink upon the surface, except where the" liver comes in contact, through the medium of the diaphragm, with the apex of the heart. The inferior margin is for the most part readily detected. It must be remembered, however, that in the same manner as a thin layer of lung covers the upper margin, so a thin layer of liver descends on the' rio-ht side over the intestine. It is, therefore, necessary to be cautious in determining the inferior margins, for a tolerably strong blow ■with the hammer may give rise to a tympanitic sound from the intestine, heard through the liver. The lower margin must be percussed in an invei-se manner to the superior, and as we proceed downwards, the force of the blow should be diminished. The inferior margin of the liver is in general readily detected, from the contrast which, on percussion, its dulness and density present, con- trasted with the tympanitic and elastic feel of the intestines and stomach. The superior limit of this organ is generally found about two inches below the right nipple, at a point corresponding with the fifth rib. Its inferior border descends to the lower margin of the ribs. The extent of the jecoral dulness in the healthy state is in general two inches on the left side, three inches in the hepatic region anteriorly, and four inches in the hepatic region laterally. (Piorry.) Variations in the size of the liver, from congestion, inflammation, ab- scesses, hydatids, tumoui-s, atrophy, etc. etc., may often be exactly determinedby means of percussion. In icterus, the increase and diminution of this organ, as evinced by lines marked on Fig. 18. Hypertrophied liver and spleen in leucocyihemia— Enlarged heart. 1, Hy- pertrophied heart with dilatation ; 2. Great dulness over the larger part of abdomen from enlarged liver on the right side ; and enlarged spleen on the Mt— {Partly from Piorry.) 46 EXAMINATION OF THE PATIENT the skin, will o-enerally be found to bear a proportion to the intensity of oro-anic disease. "When tumours are present, the inferior border often presents an irregular form. If the inferior lobes of the lung be indurated by tubercles or hepatisation, it becomes difficult or impossible to draw the limit between them and the liver. "When Huid effusion exists in the pleura, the increased density of the liver may still serve to distinguish it, and, by changing the position of the patient, its upper edge in the majority of cases may be limited. In cases of ascites, we must lay the patient on the left side, in order to measure the right lobe — on the right side to measure the left lobe, and on the abdomen to percuss it posteriorly. Sometimes the right lobe of the liver is so enormously hypertrophied, that its inferior margin extends to the right iliac fossa (Fig. 18). When the gall-bladder is much distended with bile, or contains gall- stones to any "amount, it may readily be detected by percussion, and the dulness it occasions immediately under the inferior margin of the liver, anteriorly and somewhat laterally, may be marked off (Fig. 17, 2). Spleen. — In percussing the spleen, it is necessary that the patient lie on the right side, and it is advantageous that the examination be made before, rather than after, meals. Anteriorly the sonoriety of the sto- mach and intestines causes the margin readily to be distinguished. Pos- teriorlv, however, where the organ approaches towards the kidneys, this is more difficult. Its superior and inferior margins may be made out bv striking the instrument with some force, and following the rule (Xo. 10) previously given, p. 40. This organ offers great resistance on percussion. In health the spleen never projects below the false ribs, even during a deep inspiration. Its gene- ral size is about four inches long and three inches wide. (Piorry.) In diseased states it may be atro- phied or enlarged. I have seen it measure upwards of twelve inches long and eight wide, and it then may project upwards and downwards, as indicated by the clotted lines in Fig. 19. A pleuritic effu- sion, ascites, pneumonia, or tubercular deposition in the inferior lobe of the left lung, may render a limitation of this organ difficult or impossible. If the dulness cannot be detected, we may infer that its dimensions are small. (Mailliot.) Stomach and Intestines. — The sounds elicited by percussion of the stomach and intestines are of the greatest service to the practitioner : — 1st, As fur- nishing him with the means of determining the form of other organs, as the liver, spleen, or blad- der ; 2dly, As enabling him to distinguish the pre- ^jg- 19- sence or absence of foecal or alimentary matter ; and, 3dly, As the means of diagnosing abdominal tumours. Hence it is Fig. 19. 1, Slightly enlarged spleen, pushed somewhat upwards. The dotted lines indicate how the organ may be enlarged in various diseases. 1, Elongation down- wards in leucocythemia. — {Slightly modified from Piorry.) BY PERCUSSION. 47 incumbent on every pln'sician to be able at once to recognise the differ- ence between the tones furnished by the stomach, small and large intes- tines, under various circumstances. To arrive at this knowledge, it is necessary to be acquainted with the relative positions of the different abdominal viscera, and the regions of the abdomen to which they cor- respond. For instance, it is usually the liver and not the stomach that occupies the so-called epigastric region just below the end of the ster- num. The last-named organ is for the most part situated within the left lower costal walls, just below the heart and the base of the left lung (Figs. 1 and 2), In exploring the abdomen by means of percussion, the pleximeter should first be placed immediately below the xiphoid cartilage, pressed firmly down, and carried along the median line towards the pubes, striking it all the way, now hard, now gently, with the hammer. The different tones which the stomach, colon, and small intestines furnish will thus be distinctly heard. The pleximeter should then be carried laterally, alternately to the one side, and then to the other, till the ■whole surface be percussed. In this manner, the different tones pro- duced by the ccecum and ascending colon on the right side, as well as by the stomach and descending colon on the left, will be respectively distinguished from that furnished by the small intestines. The sounds and sense of resistance will be modified according as the different viscera are full or empt)', as any one can determine on his own body by means of the pleximeter and hammer. When the intestines are full of fluid or solid contents, such portions may be circumscribed and marked out on the surface of the skin. I have thus often succeeded in determining the internal margin of the colon, in its ascending, transverse, or descending portions. Sometimes a portion of intestine is found lying between the abdominal walls and the stomach. The latter, however, may be readily limited, by pressing down the pleximeter, causing the patient to eat or drink, or by examining after dinner. The small intestines rarely ever fail to yield a tympanitic sound — a circumstance bv which they may readily be distinguished from the stomach and large intestines. The distance of any particular knuckle of intestine from the abdominal walls may be pretty accurately calculated by the force necessary to be employed in pressing down the pleximeter, and striking with the hammer, in order to elicit a tympanitic or dull sound- It is unnecessary to point out the numerous circumstances, and morbid conditions, in which percussion of the abdomen may prove useful in practice. Displacements and variations in size of the stomach or intestines, femoral and scrotal hernia, mesenteric, ovarian, and other tumoui"s, peritoneal adhesions and effusions, may all frequently be diagnosed, and their limits determined, by a careful examination with the pleximeter and hammer. By means of percussion, even the nature of the tumour may often be arrived at ; as, for instance, whether it be fungus hematodes, scirrhous, encysted, osseous, etc., by the different degrees of resistance thev possess. Care, however, must be taken not to confomid with tumours an enlarged spleen or liver, a distended uterus or bladder, stomach full of alimentary matter, etc. It should also be remembered that when the patient lies on his back the percus- 48 EXAMESTATIOX OF THE PATIEJfT si on sound over the stomach is resonant, but when he stands it is generally dull from the gravitation of the food. In a practical point of view it is often useful to determine, by means of percussion, whether an enema or a purgative by the mouth is likely to open the bowels most rapidly. If, for instance, there be dulness in the left iliac fossa, in the track of the descending colon, that part of the intestine must be full of fceces, and an enema is indicated. If, on the other hand, the left iliac fossa sound tympanitic, and the j right sound dull, an enema is of 'little service, as it will not extend to the ccecum, and purgatives by the mouth are indicated (Figs. 16 and IV). Etfusion of fluid into the peri- toneum may be determined with great exactitude by means of per- cussion, and the height of the fluid marked, as in the case of pleuritic eifusion. In the same manner, a change of position furnishes similar results. Abdominal distension from accumulation of air may also be determined. If it be within the intes- tine, the tympanitic note is partial Fig. 20. and limited, if in the peritoneal cavity more equable and diffused (Fig. 20). Kidneys. — To percuss the kidneys, the patient should lie on the abdo- men and chest ; a position which allows any ascitic fluid that may be present to gravitate downwards, while the intestines float upwards. The dulness and great resistance offered by the renal organs are, under such circumstances, at once determined (Figs. 13 and 15). Their external marcjins may for the most be easily limited, in consequence of the loud tympanitic note of the intestines, which can be elicited round their external circumference in the two flanks. Internally the dulness merges into that of the spinal column. Enlargement of one or both of these organs from calculus, or scrofulous nephritis, pyelitis, or other diseases, may in this manner be made out as seen (Fig. 15) on the left side. Atrophy of these organs is more difiicidt to determine with exactitude, but may be demonstrated by careful percussion. Bladder. — This viscus is only to be detected by percussion, when it is more or less distended, and rises above the pubes. It may then be distinguished, and its circular margin limited, by observing the tympanitic Fig. 20. Dropsy of the abdomen, enlarged heart, and aneurism. 1, Aneurism pro- jecting from the arch of the aorta on the right side ; 2, Hypertrophied heart, espe- cially of the right auricle ; 3. Liver, pushed upwards ; 4, Ascitic fluid, gravitatmg inferioriy. the patient being on the back ; 5 and 6, Stomach and intestines, superiorly and anteriorly. — {Piorry.) BY AUSCULTATION. 49 sound of the intestines, on the one hand, and the dull sound furnished by the bladder, with increased resistance on the other. When covered by intestines, it Avill be necessary to press down the pleximeter with tolerable firmness, but not in such a manner as to give the patient pain. In the infant, the situation of the bladder is not so deep in the pelvis, and a small quantity of fluid renders it cognizable by means of per- cussion. A ready approximation of the state of the bladder will be found of great service in cases of fever, apoplexy, delirium, imbecility, paraplegia, etc. etc. In several cases it has been found dangerously distended, on percussing the abdomen to determine the state of the intestines. I have here only noticed those circumstances in the art of percussion which may be readily accomplished, and which every one may master in a few months by care and attention. For a description of the more delicate points, such as percussion of the kidneys and foetus, accurately limiting the auricles and ventricles, determining and marking out the ascending and transverse portions of the arch of the aorta, etc., I must refer you to the admirable works of MM. Piorry* and Mailliot.f AUSCULTATION. The object of auscultation is to ascertain and appreciate the nature of the various sounds which occur in the intei'ior of the body. It has been found most useful when applied to the pulmonary and circulatory organs. Auscultation of the abdomen is occasionally serviceable, espe- cially in certain cases of pregnancy, and during labour. It has also been applied to the head, although I have never been able to make out any useful results from the practice. General Eules to be followed in the Practice of Auscultation. 1. Auscultation may be practised directly by applying the ear to the part, or indirectly through the medium of a stethoscope. Generally speaking, direct auscultation answers every necessary purpose except when the surface is unequal, or when it is desirable to limit the sounds to a small region, as during auscultation of the heart. In either of these cases a stethoscope is necessary. The instrument is also useful to confirm or nullify the existence of certain fine sounds which may be detected by the naked ear ; to remove the head of the practitioner a respectable distance from the bodies of persons not distinguished for cleanhness ; and lastly, as the most delicate method of auscultating the * De la Percussion Mediate, etc., Paris, 1828. Du Procede Operatoire, Paris, 1831. De rExaraen Plessimetrique de I'Aorte Ascendante, et de la Crosse Aor- tique, etc. Archives Gen. de Med., vol. ix., 1840, p. 431. On Percussion of the Uterus, and its Results in the Diagnosis of Pregnancy: Monthly Journal, 1846-7, p. 857. Atlas de Plessimetrisme, Paris, 18.51. f Mailliot (L.) Traite de la Percussion Mediate, etc., Paris, translated into English with notes, by Dr. George Smith of Madras. 4 50 EXAMIXATIO^r OF THE PATIEXT chest anteriorly in women. You should regard the stethoscope merely as a means to an end — that end being the right appreciation of the pathological changes indicated by certain sounds. 2. In the choice of a stethoscope, you should observe, 1st, That the ear-piece fits your own ear ; 2d, That the trumpet-shaped extremity is not above an inch and a half in diameter, and is rounded so as not to injure the patient's skin when pressure is made upon it ; 3d, That it is light and portable. The instruments recently made of gutta percha fulfil all these conditions. 3. In applying the ear, the body of the patient should be covered only with a smooth piece of linen or a towel. But the stethoscope should be applied to the naked skin, and held steady immediately above the trumpet-shaped extremity by the thumb and index finger ; it should be pi-essed down with tolerable firmness, whilst with the second, third, and fourth fingers, you ascertain whether the circular edge be perfectly applied, which is absolutely essential. 4. The position of the patient will vary according to the part ex- amined. In auscultating the lungs anteriorly, the erect or recumbent positions may be chosen, the two arms being placed in a symmetrical position by the side. If the chest be examined posteriorly, the indi- vidual should lean somewhat forward and cross the arms in front. In auscultation of the abdomen, various positions will be required, according as the anterior, lateral, or posterior regions demand investigation. The practitioner, also, should choose such a position as will prevent too much stooping or straining. Generally speaking, the beds in the Infirmary here are too low, and render auscultation very fatiguing to the physician. 5. Whenever individuals are thrown into such a state of agitation as to interfere with the regular action of the heart or lungs, the examina- tion should be deferred until their fear diminishes, or the greatest cau- tion should be exercised in drawing conclusions. Non-attention to this rule has led to many errors. 6. Before examining patients in a hospital, it is necessary that you should have made yourselves perfectly acquainted with the sounds which are continually going on in the healthy body. Omission of this rule not only renders the examination of patients useless, but betrays great want of consideration. For, as it is only from the alterations the healthy sounds undergo, or from their being replaced by others, that we draw conclusions, how can this be accomplished if we are ignorant of their character in the first instance ? It is expected, therefore, of every ex- amining pupil, that he should be familiar with the character and theory of the various sounds heard in the healthy body before coming to the bedside. This study belongs to the Institutes of Medicine, rather than to that of Clinical Instruction.* * Before commencing the actual examination of patients, you should make one or more serious, careful, and prolonged examinations of the chest of one of your fellow- students in private, so as to familiarise your ear with the liealthy laryngeal, tracheal, pulmonary, and cardiac sounds, and with tlie character of tlie vocal resonance, and of tlie cough, as heard in various parts of the chest. You should then listen in the same manner to the chest of a young boy of from five to eight years of age, and observe how clear and exaggerated the pulmonary sounds are. Then read the sliort description which follows, of the healthy and morbid sounds, and subsequently con- sult the more lengthened systematic treatises on this subject. BY AUSCULTATION. 51 Special Rules to be followed during Auscultation of THE Pulmonary Organs. 1. In listening to the sounds produced by the action of the lungs, we should pay attention to tliree things : 1st, The natural respiration ; 2d, The forced or exaggerated respiration ; and 3d, The vocal reso- nance. For this purpose, having listened to the sounds during ordinary breathing, we direct the patient to take a deep breath, and then, still listening, we ask him a question, and during his reply judge of the vocal resonance. 2. You should commence the examination immediately under the centre of one clavicle ; and having ascertained the nature of the sounds and vocal resonance there, you should immediately listen at exactly the corresponding spot on the opposite side. The examination should be continued alternately from one side to the other, in corresponding places, until tlie whole anterior surface of the chest is explored. The posterior surface is then to be examined in like manner. 3. When, in the course of the examination, anything different from the normal condition is discovered at a particular place, that place and the parts adjacent should be made the subject of special examination, until all the facts regarding the lesion be ascertained. 4. It is occasionally useful to tell the patient to cough, in which case we are enabled to judge, — 1st, Of forced inspiration, as it precedes the cough ; and, 2d, Of the resonance which the cough itself occasions. Of the Sounds produced by the Pulmonary Organs in Health and in Disease. I am anxious to impress upon you, that the sounds which may be heard in the lungs are like nothing but themselves. Students are too apt to take up erroneous notions from reading on this subject, and, instead of listening to the sound actually produced, fatigue theiuselves in a vain endeavour to hear something like the crackling of salt, the rubbing of hair, foaming of beer, or other noises to which these sounds have been likened. Preconceived notions frequently oppose themselves to the reception of the truth, and have to be got rid of before the real state of matters can be ascertained. Hence the great importance of deriving your first impressions of the sounds to be heard by auscul- tation, not from books or lectures, but from the living body itself. If you listen through your stethoscope, placed over the larynx and trachea of a healthy man, you will hear two noises, — one accompanying the act of inspiration, and the other that of expiration. These are called the laryngeal and tracheal sounds or murmurs. If you next place your stethoscope a little to the right or left of the manubrium of the sternum, you will hear the same sounds diminished in intensity. These are the bronchial sounds or murmurs. If now you listen under and outside the nipple on the right side, or posteriorly over the inferior lobe of either lung, you will hear two very fine murmurs. That ac- companying the inspiration is much more distinct than that accom- 52 EXAMINATION OF THE PATIENT panying the expiration. By some, on account of its excessive fineness, it is stated that there is no expiratory murmur in heahh ; but this is incorrect. These sounds, then, are the vesicular resjnrotory murmurs. All these sounds become exaggerated during forced respiration, but in a state of liealth they never lose their soft character. Again, if you listen in the same places, whilst the individual speaks, you will hear a peculiar resonance of the voice, which has been called, in the first situation, pectoriloquy ; in the second, bronchojjhoni/ ; Avhile in the third it is scarcely audible. A knowledge of these circumstances, and a capability of appreciating these sounds, are necessary preliminary steps to the right comprehension and detection of the murmurs which may be heard during disease. I have to suppose, then, that you have made your ears familiar with these sounds, and that you are acquainted with the present state of theory regarding their formation. This last may be stated in very few words to be, that the respiratory murmurs are occasioned by the vibra- tion of the tubes through which the air rushes, according to well-known acoustic principles. Hence they are loudest in the trachea, finer in the large bronchi, and finest in their ultimate ramifications. The vocal resonance, on the other hand, originates in the larynx ; and diminishes or increases — 1st, According to the distance of any point from the source of the sound ; and, 2d, According to the power which the tex- tures have in propagating it. If now you examine, in succession, any six of the cases in the wards w^hich are labouring under well-marked pulmonary diseases, you will have no difficultv in recognising that all the sounds you hear may be classified into two divisions : 1st, Alterations of the natural sounds ; 2d, New, or abnormal sounds, never heard during health. I. Alterations of the Natural Sounds. — All the sounds of which we have spoken, and which can be heard in the lungs during health, may, in certain diseased conditions, be increased, diminished, or absent ; their character or condition may be changed ; and with regard to the respiratory murmurs, they may present alterations in rhythm or dura- tion with respect to each other. Alterations in Intensity. — Some persons have naturally louder respi- ratory murmurs than others ; if this occur uniformly on both sides, it is a healthy condition. Occasionally, however, the sounds are evidently stronger at one place, or on one side [imerile respiration), and then they generally indicate increased action of the lung, supplementary to dimi- nished action in some other part. In the same manner, there may be feeble respiration simply from diminished action, as in feeble or old per- sons ; but it may also be occasioned by pleurodynia, obstructions in the larynx, trachea, or bronchi — pleurisy, or pulmonary emphysema, or exu- dations filling up a greater or less number of the air-cells and smaller tubes, as in pneumonia, phthisis, etc. Complete absence of respiration occurs where there is extensive pleuritic eft'usion or hydrothorax. Alterations in Character. — The various respiratory murmurs may, in certain conditions of the lung, assume a peculiar harshness, which, to the ear of the practised auscultator, is a valuable sign, indicative of altered texture. Thus, in incipient phthisic, the vesicular murmur under the BY AUSCULTATION. 53 clavicle is often rude or harsh. In pneumonia the broncliial respiratory murmur presents a similar character. When a cavity is formed, it be- comes what is called cavernous (hoarse or blowing) ; and in certain cases of pneumothorax with pulmonary fistula, it assumes an amphoric cha- racter. Alterations in Position. — It frequently happens that the sounds which are natural to certain parts of the chest, are heard distinctly, at places, where in health they are never detected. Thus, in pneumonia, bronchial, or tubular breathing, as it is sometimes called, may be evident, where only a vesicular murmur ought to exist. This is often well marked with regard to the vocal resonance, as certain lesions, which occasion conden- sation or ulceration of the lungs, will enable us to hear either broncho- phony or pectoriloquy, Avhere, under ordinary circumstances, no voice can be heard. Alterations in Rhythm. — In health, the inspiration is usually three times as long as the expiration. In certain diseased conditions this relation is altered, or even inverted. In incipient phthisis we often find the expira- tion unnaturally prolonged. In chronic bronchitis and emphysema it is three or four times longer than the inspiration. II. New or Abnormal Sounds. — These are of three kinds : 1st, Rubbing or friction sounds; 2d, Moist rattles; 3d, Vibrating murmurs. 1. Rubbing or Friction Sounds are caused in the puhuonary apparatus by some morbid change in the pleurae, whereby, instead of sliding noise- lessly on one another, they emit a rubbing sound. This may be so fine as to resemble the rustling of the softest silk, or so coarse as to sound like the creaking of a saddle, grating, rasping, etc. ; and between these two extremes you may have every intermediate shade of friction noise. This variation in sound is dependent on the nature of the alteration which the pleurte have undergone. If covered with a softened thin exu- dation, the murmur will be soft : if it be tougher and thicker, the sound will be louder; if hard, dense, and rough, it will assume a creaking, harsh, or grating character. These noises are heard in the various forms of pleurisy. 2. Moist Rattles are produced by bubbles of air traversing or breaking in a somewhat viscous fluid. This may occur in the bronchi when they contain liquid exudation, mucus, or pus, or in ulcers of various sizes. They may be so fine as to be scarcely audible (when they have been called crepitating), or so coarse as to resemble gurgling or splashing, when they have received the name of cavernous. Here, again, between these two extremes, we may have every kind of gradation, to which auscultators have attached names, such as mucous, submucous, subcrepi- tating, etc. etc. With these names you need not trouble yourselves; all that it is important for you to determine is, whether or not the sound be moist, and you will easily recognise that the rattles are coarse or large, in proportion to the size of the tubes or ulcers in which they are produced, and the amount of fluid present. These rattles may be heard in pneumonia, phthisis pulmonalis, bronchitis, pulmonary apoplexy, etc. etc. 3. Dry Vibrating Murmurs arise when the air-tubes are obstructed, constricted, or lose their elasticity and become enlarged, whereby the 5-i EXAMINATION" OF THE PATIENT vibrations into whicli they are thrown by the column of air, produce sounds or tones of an abnormal character. Hence murmurs may be occasioned of a fine squeaking (^sibilous murmur), or of a hoarse snoring character {sonorous viurmu?'), and between the two extremes there may be all kinds of variations, to which ingenious people have applied names. These only cause confusion ; all that is necessary is to ascertain that the murmur is dry, and you will readily understand that the fineness or coarseness of the sound will depend on the calibre of the tube or cavity thrown into vibrations. They are usually heard in cases of bronchitis and emphysema. Occasionally they present a blowing character, as when ulcers are dry, a condition which often occurs in phthisis. The vocal resonance, besides undergoing the changes already noticed in intensity, character, and i)osition, may give rise to abnormal sounds. Occasionally it presents a soft reverberating or trembling noise, like the bleating of a goat [cegojihomj). The value of this sign, as indicative of pleurisy, was much overrated by Laennec. At present it is little esteemed. Sometimes the resonance gives rise to a metallic tinklivg, a noise similar to that caused by dropping a shot into a large metallic basin, or the note produced by rubbing a wet finger round the edge of a tumbler or glass vessel. This is often best heard immediately after a cough in certain cases of chronic phthisis, ^gophony is supposed to be produced when a thin layer of serous fluid between the pleuroe is thrown into vibrations. The cause of metallic tinkling has created great discussion, and is not yet ascertained. Such, then, are the principal sounds Avhich maybe heard on ausculta- tion of the pulmonary organs in health and during disease. Many writers have endeavoured to point out their diagnostic importance, and drawn up rules which have always appeared to me much too arbitrary. Indeed, in so far as the education of medical students is concerned, I have long been persuaded that the study of these rules has retarded their powers of diagnosis, and afterwards led to dangerous errors in practice. I know of no dogma, for instance, more mischievous than the one which asserts a crepitating (that is a fine moist) rattle to be pathognomonic of pneu- monia, because such a rattle is just as common in phthisis, and is fre- quently heard in various other lesions of the pulmonary organs. Hence we should regard a crepitating rattle not as distinctive of this or that so-called disease, but simply of fluid in the smaller air-passages ; so also an increased resonance of the voice, as indicating hollow spaces with vi- brating walls, or increased induration of the pulmonary textures, and not as diagnostic of phthisis, pneumonia, and so on. I wish, then, strongly to impress upon you, — 1st, That\he difterent sounds are only indicative of certain physical conditions of the lung, and in themselves bear no fixed relation to the so- called diseases of systematic writers. 2d, No single acoustic sign, or combination of signs, is invariably pathognomonic of any certain pathological state, — and conversely, there is no pathological state which is invariably accompanied by any series of physical signs. 3d, Auscultation is only one of the means whereby we can arrive at a just diagnosis, and shouL;! never be depended on alone. BY auscultatio:n. 55 Special Rules to be followed cuRiNa Auscultation of the Circulatory Organs. 1. In listening to the sounds produced by tlie action of the heart and arteries, we should pay attention — 1st, To the impulse ; 2d, To the cha- racter and rhythm of the sounds ; 3d, To the place where they are heard loudest, and the direction in which they are propagated, 2. You should commence the examination by feeling for the spot where the apex of the heart beats against the walls of the chest, wj|ich will enable you to judge of the impulse. This ascertained, place your stethoscope immediately over it, and listen to the sounds. Then place the instrument above, and a little to the inside of, the nipple, near the margin of the sternum, and listen to the sounds there. In the one situation you will hear the first or systolic sound, in the other the second or diastolic sound louder. 3. If anything different from the normal condition be discovered in either one or the other position, or in both, this should be again care- fully examined, and by moving the stethoscope below and round the apex of the heart, or above, in the course of the aortic arch or carotids, on the right and left side, etc., etc., it should be ascertained at what point, or over what space, the abnormal sounds are heard loudest, and whether they be or be not propagated in the course of the large vessels. Occasionally listening over the back and in the course of the descending aorta may be useful. 4. When, during the above examination, we discover a new^ source of impulse or of sound in one of the large vessels, this must be especially examined, the limits of such impulse and sound carefully ascertained — whether it be or be not synchronous with those originating in the heait — its direction, etc. 5. Under ordinary circumstances, the respiratory do not interfere with the detection of the cardiac sounds ; but where the former are very loud and the latter indistinct, it is useful to direct the individual to hold his breath for a few moments. Sometimes the impulse and sounds of the heart are heard better by directing the patient to lean forward ; they may also, if necessary, be exaggerated and rendered more distinct by directing him to walk quickly, or to make some exertion for a short time. Of the Sounds produced by the Circulatory Organs in Health AND Disease. On placing your ear over the cardiac region in a healthy person, you will feel a beating, and hear two sounds, which have been likened to the tic-tac of a watch, but to which they bear no resemblance.^ They may be imitated, however, very nearly, as pointed out by Dr. Williams,^ by pronouncing in succession the syllables Itqyp, diijq). The first ot these sounds, which is dull, deep, and more prolonged than the second, coincides with the shock of the apex of the heart against the thorax, and immediately precedes the radial pulse ; it has its maximum intensity 56 EXAMINATIOX OF THE PATIEXT over the apex of the heart — below and somewhat to the inside of the nipple. The second sound, "nhich is sharper, shorter, and more superfi- cial, has its maximum intensity nearly on a level with the third rib, and a little above and to the right of the nipple — near the left edge of the sternum. These sounds, therefore, in addition to the terms first and second, have also been called inferior and superior, long and short, dull and sharp, systolic and diastolic — which expressions, so far as o-jving a name is concerned, are synonymous. The two sounds are repeated in couples, which, if we commence with the^rst one, follow each other with their intervening pauses, thus — 1st, There is the long dull sound coinciding with the shock of the heart ; 2d, There is a short pause ; 3d, The short sharp sound, and 4th, A longer pause, — all which correspond with one pulsation. In figures, the duration of these sounds and pauses by some has been represented thus, — the first sound occupies a third, the short pause a sixth, the second sound a sixth, and the long pause a third. Others have divided the whole period into four parts ; of which the two first are occupied by the first sound, the third by the second sound, and the fourth by the pause. The duration, as well as the loudness, of the sounds, however, are very variable, even in health, and are influenced by the force and rapidity of the heart's action, individual peculiarity, and form of the thorax. Their extent also difi"ers greatly. They are generally distinctly heard at the precordial region, and diminish in proportion as we with- draw the ear from it. They are less audible anteriorly on the right side, and still less so posteriorly on the left side. On the right side posteriorly they cannot be heard. Their tone also varies in diff'erent persons ; but in health they are free from a hareh or blowing character. Great divei-sity of opinion has existed regarding the causes of these sounds — which you will have heard discussed before coming here. You must never forget, however, the cardiac actions which coincide with them ; for our reasoning from any changes we may detect in the sounds will entirely depend upon our knowledge of these coincidences. "VVe mav consider, then, that there occur with the first sound — 1st, The impulse, or striking of the apex against the thoracic walls ; 2d, Contrac- tion of the ventricles ; 3d, Rushing of the blood through the aortic orifices : and 4th, Flapping together of the auriculo-ventricnlar valves. There coincide with the second sound — 1st, Rushing of the blood through the auriculo-ventricular valves ; and 2d, Flapping together of the aortic valves. Contraction of the auricles immediately precedes that of the ventricles. The result of numerous pathological observations, and of many experiments, is, that in health the first sound is produced by the combined action of the auriculo-ventricular valves, of the ven- tricles, and of the rushing of the blood, which sound is augmented in in- tensity by the impulsion of the heart's apex against the thorax ; whereas the second sound is caused only by the flapping together of the sigmoid valves. T\'ith the cardiac as with the respiratory sounds, the alterations which take place during disease may be divided into — 1st, Modification of the sounds heard in health; 2d, Xew or abnormal sounds. I. MoDiFicATioxs OF THE Healthy Souxds. — These refer to the BY AUSCULTATION. 57 variations the liealtliy sounds present in their seat, intensity, extent, character, and rhythm. Seat. — The somxls may be lieard at their maximum intensity lower than at the points previously indicated, as in cases of dilated hyper- trophy of the left ventricle, enlargement of the auricles, or of tumours at the base, depressino- the organ. They may be Imjher, owing to any kind of abdominal swelling pushing up the diaphragm. They may be more on one side or theother, in cases where the heart is pushed laterally by effusions of air or fluid in a pleural cavity. Various other circumstances may also modify their natural position, such as tumours in the anterior or posterior mediastinum, aneurisms of the large vessels, adhesions of the pericardium, deformity in the bones of the chest, etc. etc. Intensity and Extent. — These are diminished in cases where the heart . is atrophied or softened ; when there is pericardial cflfusion, concentric hypertrophy of the left ventricle, or emphysema at the anterior border of the left fung. They are increased in cases of dilated hypertrophy, of nervous palpitations, and when neighbouring portions of the lung are indurated, especially in certain cases of pneumonia and phthisis pul- monalis. Character. — The sounds become clearer or duller than usual, accord- ing as the walls of the heart are thinner or thicker. Occasionally they sound muffled in cases of hypertrophy or softening of the muscular walls. Not unfre'quently there is a certain degree of roughness, which is difficult to determine as being healthy or morbid. Occasionally it ushers in more decided changes ; at other times it continues for years without alteration. These alterations in character are distinguished by some auscultators as variations in the tone of the sounds. Rhythm or Time. — I need not say that the frequency of the pulsations differs greatly in numerous affections altogether independent of any special disease in the heart. In certain cardiac affections, however, the beats are intermittent, in others irregular — that is, they succeed each other at unexpected intervals. The number of the sounds also varies. Sometimes only one can be distinguished, it being so prolonged as to mask the other. Occasionally three or even four sounds may be heard, depending either on reduplication in the action of ■the valves when diseased, "or on want of synch ronisin between the two sides of the heart. Not unfrequently the increased and irregular movements of the organ, combined with the sounds, are of such a character as to receive the name of tumultuous. IT. New or Abnormal Sounds. — These are of two kinds : 1st, Friction murmurs ; 2d, Blowing or vibrating murmurs. Dr. Latham has called them exocardial and endocardial. I am in the habit of deno- minating i\\eiQ jyericardial and valvular. Pericardial or Friction Murmurs. — These murmurs are the same in character, and originate from the same causes, as the friction noises con- nected with the pulmonary organs. It is only necessary to observe, that occasionally they are so soft as closely to resemble blowing murmurs, from which they are only to be distinguished by their superficial character and limited extent. 58 EXAMINATION OF THE PATIENT. Valvular or Vibrating Murmurs. — These murraurs vary greatl}' in character ; some being so soft as to resemble the passage of the gentlest wind ; others are like the blowing or puff from the nozzle of a bellows (bellows murmurs) ; whilst others are harsher, resembling the noise produced by grating, filing, sawing, etc. They are all occasioned, however, by diseases interfering with the functions of the valves. Some- times these do not close, and the blood consequently regurgitates through them ; at others, whilst this is the case, they are constricted, indurated, roughened, and even calcareous — whence the harsher sounds. They mB.y be single or double, and have their origin either in the auriculo- ventricular or arterial valves, or in both at once, the detection of which constitutes the diagnosis of the special diseases of the organ. Occa- sionally these sounds resemble musical notes, more or less resembling the cooing of a dove, singing or twittering of certain small birds, whis- tling, tinkling, etc. etc. These depend either upon excessive narrowing of the orifices, or upon any causes which induce vibrations of solids in the current of blood — as, when there are perforations in the valves, irregularities of their margins, string-like or other shaped exudations on their surface, etc. etc. Auscultation of the Abdomen. On applying the stethoscope over the stomach and intestines in a healthy state, various gurgling and churning noises may be heard. In the former they may assume an amphoric or metallic character, in the latter they are called borhorygmi. They are caused by the displacements of gas and water, and are most audible during the period of digestion, and the action of a purgative or enema. The impulse of the aorta can be detected especially in thin subjects, when the pressure of the stetho- scope may often be made to elicit a blowing sound. In disease these sounds may be increased or diminished, and in addi- tion, there may be present various kinds of friction or grating sounds when the surface of the peritoneum is roughened, owing to exuda- tion or the unequal pressure of tumours. These last may also give rise to blowing murmurs, when it often becomes difficult to determine whether the morbid sound originates in the tumour itself, or is the result of the pressure it exercises on the aorta. In cases of doubtful pregnancy, the marked rapidity of the foetal pulse contrasted with that of the individual examined, constitutes a positive sign. Auscultation of the Large Vessels. On listening through the stethoscope placed over the arteries in the neighbourhood of the heart, w^e hear the same sounds as are produced at the sigmoid valves, propagated along its course, but more indistinctly as we remove the instrument away from the base of the heart. In those which are more distant only one sound, which is synchronous with their impulse and their dilatation, is heard. This sound is of a dull character, but in health always soft. USE OF THE MICROSCOPE. 59 In tlie various conditions of disease we have a single or double bellows sound, or it may be harsh, grating-, rasping, etc. In the first place, you must ascertain whether any of th'ese sounds are propagated along the artery from the heart, and this you will learn by listening over its course from'that organ, and by observing whether they increase as you proceed towards it. If the sound have an independent origin, it may originate fi-om disease of the internal surface of the artery, when it will be harsh in proportion to the roughness ; from stricture of, or pressure on the vessel, or from its dilatation. Generally speaking, the more dilated and superficially seated the vessel is, the sharper is the sound. Sometimes there is a double murmur in the course of a vessel, having an undoubt- edly independent origin. This is most common in cases Avhere there is an aneurismal pouch!^ into which the blood passes in and out through an opening narrower than the swelling itself. Occasionally one or both such murmurs may possess somewhat of a metallic ringing, or even musical character, 'and in such case the margins of the opening are probablv tense, and thrown into peculiar vibrations. Not {infrequently a soft systolic blowing is audible at the base of the heart, or over the carotid and deep jugular vein. At other times it is continuous, resembling humming, or the noise of a Parisian toy called le diahle. These mm-murs are'distinguished from valvular ones — 1st, By being systolic at the base of the heart; 2d, By their softness; 3d, By not being permanent ; and 4th, By occurring in ana'mic or debilitated persons, and especially in young girls. I have already told you never to form a conclusion as to the natiire of the disease fi-om auscultation alone. Even when combined with percussion, it is not safe to form a diagnosis without a knowledge of all the circumstances of the case. Hence why I repudiate those rules which have been published in books, that have for their object the establishment of opinions from physical signs alone. At the same time, there can be no doubt that percussion and auscultation are abso- lutely essential to the proper investigation of maladies, although not more so than other modes of inquiry. I have, therefore, thought it best to give you a condensed resume of the sounds which may be heard by auscultation of the lungs, heart, abdomen, and large vessels; pointing^ out a few of the diseased states in which they may be some- times (not always) heard, and especially indicating the physical con- ditions on which they are supposed to depend. Their true diagnostic value can only be learned by the careful examination of individual cases. rSE OF THE MICROSCOPE. A knowledge of the ultimate structure of the human body, in its healthy and diseased conditions, is now so advanced as to necessitate the introduction of the microscope among the ordinary instruments of the medical practitioner. But you must not suppose that an additional method of gaining information implies abandonment of those, the utility of Avhich has stood the test of experience. Men must learn the every- 60 EXAMINATION OF THE PATIENT. day nse of theii" senses ; must know liow to feel, hear, and see, in the same manner as they did before instruments were invented. We don't see the stars less clearly with our naked sight, because the telescope is necessary for an astronomer. Neither should a physician observe the sjTnptoms of a disease less accurately because he examines the chest with a stethoscope, or a surgeon be less dexterous with the knife, because it is only by means of the microscope he can determine with exactitude the nature of a tumour. But it is unnecessary to enter into a lengthened argument to prove that the science and art of medicine are greatly indebted, in modern times, to the invention and proper application of ingenious instruments. The following examples will serve to convince you that the microscope is one of these : — Example 1. — Some years ago I was summoned to see a Dispensary patient labouring under bronchitis, who was spitting tlorid blood. On examining the sputum with a microscope, I found that the coloured blood corpuscles were those of a bird. On my telling her she had mixed a bird's blood with the expectoration, her astonishment was unbounded, and she confessed that she had done so for the purpose of imposition. Example 2. — A gentleman, for some years, had laboured under a variety of anomalous symptoms, referable to the head and digestive systems, under which he had become greatly reduced. He had con- sulted many practitioners, and visited innumerable watering places, in a vain search after health. On examining the urine with a microscope, I found it crowded with spermatozoa. He evidently laboured under sper- matorrhoea, a disease which had never been suspected, but which was readily cured on the employment of an appropriate treatment. Examjjle 3. — A boy was brought to me with an eruption on the scalp, which was of so indefinite a character that its nature could not be determined. He had lately been elected to occupy a vacancy in one of our charitable educational establishments, and the question to decide was, whether the disease was or was not contagious. On examining the scab with a microscope, I readily discovered the Achorion Schoen- leini, or fungus constituting true favus ; and as this has been experimen- tally proved to be inoculable, I had no hesitation in preventing his admission to the school. Example 4. — A child was supposed to be affected with worms, be- cause it passed in abundance yellowish shreds, which, to the naked eve, closely resembled ascarides. All kinds of vermifuge remedies had been tried in vain. On examining the shreds with a microscope, I found them to consist of the undigested spiral vessels of plants ; and they ceased to appear when the vegetable broth used as food was abandoned. Example 5. — I was called to see an infant a month old, which was in a state of considerable emaciation, with constant diarrhoea. — The mother, however, maintained that her milk was abundant, and that it was taken in sufficient quantity. On being examined with a microscope, it was found to contain numerous compound granular bodies, and compara- tively few milk globules. In short, it presented, in an exaggerated degree, all the characters of colostrum, and this thirty days after deliv- ery. It was evident, then, that the qualiti/ of the milk was iu fault, an opinion which was confirmed by the recovery of the infant, when a healthy nurse was procured. USE OF THE MICROSCOPE, 61 Example 6. — An individual was supposed to be labouring under dysentery, from the frequent passage of yellowish pulpy masses in the stools, accompanied witli tormina and other symptoms. On examining these masses with the microscope, I found them to consist of undigested potato skins. On inquiry, it was ascertained that this person had eaten the skins with the potatoes. On causing these to be removed before dinner, the alarming appearance ceased, and the other symptoms also disappeared. Example 7. — An elderly lady conceived herself to be affected with insects continually fonuing in the skin, which produced incessant itch- ing and tingling. All the hair was removed, and every kind of applica- tion, including mercurial preparations, was tried without eft'ect. On rubbing the surface, she always saw minute white rolls and black specks, which she regarded as insects in different stages of development. The toiTuent and anxiety this caused her for many months it is scarcely pos- sible to conceive. At length she laboured under the idea that she was communicating the disease to her husband and daughter, when, at the request of her medical attendant in the west of Scotland, she came to Edinburgh, in order that I might investigate and treat it. I had the pleasure of shewing this lady, under the microscope, that the white bodies were minute rolls of epidermis or of the cotton cloth with which she rubbed the skin, and that the black specks were portions of dust or soot. Her hallucination being in this way dissipated, she returned home perfectly well. Example 8. — A child had been suffering for four years from copious and foetid discharge fi'om the nostrils, accompanied with great pain. At the end of that time, a dark brown and indurated mass was discharged, about an inch long, and a quarter of an inch broad, closely resembling a sequestrum of bone. This mass I was requested to examine microscopi- cally by Dr. Littlejohn, under whose care the patient was, and from its structure I readily determined that it consisted of some fir wood. When this was known, the parents remembered that, about the time the dis- ease commenced, alterations were made in the house, and that the chil- dren used to play with the wood shavings. There could be little doubt that a piece of shaving had been thrust up the nose, and been the cause of all the svmptoms. Examples of this kind could be readily multiplied. Xo doubt mis- takes will be made with this instrument in the hands of inexperienced persons, in the same manner as the use of the stethoscope, or of a scalpel, may lead to a false conclusion, or to an accident. But this, so far from being an argument opposed to their employment, only proves the neces- sity of becoming more skilful in their use. Certainly there is no instru- ment which requires more expert management in itself, or more caution in drawing conclusions from its employment, than the microscope. Description of the Microscope. It is not my intention to enter upon a description of the optical prin- ciples on which microscopes are constructed, although you will find a knowledge of these very useful. I shall suppose that you are desirous 62 EXAMIlSrATIOJ^ OF THE PATIENT. of obtaining an instrument that will answer all the purposes of the ana- tomist and physiologist, as well as afford you every possible assistance in the way of diagnosis as medical men. For this purpose, you should learn to distinguish what is necessary from what is unnecessary, in order that you may procure the former in as convenient a form, and at as moderate a cost as possible. A microscope may be divided into mechanical and optical parts. The former determine its general form and appearance. Of the numerous models which have been invented, the one here figured, exactly one-fourth its real size, ap- pears to me the most useful for all the purposes of the physiologist and medical practitioner. The body consists of a telescope tube, eight inches in length, held by a split tube, three inches long. It may be elevated and depressed with great readiness by a cork-screw movement, communicated to it by the hand, and this constitutes the coarse adjustment. It is attached to a cross-bar and pillar, at the lower portion of which last, veiy conveniently placed for the hand of the observer, is the fine adjust- ment. The stage is three inches broad, and two and a half inches deep, strong and solid, with a cir- cular diaphragm below it. The base of the instrument is heavily loaded with lead to give it the necessary steadiness. This form of microscope possesses all the mechanical qualities required in such an instrument. These are — 1st, Steadiness; 2d, Power of easy adjustment ; 3d, Facility for obser- vation and demonstration ; and, 4th, Portability. 1. Steadiness. — It must be evident that if the stage of the microscope is subject to any sensible -vnbration, minute objects, Avhen magnified highly, so far from being stationary, may be thrown altogether out of the field of view. Nothing contributes more to the comfort of an observer than this quality of a microscope, and great pains have been taken to produce it. In the large London instruments this end has been admira- bly attained, but at so much cost and increase of bulk as to render it almost useless. In the small model I have recommended, all the steadi- ness required is present in the most convenient form. Fi?. 21. Fig. 21. Oberhaeuser's model, made at my suggestion for medical men, ^i\\ real size. Tliis instrument may be procured at M. O.'s manufactory, Place Dauphine, Paris, or at Mr. Youngs, cutler, Princes Street, and Mr. Kemp's, Infirmary Street, Edinburs-h. USE OF THE MICROSCOPE. 63 2. Poioer of Uasy Adjustment. — It is a matter of great importance to tliose who use the instrument much, and work with it for hours together, that the adjustment should work easily and rapidly, and be placed in convenient situations. Nothing can be more commodious than the manner in which these ends are arrived at in the model figured. By insertion of the body of the instrument within a split tube, you may, by a spiral movement, elevate and depress it with the greatest rapidity, and even remove it altogether if necessary. The necessity of continually turning the large screws affixed to most microscopes becomes fatiguing in the extreme. Then the fine adjustment, placed conveniently behind the microscope, near the hand which rests on the table, is in the very best position ; whereas, in some London instruments, it is placed on the top of the pillar, so that you must raise your hand and arm every time it is touched. In other London instruments, it is placed in front of the body, so that you must stretch out the arm and twist the wrist to get at it. No one could woi-k long with so inconvenient a contrivance. 3. Facility for Observation and Demonstration. — For facility of ob- servation and demonstration, it is necessary that the instrument should be of a convenient height, and that the stage on which the objects are placed should be easily accessible. Here, again, nothing can be more commodious than the microscope I have recommended, for, when it is placed on a table, its height is almost on a level with the eye, and we can look through it for hours without the slightest fatigue. On the other hand, the stage is elevated, just so much as enables the two hands, resting on their external edges, to manipulate with facility all kinds of objects placed upon it. The large London instruments are so high as to render it necessary to stand up to see through them. To obviate this disadvantage, a movement is given to the body, by which it can be depressed to any angle. But this movement renders the stage oblique, and removes it to a distance, where it becomes very inconvenient to manipulate on its surface. To obviate this difficulty, the stage itself has been rendered moveable in various ways by diff"erent screws, so that in this way complexity has been added to complexity, until a mass of brass work and screws is accumulated, to the advantage of the optician, but to the perplexity and fatigue of the observer. But by no contrivance is it possible to avoid the aching arms which such a position of the stage invariably produces in those who work with such a cumbrous machine for any length of time. 4. Portabilitij. — This is a property which should by no means be overlooked in instruments that are intended more for utility than orna- ment. A medical man is often called upon to verify facts in various places ; at his own house, at a hospital, at the bed-side of his patient, or at a private post-mortem examination. It is under such circum- stances that the value of portability is recognised. The large London instruments require an equipage or a porter to transport them from place to place ; even the putting them in and out of the large boxes or cabinets that are built around them, is a matter of labour. In short, notwithstanding the splendour of the screws, the glittering of the brass, and the fine workmanship, there can be little doubt that, on the whole, they are very clumsy afi'airs. There are many occasions on which a medical man may find it useful •64 EXAMINATION OF THE PATIENT. to carry a microscope with hiin, especially in the case of post-mortem examinations. Many attempts have been made to construct a pocket microscope ; and for the pur- poses above alluded to, I myself caused one to be con- structed some years ago, Avhich, with its case, resem- bled a small pocket tele- scope. Dr. Gruby of Paris, however, has planned the most ingenious instrument of this kind, which possesses most of the properties we have enumerated, and will be found very useful for those accustomed to micro- scopic manipulation. It is contained in a case, the size Fig. 22. of an ordinary snutF-box, and possesses all the conveniences of the larger instruments, with various lenses, a micrometer, slips of glass, needle, knife, and forceps, in that small compass. The annexed woodcuts, exactly one-half the real size, will give an idea of this ingenious microscope, manufactured by Brunner of Paris. For a more minute description, I must refer you to the " Monthly Journal of Medical Science" for December 1846. There is a general feeling among the public that the larger a micro- scope is, the more it must magnify ; but I need not tell you this is error. A very imposing mass of brass work and mechanical com- plexity is no guarantee that you will see objects better, or, what is of more conse- , quence, become good ob- servers. On the contrary, the more unwieldy the in- strument, the less disposed will you be to use it. Besides, the habitual em- ployment of artificial me- thods of moving about the object, as by the screws of a moveable stage, will pre- \ent your acquiring that dexterous use of your fin- gers and accuracy of mani- pulation which are at all times so useful. Nothing, indeed, can be more amusing than to see Fig. 22. Gruby's compound pocket microscope, exactly one half the real size. Fig. 23. The same microscope mounted, ready for use. Fig. 23. USE OF THE MICROSCOPE. 65 a man twisting his screws, pushing his heavy awkward stage about, and laboriously wasting time to find a minute object which another can do in a moment, and without fatigue, by the simple use of his fingers. But perhaps you will consider the weightiest objection to the large instruments is the expense they necessitate, — the cost being necessarily in proportion to the amount of brass and mechanical labour employed upon them. If, then, you have to choose between a complex model and a simple one, I strongly advise you, as a matter of real economy, to choose the latter. Indeed the former, to a practical histologist, is worthless. We have next to speak of the optical parts of microscopes, which are certainly much more important than the mechanical ones — for every- thing depends upon obtaining a clear and distinct image of the object examined. Under this head we may describe the objective, the eye- piece, and methods of illumination. 1. The Objective^ or series of Achromatic Lenses, is that part of the optical portion of a microscope which is placed at the bottom of the tube or bod}', and is near the object to be examined. This may be considered the most important part of the instrument, and the greatest pains have been taken by all opticians in the manufacture of good lenses. It is here I consider that the London opticians are pre-emi- nent, for I am not aware that in any part of the world such perfect objectives have been manufactured as the eighth of an inch by Smith, the twelfth of an inch by Eoss, and the sixteenth of an inch by Powell. But when we come down to the one-fourth of an inch, which is bv far the most useful objective for anatomical and medical purposes, the superiority of the London opticians is very slight, if any. At this mag- nifying power the compound lenses of C. Chevalier, Oberhaeuser, Brun- ner, and Xachet of Paris ; Schick and Pistor of Berlin ; Frauenhofer of Munich, and Ploesl of Vienna, may be employed with the greatest con- fidence, and it may be said that by far the largest number of important discoveries in science have been made through their employment. The Parisian lenses, in addition, have one great advantage, namely, their cheapness. The London opticians have succeeded in combining the lenses of their objectives, so as to obtain a large field of vision, with as little loss of light as possible. These qualities are valuable in the lower magnifying lenses during the examination of opaque objects, and in the higher ones ■when observing transparent objects by transmitted light. But in the lenses of medium power, such as the one-fourth of an inch, the amount of light is so great as to be almost a defect. Notwithstanding careful management of the mirror and diaphragm, the field of vision is often dazzling, and always presents a glare most detrimental to the eyes of the observer. I cannot employ Ross's fourth of an inch for fifteen minutes without feeling intense headache, and I know of more than one excellent observer in whom the sight has so much suff'ered from this cause as to incapacitate them from continuing their researches. In the same manner, the lenses of Brunner and Xachet give rise to a yellow light highly disagreeable ; while those of Oberhaeuser, Schick and Pis- tor, and Frauenhofer (with Amici's and Ploesl's I am not familiar), pre- sent a pale blue light, most pleasant to work with, and which may be gazed at for hours without fatiguing the eye. 5 66 EXAMINATION OF THE PATIENT. For the above reasons, as well as from considerable experience in the use of many kinds of microscopes by different manufacturers, I am satis- fied that tiie best lens you can employ for ordinary purposes is Ober- haeuser's No. 1, which corresponds to vfhat is called in England the quarter of an inch. For low powers yon may have Oberhaeuser's No. 3, or the one-inch lens of the London opticians. For all the wants of the medical man these will be suificient. The anatomist may occasion- ally require a higher lens, as during the examination of the ultimate fibrillaj of muscle, when the eightb,"twelfth, or sixteenth of an inch of the London opticians may be procured. All these lenses may be at- tached to the model we have recommended by means of a brass screw made on purpose. 2. The Eye-piece. — This is that portion of the optical apparatus which is placed at the upper end of the tube or body, and is near the eye of the observer. While the objective magnifies the object itselt; the eye- piece only magnifies the image transmitted from below. Hence, as a source of magnifying power, it is inferior to the lens ; and when this possesses any defects, these are enlarged by the eye-piece. Two eye- pieces are all that is necessary with tlie model I have recommended, and those of Oberhaeuser, called Nos. 3 and 4, are the most useful for the medical man. 3. Methods of niumination. — There are few things of more impor- tance to the practical histologist than the mode of illumination. This is accomplished — 1st, By transmitted light ; 2d, By reflected light; and 3d, By achromatic light. Transmitted light is obtained by means of a mirror placed below the object which, to be seen, must therefore be transparent. In large micro- scopes the mirrors are provided with universal joints, so that they may easily be turned in any direction. Below the stage every microscope should possess a diaphragm pierced with variously sized holes, whereby the amount of light furnished by the mirror may be moderated. lu Oberhaeuser's and Nachet's instruments the smallest aperture should be employed for the higher objective. It is also useful in the examination of many objects that the light should be directed upon them sideways ; this may be done by the diaphragm, or by the mirror, and in the small model formerly figured, is admirably attained by simply turning the whole microscope. The best light for microscopic purposes is that obtained by catching the rays which are reflected from a white cloud. The conjoined use of the mirror and diaphragm can only be learned from actual experience. Reflected light is employed in the examination of opaque objects, and the lenses of "low power, 'manufactured by the principal London opti- cians, enable us to do so without assistance. Occasionally, however, the light of the sun is useful ; and when this cannot be obtained, the rays of a lamp or gas light, concentrated by a bull's-eye lens, may be emploved. Hence every microscope should be possessed of such a lens, and it is most convenient to have it attached to the body of the instrument by a moveable ring, and stem with two joints, as in the model figured. Achromatic light is only serviceable in the examination of very deli- cate objects, witii high powers. The apparatus necessary for obtaining it is occasionally useful in ascertaining the ultimate structure of muscle, USE OF THE MICROSCOPE. 67 or the nature of tbe marking-s on minute scales or fossils, but is useless for the purposes of the medical man. In the same way I know of no benefit to be obtained by a polarising apparatus. In addition to the mechanical and optical parts constituting the microscope itself, the box which contains it should possess a convenient place for holding a few slips of glass, a pair of small forceps, a knife, and two needles firmly set in handles. A micrometer to measure objects with is also essential to those who are making observations with a view to their exact description. No other accessories are necessary. An excellent microscope of the model previously figured, by Ober- haeuser, with two objectives (Nos. 3 and 7), two eye-pieces (Nos. 3 and 4), a neat box with all the accessories necessary (with the exception of a micrometer, which had better he English), may be obtained in Paris for the sum of about 150 francs (£0), and will cost in Edinburgh, after payment of carriage and duty, about seven guineas. Nachet's and Brunner's instruments are much cheaper, as are the smaller models of Oberhaeuser. Either of them, for all the purposes of the medical man, is amply sufficient. Test-Objects. — The defining power of a microscope is generally tested by examining with it a transparent object, having certain fine markings, which can only be rendered clearly visible when the glasses are good. In all such cases, it is of course necessary to be familiar with the structure of the test-object in the first instance. If you are not confident on this point, it is better to trust to the judgment of a friend, whose knowledge of histology is ascertained, or place your dependence entirely on a respectable optician. One of the best test- objects for a quarter of an inch lens is a drop of saliva from the mouth. For, if the microscope shows with clearness the epithelial scales, the structure of the salivary globules, their nuclei, and contained molecules, you may be satisfied that the instrument will exhibit all the facts Avith which, as medical men, you have to do — (See Fig. 25.) Mensuration and Demonstkation. Having, then, obtained a good instrument, and tested its qualities in the manner described, you should next determine the number of diame- ters linear the various combinations of glasses magnify. This you may do for yourself with the aid of a micrometer, a pair of compasses, and a measure. A micrometer is a piece of glass on which lines are ruled at the distance of y^g or yoVo *^^" ^^^ inch. This must be placed under the instrument, when the lines and the distances between them will of course be magnified by the combination of glasses employed, like any other object. Taking a pair of compasses in one hand, we separate the points, and place them on the stage (always on a level with the micrometer magnified). Now, looking through the instrument with one eye, we regard the points of the compasses with the other, and mark off by the naked sight, say the y^oth of an inch, as magnified by the instrument. Though difficult at first, a little practice enables us to do this with the greatest accuracy. The result is, that if the distance 68 EXAMINATION OF THE PATIENT. uiao-nified and so raarted off (y^oth of an inch) is equal to three inches, the instrument magnifies SOU times linear; if two inches, 200 times; and so on. To measure the size of objects, they may be placed directly on the micrometer ; but as this is at all times inconvenient, whilst the object and micrometer, from their not being in the same plane, cannot, under high powers, both be brought into focus at once, it is better to use an eve-micrometer. Many ingenious inventions of this kind are to be procured. The most simple is a ruled micrometer placed in the focus of the upper glass of the eye-piece. With this we observe how many divisions of the eye-micrometer correspond with one of those magnified bv the microscope, always making our observation in the centre of the field, where the aberration of sphericity is least. On the latter being- removed and replaced by an object, it becomes a matter of mere calcu- lation to determine its size. Thus, supposing each of the upper spaces in Fig. 24 to represent the VoVo^^^ of an inch magnified 250 diameters Imear, and five of the lower spaces, as seen in an eye-micrometer, to ^'g- 24- correspond with one of these — it follows that each of these latter must measure j oVo^^^ ^^ ^^ inch. Oberhaeuser has made beautifully ruled eye-micro- meters, for the model recommended, which those who wnsh to make measurements would do well to procure. If it be not in your power to estimate the Spaces equal to l-ioooth of magnifying power for yourself, the optician will an inch magnified 250 dia- give vou a table. Setting foitli the various degrees meters Imear. ^^ enlargement possessed by the lenses, and different eye-pieces, with the tube up or down. This table should always be referred to during the description of objects, and the amount of magnifying power invariably stated. The art of demonstrating under the microscope is only to be acquired by long practice, and, like Five ruled spaces in an everything requiring practical skill, cannot be learnt eve-micrometer, corres- ,. it x i.- i x t i ii ponding to one of those troui books or systematic lectures, i can only, there- above, and consequently f g „j^-g „q^ ^^^.y nreueral directions on tliis head. equal tothel-5000thofan '& .'. •' o . .. j., ,, inch. All that is necessary m examining fluid substan- ces, is to place a drop in the centre of a slip of glass, and letting a smaller and thinner piece of glass fall gently upon it, so as to exclude air bubbles, place it upon the stage under the objective. In this way the fluid substance will be diffused equally over a flat surface, and evaporation prevented which would dim the objective. The illumina- tion must now be carefully arranged, and the focus obtained, first by means of the coarse, and then by means of the fine, adjustment. It will save much time, in examining structures, to employ always, at one sittiiif, the same slips of glass, as it is easier to clean these with a towel, after dipping them in water, than to be perpetually shifting the coarse adjustment. The action of water, acetic acid, and of other re-agents, on the particles contained in a fluid, may be observed by mixing with it a drop of the re-agent before covering with the upper glass ; or if this USE OF THE MICROSCOPE. 69 be already done, the drop of re-agent may be placed at the edge of the upper glass, when it will be difiused through the fluid under ex'araina- tion by imbibition. The^ mode of demonstrating solid substances will vary according as they are soft or hard, cellular or fibrous. The structure of a soft tissue, such as the kidney, skin, cartilage, etc., is determined by making very minute, thin, and "transparent slices of it in various directions, by means of a sharp knife or razor. These sections should be laid upon a slip of glass, then covered over, and slightly pressed fiat, by means of an upper one. The addition of a drop ot^ water renders the parts more clear, and facilitates the examination, although it should never be forgotten that most cell-structures are thereby enlarged or altered in shape fi-om endos- mosis. Acid and other re-agents may be applied in like manner. The double-bladed knife of Valentin will* enable you to obtain large, thin, and equable sections of such tissues, and permit you to see the manner in which the various elements they contain are arranged with regard to each other. Harder tissues, such as wood, horn, indurated cuticle, etc., may also be examined after making thin sections of them. Very dense tissues, such as bone, teeth, shell, etc., require to be cut into thin sec- tions, and afterwards ground down to the necessary thinness. Prepara- tions of this kind arenow manufactured on a large scale, and may be obtained at a trifiing cost. A cellular parenchymatous structure, such as the liver, may be examined by crushing a minute portion between two glasses. If it be membranous, as the cuticle of plants, epithelial layers, etc., the membrane should be carefully laid fiat upon the lower glass, and covered with an upper one. A fibrous structure, such as the areolar, elastic, muscular, and nervous tissues, must be separated by means of needles, and then spread out into a thin layer before examina- tion, with or without water, etc. The commencing observer should not be discouraged by the difil- culties he will have to encounter in dissecting and displaying many tissues. He must remember that the figures he sees published in books are generally either fortunate or very carefully prepared specimens. Practice will' soon enable him to obtain the necessary dexterity, and to convince himself of the importance of this mode of inquiry. He should early learn to draw the various objects he sees, before and after the action of re-agents, not only because such copies constitute the best notes he can keep, but because drawing necessitates a more careful and accurate examination of the objects themselves. A note-book and pen- cil for the purpose should be the invariable accompaniments of every microscope. How TO Observe with a Microscope. The art of observation is at all times difficult, but is especially so with a microscope, which presents us with forms and structures concerning which we had no previous idea. Rigid and exact investigation, there- fore, should be methodically cultivated from the first, in order to avoid those errors into which the" tyro, when using a microscope, is particu- larly liable to fall. Thus, you should carefully examine the physical properties of the particles and ultimate structures you may see, and not 70 EXAMINATION OF THE PATIENT. hastily conclude tliat you have under observation so-called pus, tubercle, or cancer-corpuscles, because they were obtained from what was, a j^fiori, believed to be pus, tubercle, or cancer. Nothing has been more clearly demonstrated by the progress of histology, than the fact, that the naked sight has confounded different structures together, from a similarity of external appearance, and that the gi-eatest caution is required at all times, but especially by learners, in forming opinions as to the nature of different tissues. The physical characters which distinguish microscopic objects consist of — 1st, Shape; 2d, Colour; 3d, Edge or border; 4th, Size; 5th, Transparency ; 6th, Surface ; 7th, Contents ; and 8th, Effects of re- agents. These we may notice in succession. 1. Shajje. — Accurate observation of the shape of bodies is very neces- sary, as many of these are distinguished bv this physical property. Thusthe human blood globules, presenting a bi-concave round disk, are in this respect diff'ereiit from the oval corpuscles of the camelida?, of birds, rep- tiles, and fishes. The distinction between circular and globular is very necessary to be attended to. Human blood corpuscles are circular and flat, but they become globular on the addition of water. Minute struc- tures seen under the microscope may also be likened to the shape of well- known objects, such as that of a pear, balloon, kidney, heart, etc. etc. 2. Colour. — The colour of structures varies greatly, and often differs, under the microscope, from w^hat Avas previously conceived regarding them. Thus the coloured corpuscles of the blood, though commonly called red, are in point of fact yellow. Many objects present different colours, according to the mode of illumination — that is, as the light is reflected from, or transmitted through their substance, as in the case of certain scales of insects, feathers of birds, etc. Colour is often produced, modified, or lost, by re-agents, as when iodine comes in contact with starch corpuscles, when nitric acid is added to the granules of chlorophyle, or chlorine water affects the pigment cells of the choroid, and so on. 3. Edge or Border. — The edge or border may present peculiarities Avhich are worthy of notice. Thus, it may be dark and abrupt on the field of the microscope, or so fine as to be scarcely visible. It may be smooth, irregular, serrated, beaded, etc. etc. 4. Size. — The size of the minute bodies, fibres, or tubes, which are found in the various textures of animals, can only be determined with exactitude by actual measurement, in the manner formerly described. It will be observed, for the most part, that these minute structures vary in diameter, so that when their medium size cannot be determined, the variations in size from the smaller to the larger should be stated. Human blood globules in a state of health have a pretty general medium size, and these may consequently be taken as a standard with advantage, and bodies may be described as being two, three, or more times larger than this structure. 5. Transparency . — This visible property varies greatly in the ultimate elements of numerous textures. Some corpuscles are quite diaphanous, others are more or less opaque. The opacity may depend upon corru- gation or irregularities on the external surface, or upon contents of dif- ferent kinds. Some bodies are so opaque as to prevent the transmission of the rays of light, whgn they look black by transmitted light, although USE OF THE MICROSCOPE. 71 they be white, seen by reflected light. Others, such as fatty particles and oil "globules, refract the rays of light strongly, and present a peculiar luminous appearance. 6. Surface. — Many textures, especially laminated ones, present a dif- ferent structure on the surface from that which exists below. If, then, in the demonstration, these have not been separated, the focal point must be changed by means of the fine adjustment. In this way the capillaries in the web of the frog's foot may be seen to be covered with an epidermic layer, and the cuticle of certain minute fungi or infusoria to possess peculiar markings. Not unfrequently the fracture of such structures enables us, on examining the broken edge, to distinguish the difference in structure between the sui-face and the deeper layers of the tissue under examination. 7. Contents.— The contents of those structures, which consist of enve- lopes, as cells, or of various kinds of tubes, are very important. These may consist of included cells or nuclei, granules of ditferent kinds, pig- ment matter, or crystals. Occasionally their contents present definite moving currents, as in the cells of some vegetables or trembling rotatory molecular movements, as in the ordinary globules of saliva in the mouth. 8. Ufects of Re-(ujeuts. — These are' most important in determining the structure and chemical composition of numerous tissues. Indeed, in the same manner that the anatomist with his knife separates the various layers of a texture he is examining, so the histologist, by the use of re- agents, determines the exact nature and composition of the minute bodies that fall under his inspection. Thus, rvater generally causes cell formations to swell out from endosmosis ; whilst syrup, gum water, and concentrated saline solutions, cause them to collapse from exosmosis. Acetic acid possesses the valuable property of dissolving coagulated albu- men, and, in consequence, renders the whole class of albuminous tissues more transparent. Thus, it operates on cell walls, causing them either to dissolve or become so thin as to display their contents more clearly. JEther, on the other hand, and the alkalies, operate on the fatty com- pounds, causing their solution and disappearance. The mineral acids dissolve most of the mineral constituents that are met with, so that in this way we are enabled to tell, with tolerable certainty, at all events the group of chemical compounds to which any particular structure may be referred. PRINCIPAL APPLICATIONS OF THE MICROSCOPE TO DIAGNOSIS. A perfect application of the microscope, for the purpose of diagnosis, can only be arrived at by obtaining, in the first instance, a complete knowledge of the tissues of plants and animals, both in their healthy and diseased conditions. The medical practitioner may be called upon to distinguish, not only the various structures which enter into every species of food, every kind of animal texture and fluid, and every form of morbid product, but he will frequently have to judge of these when more or less disintegrated, changed, or otherwise aff'ected by the pro- 72 EXAMINATION OF THE PATIENT. cesses of mastication, digestion, expectoration, ulceration, putrefaction, maceration, etc., etc. In this place, however, I propose merely calling your attention to those points -which are more likely to fall under your notice at the bed-side. No doubt, the practical applications of the microscope are daily extending, and whilst there are many points which may be said to be scarcely investigated, those Avhich have been most so require to be further studied. At the same time, a careful and perse- vering examination of the morphological elements found in the various excreta of the body, as modified by different diseases, or by constitution and diet, cannot but prove of great importance in the present state of practical medicine. Hence, besides shortly discussing what is known, I shall especially indicate Avhat are those subjects which may be elu- cidated by such of you as, by previous histological observations, are qua- lified for the task. Saliva. The readiest way of examining the saliva is to collect a drop of that fluid at the extremity of the tongue, and let it fall on the centre of a slip of glass. It should be allowed to remain quiescent for a minute or so, until most of the bubbles of air have collected in a mass on the surface. This should then be gently scraped off or placed aside with a needle, and the subjacent fluid covered with a thin glass. There will now be observed, with a magnifying power of 250 diameters linear, — 1st, The salivary corpuscles ; 2d, Epithelial scales of the mouth ; 3d, Molecules and granules. 1. The salivary corpuscles are colourless spherical bodies, with smooth margins, varying in size from the 3-0V0 to the y-gV^ of an inch in dia- meter. They contain a round nucleus, varying in size, but generally occupying a third of the cell; and between this nucleus and the cell wall are numerous molecules and granules, which communicate to the entire corpuscle a finely molecular aspect. The addition of water causes these bodies to swell out and enlarge from endosmosis. Acetic acid somewhat dissolves the cell wall, and it becomes more transparent ; Avhile the nucleus appears more distinct as a single, double, or tri- partite body. Both water and acetic acid ,--' produce also coagulation of the albuminous • Y". matter contained in the fluid of the saliva, ^'0.;. which assumes the form of molecular fibres, .-^.-»-. ' in which the corpuscles and epithelial scales become entangled, and 25resent to the naked ^'^- ^^- eye a white film. 2. The Epithelial scales found in the saliva are derived from the mouth, and consist of flat plates, variously shaped, but generally pre- senting an oblong or squarish form, more or less curled up at the sides. Not unfrequently these have five or six sides, and are assembled together in groups, with their edges adherent. In size they vary from the g-^oth Fig. 25. Salivary corpuscles, epithelial scales, with molecules and granules, as seen in a drop of saliva. USE OF THE MICROSCOPE. 73 to the -J^otli of an inch in length. Embedded in their substance is a round or oval nucleus, together with numerous molecules and granules. Water produces no change in these bodies ; but acetic acid renders^ the scale more transparent, and causes the nucleus to appear more distinct, with a darker edge. 3. Associated with the salivary corpuscles and epithelial scales are several molecules and granules, which vary in number in different people, and at various times of the day. There may also be occasionally found in the saliva various foreign substances derived from the food — such as granular debris of different kinds, starch globules or vegetable cells, muscular fasciculi, portions of areolar tissue, tendon, or spiral filaments, etc. — derived from pieces of texture which have adhered to the teeth during mastication. The saliva may present various alterations, dependent on disease of the mucous membranes of the mouth and tongue. This, when ulcerated, causes an increase in the molecular and granular matter. Many of the epithelial scales also lose their . \mmm :SjS\C);^:. transparent character and be come opaque, from an augmen- tation of granular matter in their substance. Not unfrequently, under such circumstances, they give rise to confervoid growths, which mainly spring up in the debris collected in the mouth, either on the surface of ulcers, in the sordes which collect on the teeth, gums, and tongue of individuals labouring under fever, or even in the inspis- sated mucus of persons who sleep for a con- siderable time with the mouth open (Fig. 26). In infants the tongue and cavity of the mouth are not unfrequently covered with a yellowish flocculent matter, constituting the \ disease named muguet by the French, in which \^' sporules and confervoid filaments, in a high state of development, may be detected in considerable numbers (Fig. 2*7). In epithelial cancroid of the tongue, the epithelial scales exhibit a great tendency to split up and form fibres, and may frequently be found on the surface of the ulcer, present- ing the form here figured (Fig. 28). An histological examination of the saliva, of the fur and load of the tongue, in the great majority of diseases, is still a desideratum. Fig. 26. Minute confervoid filaments springing from an altered epithelial scale, scraped from the surface of a cancroid ulcer of the tongue {Leptothrix huccalis). Fig. 27. Confervoid filaments and sporules, in the exudation on the mouth and gums, constituting Muguet in infants. Fig. 28. Fringe-like epithelium, from the surface of an ulcer on the tongue. Magnified 250 diameters linear. 74 EXAMINATION OF THE PATIENT. Milk. On examining a drop of milk* we observe a number of bodies rolling in a clear fluid." These bodies, in healthy milk, are perfectly spherical, -with dark margins, smooth and abrupt on the field of the microscope, with a clear transparent centre, which strongly refracts light. In size they vary in different specimens from a point scarcely measurable, up to the joV^th or 3 oVoth of an inch in diameter. In excess of ether they are dissolved or disappear ; but if this re-agent be in small quantity, exosmosis takes place, and the field of the microscope is covered with loose globules of oil, of various forms. Water causes tlie milk globules to swell out, but very slightly. Acetic acid coagulates the caseous fluid in which they swim, and causes the globnles to be aggregated together in masses. 'Several of the globules also exhibit, under the action of this re-agent, a certain flaccidity, and readily run into one another under pressure. These globules consist of a delicate envelope of casein, enclosing a drop of oil or butter. The membrane keeps them separate, so long as it is intact ; but, dissolved by means of acetic acid, or ruptured by heat or mechanical violence (as in the churn), the butter is readily separated and collected. Cream is composed of the larger of these globnles, which, owing to their low specific gravity, float on the surface of milk when allowed to repose. The richness of milk is determined by the quantity of these globules. An examination of cow's and human milk will at once show that the former contains a larger number than the latter. In all efforts, however, to determine the relative value of milk by microscopic examination, great care must be taken that the drop of fluid examined should be of the same bulk, that the same upper glass should be used in every case, and that it should be applied and pressed down with the same force. It it very diflBcult at all times strictly to fulfil these conditions, for not only is great skill in manipulation required, but an intimate acquaintance with the appearance of milk as seen under the microscope, is necessary, before any confidence can be placed in this mode of testing the quality g , ^ ^ of different specimens of the fluid. At the same time, the difference in the amount of oily M^9p^§^^ ^^^■■'^e-°-''^^ constituents between the milk ■■M:^^'^^^ ^^i:'mS^'^mo''o of the cow, ass, and human 'mSm^^ ^-l^iM' determined. In the same manner the va- Fig- 29. Fig- 30. rious adulterations of milk are at once determined. Water, of course, separates the globules more and more from each other according to its amount. Flour will exhibit the * The mode of examining all fluids is the same, and is described p. 67. Fig. 29. Globules of cow's milk. Fig. 30. Colostrum of the human female, containing milk globules greatly varying in;size, with compound granular corpuscles. 250 dtam. USE OF THE MICROSCOPE. 75 large starch corpuscles, which are changed blue by the action of iodine. Chalk shews numerous irregular mineral particles, -which are soluble in the mineral acids; and broken-down brain will be distinguished by large oil globules, mingled with fragments of fine nerve-tubes. Milk, when acid, exhibits the same character that it does under the action of acetic acid. Healthy and fresh milk is indicated by a certain uniformity in the size of the globules; by their perfectly globular form ; by their rolling freely over each other, and not collecting together in masses (Fig. 29). When the latter circuinstance occurs, it is a sign of acidity. The milk first secreted after parturition is called the colostrum. It is yellow in colour, and may be seen under the microscope to contain glo- bules more variable in size, mingled with a greater or less number of granule cells (Fig. 30). These latter ought to disappear in the human female on the fifth or sixth day after parturition, but occasionally they remain, when the milk must be considered as unhealthy. In some cases I have seen them abundant so late as six weeks after the birth of the infant. On some occasions, milk may be mixed with pus and blood, which are readily detected by the characters distinctive of each. Dr. Peddie has pointed out that milk can be squeezed from the mamma during the early months of pregnancy. Under such circumstances, it constitutes a most important sign of the pi'egnant state, especially of a first pregnancy ; for although the secretion at this time has seldom the external appear- ance of milk, but is serous-looking, and often very viscid and syrupy, still, if examined with the microscope, the characteristic milk globules will at once appear. See his valuable paper, " Monthly Journal of Medical Science," August 1848. The Blood. On examining a drop of blood drawn from the extremity of the finger by pricking it, there will be seen a multitude of yellow round bi-concave discs, rolling in the field of the microscope, which soon exhibit a tendency to turn upon their edge, and arrange themselves in rolls, like rouleaux of coins. These rouleaux, by crossing one another, dispose themselves in a kind of net-work, between which may be seen a few colourless spherical corpuscles, hav- ing a molecular surface, and a few granules. The coloured-blood corpuscles vary in size from the joVo"^^ Fig. 31. Blood-corpuscles, drawn from the extremity of the finger. On the left of the figure thej'- are isolated, some flat and on edge, some having a dark and others a light centre, according to the focal point in which they are viewed. On the right of the figure several rolls have formed. Two colourless corpuscles and a few granules are also visible. Fig. 32. Blood-corpuscles altered in shape from exosmosis. 250 diam. 76 EXAMINATION OF THE PATIENT. to the aoVotli of an inch in diameter, their average size being about the ~Vott of an inch — according to Gulliver, 3 aVo^li of an inch. Owing to their bi-concave form, they present a bright external rim with a central shadowed spot, or a bright centre and a dark edge, according to the focal point in which they are viewed (Fig. 31). If the blood be exposed to the air a little time before examination, or if it be obtained by venesection, the edges of the corpuscles may often be observed to have lost their smooth outline, and to have become irregular, notched, serrated, beaded, etc. (Fig. 32). Long maceration in serum, or other circumstances, frequently cause them to diminish in bulk half their natural size, and to present a perfectly spherical coloured body. On the addition of water, the blood discs become spherical, and lose their colour. On adding syrup, they become flaccid and irregular. Strong acetic acid dissolves them rapidly, and very weak acetic acid does so slowly, or diminishes their bulk by one-half. The colourless corpuscles of the blood are spherical in form, and vary in size from the 2 sVoth to the ^ oV ott of an inch in diameter. Their surface presents a molecular or dotted appearance, almost disappearing on the addition of water, when they swell out by endosraosis. Acetic acid renders the external cell-wall very transparent, and brings the nucleus into view, consisting of one, two, or three round granules. The examination of the blood by the microscope enables us to deter- mine certain pathological conditions of that fluid, which, though few in number, are by no means unimportant. In several diseases, the blood presents unusual spissitude, depending on excess of fibrine. In this condition the coloured blood-corpuscles easily lose under pressure their rounded margin, and assume a caudate or ilask-like shape. They do f^\Q;-}Q.,:: not present their usual tendency -M'fi>;°;'f^-.'¥® to accumulate in rolls, but ag- trrefate themselves tocjether in ■^ jy°^:^^ • ^; Fip. 34. irregular masses, as represented Fig." 33. In certain internal hemor- rhages the blood - corpuscles Fig. .33. Fip. 34. break down, or become par- tially dissolved, when the external envelope is seen very transparent, the shadowed spot disappears, and there is found in their interior one or more granules. The liquor sanguinis also contains an unusual number of granules (Fig. 34). The same change is occasionally observable in the blood extraTvasated below the skin in scurvy or purpura hemor- rhagica. In a woman who died of cholera, Dr. James M. Cowan observed a remarkable alteration in the blood, which he was so good as to shew me. It consisted in the coloured corpuscles being paler than usual, and the colourless ones normal, but mingled with these were others varying Fig. 33. Blood-corpuscles altered in form, and aggregated together, in thickened blood. Fig. 34. Altered blood-corpuscles in the fluid of an hsematocele. 250 cUam. USE OF THE MICROSCOPE. 77 in shape and size. They were generally circular, bnt some were oval, and a few caudate. Tliey had a well-defined external smooth border, having one or two bright 0° ^ ° ° ^ refracting granules, generally situated in the external o /p* o o J^ •» r\ membrane, and occasionally projecting from it. O^^^ c?^^o Wlien seen edgeways, they were flattened, and g\ ^^ f\'-^'' O existed in the proportion of one to seven of the v \ (T^^ O" " coloured corpuscles. Their long diameter varied "Zr-^K^' v^crS"^ from the^2Vo th to the 20^*00^^^ ^^ ^'^ inch, and their ^q ^S q-^ q transverse diameter from the 2 oVo^^^ ^^ the joVo^^^ Fie 35 of an inch. The addition of acetic acid caused them to swell out, dissolved their external wall, and liberated the granules. Aqua potassae rendered the whole structure paler, and a solution of muriate of soda rendered them more distinct, and of smaller size.* We have seen that, in a healthy condition, the blood possesses very few colourless corpuscles ; but there is a certain state of that fluid I was the first to describe in 1845, and have since called " Leucocythemia," or white-cell blood, in which they are very numerous, generally associ- ated with enlargement of the spleen or other lymphatic glands. The - 1^ "ff ) )^^ m foV^> f^ Fig. 37. Fig 3S. blood then presents the characters represented in the accompanying figures. (See also the section on diseases of the blood.) It has been affirmed that the colour and number of the corpuscles of the blood undergo a change in plethora, fever, jaundice, dropsies, cholera, etc., but exact observations are wanted to confirm the statement. I have never been able to satisfy myself that any such changes were observable in these diseases by means of the miCToscope. In chlorosis the number of the blood-globules is undoubtedly diminished ; but this is determined by the size of the clot, rather than by microscopic demonstration. Occasionally the serum of the blood presents a lactescent appear- ance ; and, on being allowed to remain at rest some hours, a white creamy pellicle forms on the surface. This consists of very minute * See Dr. Cowan's case — Monthly Journal of Medical Science. March, 1854. Fig. 35. Appearance of blood once observed in a case of cholera. Fig. 36. Appearance of a drop of blood, in Leucocytlaemia. Fig. 37. Tlie same, after the addition of acetic acid. Fig. 38. The same after the blood has stood 24 hours. 250 dia7n. 78 EXAMINATION OF THE PATIENT. particles of oil, which resemble the smaller molecules found in milk, and in the chyle. Pus. Normal or good pus, when examined under a microscope, is found to consist of numerous corpuscles, floating in a clear fluid, the liquor ^^ puris. The corpuscles are glo- ( %) (qS>) bular in form, having a smooth (mS (^'^■''''/^\ "margin, and finely granular sur- ^•-'^.^•;_--' \0 ; face. They vary in size from iCP i©( § j ^ /~--: the ifoVot^ t^ t^^^ TzVotb of an ^ ^ , ,_ ,. inch in diameter. In some of leCr : (.>rv and granules. This occurs in ■vi^i.'/-'^. _. \^^// ^ ^-vo'i-Vt^i:;^^ what IS called scrofulous pus, ^ ^Qi^^ 60^ ^"'1 ^'ai-ious kinds of unhealthy discharges from wounds and ^'?- ^^- ■^'^' ^^- granulating surfaces. (Fig. 42.) In gangrenous and ichorous sores, we find a few of these irregular pus corpuscles associated with a multitude of molecules and granules, and with transformed and broken-down blood globules, the debris of the involved tissues, etc., etc. Sputum. A microscopic examination of the sputum demands a most extensive knowledge of both animal and vegetable structures. I have found in it, — 1st, All the tissues which enter into the composition of the lung, such as filamentous tissue, young and old epithelial cells, blood-cor- puscles, etc. 2d, Mucus from the oesophagus, fauces, or mouth. 3d, Morbid growths, such as pus, pyoid, and granular cells ; tubercle cor- puscles, granules, and amorphous molecular matter ; pigmentary deposits of various forms, and parasitic vegetations, which are occasionally found Fig. 39. Pus corpuscles, as seen in healthy pus. Fig. 40. The same, after the addition of acetic acid. Fig 41. Pus corpuscles, surrounded by a delicate cell-wall. Fig. 42. IiTegular-shaped pus corpuscles, in scrofulous pus. 250 diam. USE OF THE MICROSCOPE. 79 on the lining membrane of tubercular cavities. 4tb, All tbe elements tbat enter into the composition of tbe food, whetber animal or vegeta- ble, wbicb become attached to tbe moutb or teeth, and which are often mingled with the sputum, such as pieces of bone or cartilage, muscular fasciculi, portions of esculent vegetables, as turnips, carrots, cabbages, etc. ; or of grain, as barley, tapioca, sago, etc. ; or of bread and cakes ; or of fruit, as grapes, apples, oranges, etc. All these substances render a microscopic examination of expectorated matters anything but easy to the student. To examine sputum, it should be thrown into water, when, on account of the air it contains, it will generally tloat on the surface; while the more dense portions, such as masses of crude tubercle or cretaceous concretions, occasionally mingled with it, will fall to the bottom. It should be then teased, or broken up with a rod, when the various ele- ments and particles it contains will gradually disengage themselves, and may be separated from the mass without difficulty. Xothing is more common, on examining portions of sputum with a microscope, than to observe the various a(ro:reofations of molecular and g-ranular matter here fiofured — t^ 1^ ^4m #^ .^.. fe^..^ ^^ ^^^ ^H^. Fig. 43. Fig. 44. Fig. 45. Fig. 46. Fig. 47. Occasionally little masses of a cheesy substance, and yellowish colour, may be found entangled in the purulent mucus, or collected at the bot- tom of the vessel. These, when examined, present a number of irregular shaped bodies approaching a round, oval, or triangular form, varying in their longest diameter from the ^ oVo^^ to ^oVoth of an inch. These bodies contain from one to seven granules, are unatfected by water, but are rendered very transparent by acetic acid. They are what have been called tubercle coqjusdes. They are frequently mingled with a multitude of molecules and granules, which are more A ^^^^ numerous in proportion to the softness of the tubercle C^^^^^^S (Fig. 47). (See also description of the tubercular exu- "^ "~ dation.) Sometimes indurated or gritty little masses are brought up with the sputum, which are derived from the cretaceous or calcareous transformation of chronic tubercle in the lungs. They consist of irregular masses of phosphate of lime, combined with more or less ani- mal matter. On scjueezing such as are friable between Fig. 4S. glasses, and examining their structure, they frequently may be seen to contain the elements represented in Fig. 48. Fig. 43. ilass, consisting of minute molecules, frequently seen in disintegrated tubercle. Figs. 44 and 45. Masses composed of molecules and oily granules varying in size and mode of aggregation. Fig. 46. Mass partly composed of the debris of a fibrous structure. Fig. 47. Mass composed of tubercle corpuscles. Fig. 48. Fragments of phosphate of lime occasionally found in the sputum. 250 c?j. 80 EXAMINATION OF THE PATIENT. Sputum frequently presents the fibrillated appearance which is com- mon to all mucous discharges. It is caused by the deposition in viscid mucus of molecules, which assume a linear arrangement. This deposi- tion is increased by the addition of water and acetic acid, so that they consist of albumen. These fine molecular fibres (see Figs. 55, 69, 72), must be distinguished from the ai'eolar and elastic tissue of the lung, which is not uufrequently found in sputum, and which indicates ulcera- tion or sloughing of the pulmonary texture (Figs. 49, 50, 51). Sehroeder van der Kolk has lately stated that these fragments may be found in the sputum before the physical signs of ulceration of the lung, as determined by auscultation, are well characterised. This fact I have confirmed, and believe it to be one of great diagnostic importance. Fig 49. Fig. 50. Fig. 51. In acute pneumonia, the sputum fi-equently contains fibrinous casts of Fig. 52. Fi^. 53. the minute bronchi, which present a branched mould of the tubes. Fig. 49. Fragment of elastic tissue of the lung, in phthisical sputum. Fig. 50. Fragment of areolar and elastic tissue, still exhibiting the form of air cells, from phthisical sputum. Fig. 51. Another fragment. — ( Van der Kolk.y Fig. 52. Fibrinous coagula in sputum, exliibiting moulds of the bronchi. Natural size. — ( After Peacock.) Fig. 53. Fibres, with corpuscles, in a fibrinous coagulum from a bronchus. 250 diam. USE OF THE MICROSCOPE. 81 Tliese casts (Fig. 52) may be readily separated in water, as previously described ; and when examined with the microscope, are found to consist of molecular fibres, in which pyoid and pus corpuscles are infiltrated. (Fig. 53.) The inspissated sputum, so commonly expectorated in the morning, is derived from the fauces. It often presents a dirty green or brownish colour, passing into black. When examined with a microscope, it may be seen to consist of epithelial cells, more or less compressed together, and varying in size from the 2 oVo^^i ^o the ^\o^^ of an inch in diameter. The smaller ones are round, and closely resemble pus corpuscles ; the larger ones are round or oval, with a distinct nucleus. In the dark- coloured portions of this sputum, the cells contain numerous granules and molecules, several of which are black and quite opaque. This black matter consists of carbon, and .,.; .^.■^,. ,fl■^5^, is unaffected by re-agents. The ;i;';, = ; ; ■ addition of acetic acid causes '-t'-' V coagulation of the mucus in ; which the cells are embedded ; and whilst it produces little chanjre in the older cells, it ; dissolves, or renders transpa- rent, the walls of such as are Fig. 54. young, displaying a round, oval, or divided nucleus, as seen in the figure (Fig. 55). In the " black phthisis " of colliers the sputum is ink-black, and more or less tenacious. On examination with a microscope, the cells iu it are seen to be loaded with carbonaceous pigment. Sevei'al of these cells are perfectly opaque, whilst others are almost colourless ; and between the two extremes there is every gradation as to intensity of blackness. This black pigment is unaffected by the strongest re-agents, nitro-muriatic acid, chlorine, and even the blow-pipe, failing to decompose it. It is, therefore, pure carbon, and differs from the pigment contained in cells of similar appearance in melanotic tumours, as in these latter the re-agents just mentioned at once destroy the colour. ( See Carbonaceous Lungs.) Fig. 56. Vomited Matters. The matters rendered by vomiting have not been made so frequent an obiect of microscopical observation as is necessary for the purposes ol diagnosis. In organic diseases of the organ, nothing has been ascer- tained on this head. In other cases, it almost always happens, that the matters returned consist — 1st, Of food and drink, in various stages of Fig. 54. Epithelial cells, embedded in mucus, expeclorated from the fauces. Some are seen to contain black pigment ; others resemble pus corpuscles. Fig. 55. Another portion of expectorated mucus from the feuces, acted on by acetic acid, showing fibrillation and the ciianges in the young cells. Fig. 56 and 57. Cells loaded with pigment in the sputum of the collier. 250 diam. 6 82 EXAMINATION OF THE PATIENT. decomposition and disintegration ; 2d, Of portions of the epithelial lining membrane of the stomach, oesophagus, or pharynx, altered in its characters, and mingled with more or less mucus ; 3d, Of certain new formations, which are produced in the fluids of the stomach. 1. It would constitute a very interesting series of obseiTations, to determine, with the aid of the microscope, the structural changes which various articles of food undergo during the process of digestion in the stomach. This has not yet been done with accuracy, although there can be little doubt that compound tissues become disintegrated in the inverse order to that in which they are produced — that is to say, fibres become separated, embedded cells become loose, and, when aggregated together, their cohesion is destroyed. The cell-walls then dissolve, the nucleus still resisting the solvent process for some time ; but at length the whole is resolved into a molecular and granular mass, which in its turn becomes fluid. Such, however, are the differ- ent soluble properties of various edible substances, that, in a time sufficient for the perfect solution of some, others are scarcely affected. It may readily be conceived, that the transitions which these sub- stances undergo, may occasionally render their detection difficult ; and such is really the case. Starch corpuscles, for instance, break down into rounded granules or molecules, and are very liable to puzzle an inexperienced observer. Tincture of iodine, from its peculiar reaction on these bodies, will always enable us to recognise them. 2. The various epithelial cells which line the passages leading to the stomach, as well as the structures peculiar to that organ itself, may be found in the vomited matters — of course mingled with the debris of Fig. 59. edible substances. They also may have undergone various chancres in appearance, from endosmosis, or even partiardigestion. In clfolera, the vomited matter consists principally of such altered epithelial cells or scales, many of which are derived from the fauces or oesophagus. 8. The new formations which may be produced in the stomach are prmcipally vegetable fungi— such as various kinds of torula? (see Fig. ^•^' ro :^PP^^''^"ce of starch corpuscles after partial digestion in the stomach tl^\-^ W^^^J^ tl^e nce-water vomiting of a cholera patient, shewing, a, large epithelial cells; b, milk globules, and coagulated caseine ; c, toruke- and d ha&- digested epithelial scales, with liberated nuclei, more or less broken down. Fig. 60. Structures observed in certain rice-water vomitings from a cholera patient filiewing bodies which consist of the half-digested uredo in bread. 250 diam. ' •v;^ USE OF THE MICROSCOPE. 83 59, c), and especially one first discovered in vomited matters by Mr. Goodsir, and which he has called Sarcina VentricuU. It consists of square particles, which apparently increase by fissiparous division in reu-ular order, so that they present square bundles of four, sixteen, or some other multiple of four. Although at first supposed to be peculiar to the stomach, I have frequently found them in the foeces; and in one case, in the urine. They have also been found by Virchow and by myself, in the lung, and by Robin, inside the capsule of the crystalline letis. In addition to the bodies now alluded to, vomited matters may contain various morbid products, such as blood, pus, and cancer cells, colouring matter of the bile, etc. FCECES. The same difiiculty attends the examination of the foeces as of the sputum; for there may be found in it, — 1st, All the parts which com- pose the structure of the w^alls of the alimentary canal : 2d, All kinds of morbid products ; and 3d, All the elements which enter into the com- position of food. The only difference is, that these last are generally more broken down or disintegrated. Under certain circumstances, the diagnostic value attached to the examination of the foeces is greater than that of the sputum, or of vomited matters. For instance, when pus or blood globules are detected, we may infer that the more perfect these are, the nearer to the anus is their origin. In examples 4 and 6 (pp. 60, 61) I have shewn how the detection of certain vegetable structures, used as food, was serviceable in diagnosis ; but this subject merits more extensive attention than has hitherto been paid to it. Among the indigestible articles connected with the food, it was observed in the autumn of 1849, that curious-shaped bodies were detect- able, both in the vomited matters and stools of cholera patients. These were supposed to be parasitic formations connected with the cause of Fig. 63. Fis. 64. cholera, but were pointed out by Mr. Busk to be the uredo-segitum, occasionally found in bread. (Figs. 60 and 62.) Fig. 61. Sarciua Ventriculi. Fig. 62. Portions of the uredo in bread, still further digested and disintegrated than is observable in the vomited matters. (Fig. 60.) Some toruhe are also present. Fig. 63. Structure of confervoid mass passed from the bowels. 250 diain. Fig. 64. The same, magnified 500 diameters linear, shewing their vegetable nature. 84 EXAMINATION OF THE PATIENT, On one occasion, a dispensary patient brought to me a membranons mass, which had been evacuated by the bowels. It resembled a piece of boiled fine leather, of a greenish-yellow colour, and fibrous structure. On microscopic examination, it was found to be made up of an inex- tricable mesh work of confervoid, gi'owths, consisting of long tubes, with joints, and a few oval sporules, the former having a great tendency to break across, (Figs. 63 and 64.) In typhus, and other putrid fevers, the stools contain masses of large crystals of phosphates or carbonates, as in the case of a girl of 18 admitted into Addinbroke's Hospital, Cambridge. The material passed from the bowel was of a very dark colour, perfectly fluid, and yielded a Fig. 65. precipitate on the application of heat, and the addition of nitric acid. (See Fig. IV, BeaWs Archives, vol. i. p, 141,) In dysentery they are X;--- ^ loaded with pus and blood ; and the former may ;:::::? o ^^vi^^jPs:! also be detected on the surface of foecal masses when the intestine is ulcerated. There may also be ob- served numerous torula3, and occasionally sarcinae. In cholera the white stools consist of mucus, in which the debris of epithelial cells is entangled ; and as the nuclei of these cells resist disintegration for a long time, these round or oval bodies generally exist in considerable number (Fig. 60), In a disease very common in Edinburgh, especially in women, flakes of membranous matter are thrown off from the bowels in large quan- tities; these present a very similar appearance to the cholera flakes ja.st noticed. Fist. Fig. 65. a. Rounded masses of earthy matter, probably carbonate and phosphate of lime. b. Crystals of triple or ammoniaco-magnesian phosphate, c. Oval masses, probably fragments of a clot. In one to the left of the figure the outline of the blood corpuscles is more distinct than in most, and in a the individual corpuscles can be seen. e. Dark amorplious masses, probably derived from the food. /. Ovum of an entozoon, probably an ascaris. g. Small coUec'ion of blood globules.— {5ea?€.) Fig. 66. Structure of flakes in a rice-water stool, from a cholera patient. 250 diam. USE OF THE MICROSCOPE. 85 Uterine and Vaginal Discharges. The diagnostic indications to be derived from the microscopic examina- tion of these discharges, have not been much investigated ; but there are few subjects which hold out the promise of more useful results to the medical practitioner. It can only be prosecuted by the obstetric histolo- gist, who, on collecting the secretions poured out from the os uteri, or on the vaginal walls, by means of the speculum, should observe their structural peculiarities when quite fresh.* The menstrual discharge will be found to consist of young epithelial cells, old e2:»ithelial scales, and blood globules, the number of which ~X-'e-o ">' ^— -— — -^ Fig G7 last will be greater or less according to the intensity of the colour. A leucorrhoeal discharge always consists of old epithelial scales, which may be more or less loaded with fat, combined with numerous young epithe- lial cells (round or oval), and pus corpuscles. (Fig. 67.) The white gelatinous discharge, so frequently seen with the speculum to be derived from the os uteri, consists of gelatinous mucus, in which round or oval young epithelial cells are mingled. The mucus is copiously deposited in a molecular form, on the addition of acetic acid or water, M'hilst the walls of the cells are rendered transparent, and an oval granular nucleus made visible. (Figs. 68 and 69.) Not unfrequently leucorrhoeal and other discharges contain groups of blood globules, the shapes of which are almost always more or less altered by exosmosis, on account of the viscid fluid mingling with them (see Fig. 67). Indeed, the variations observable in these discharges are dependent for the most part on the excess'of one or other of the elements just men- tioned — namely, epithelial cells or scales, pus or blood corpuscles, and gelatinous mucus. In dysmenorrhoea considerable patches of the epi- * On this poiut Dr. Tyler Smith's work ou Leucorrhoea may be consulted with advantage. Fig 67. Corpuscles seen in a chronic leucorrhoeal discharge, consisting of, — 1st, Large epithelial scales, from the vagina and cervix uteri On the left of the figure some of these may be observed to have undergone the fatty degeneration. 2d, Numerous pus corpuscles; and 3d, Blood globules, the external edges of which are more or less dentated from exosmosis. Fig. 68. Structure of gelatinous mucus from the os uteri. Fig. 69. The same, after the addition of acetic acid. 250 diam. 86 EXAMINATION OF THE PATIENT. thfclial membrane desquamate, and even entire casts of the uterus or vagina have been separated. In addition to the fluid discharges poured out from the uterus and vagina, tliere are a variety of morbid growths connected with these oi-gans, tlie diagnosis of which may be materially facilitated by micro- scopic examination. The separation of fibrous, epithelial, and cancerous Fig. TO. tumours and ulcers belongs to this category, and must be conducted on the principles referable to the diagnosis of morbid growths in general. I have had abundant opportunities of satisfying myself of the importance of this mode of proceeding, in cases where the substance, mucous sur- face, or cervix of the uterus has been more or less involved. Mrcus. In all fluids secreted from a mucous membrane, many of which have been noticed, there may be found a gelatinous material, which has long been called mucus. It may vary in colour from a milk-white to a yel- lowish brown or even black tint, these variations being dependent on the cell structures or pigment it contains. By some it has been supposed that there are certain cell formations peculiar to mucus, which have been called " mucus corpuscles ;" but it has alwaj's appeared to me that the various bodies found in this secretion are either dift'erent forms of epithelium, on the one hand, or pus cells on the other. Thus the round epithelial cells found in mucous crypts, or the bodies constituting per- manent epithelium, when newly formed, before they have had time to flatten out, and become perhaps more or less aflfected by endosraosis, are represented. Figs. 54 and 68. These are the mucous corpuscles of some writers. Again, when exudation is poured out on a mucous surface, and is mino-led in greater or less quantity w ith the gelatinous secretion, it presents a marked tendency to be transfoimed into pus corpuscles, and hence whv all irritations of mucous surfaces are usually accompanied by purulent discharges. The pus corpuscles, under such circumstances, present all the characters formerly noticed as peculiar to these bodies (see Figs. 39 and 6*7). Hence, properly speaking, there is no such body as a mucus corpuscle, Figs. 70 and 71. Two specimens of cancerous juice squeezed from the uterus. 250 diam. USE OF THE MICROSCOPE. 87 the cells found in mucus being either epithelial or pus cells, the number of which present communicates certain peculiarities to the discharge. Thus, as we have seen, the white gelatinous mucus discharged from the os uteri contains the former, whilst the pe- culiar fluid characteristic of a gonorrhoea '<£) . ^-^J^J^ or catarrh, in either sex, abounds in the ,,-=«-'^"''/^" @) latter. The gelatinous substance, how- ■•:::::::^3~i^i^^'^ ever, in which these bodies are found [Mucin), is what is peculiar to the fluid secreted from mucous surfaces, containing, as it does, a large amount of albumen possessing a remarkable tendency to co- agulate in the form of molecular fibres. (Fig. 72.) When recent, these are few in number, but on the addition of water or acetic acid they are precipitated in such numbers as to entangle the cell formations, and present a semi-opaque membranous structure (Fio-s 55 and 69). * ' The more healthy a mucous secretion, the more it abounds in this viscous albuminous matter, and the fewer are its cell elements. On the other hand, when altered by disease, the cell elements increase, and the viscosity diminishes. Dropsical Fluids. Fig. T3. The fluids obtained by puncture of dropsical swellings, may in some cases, when examined microscopically, present peculiarities worthy of notice. Thus, in the serum collected within the tunica vaginalis testis, numerous spermatozoa may be found, constituting what has been called spermatocele. How these bodies find their way into this fluid is unknown, as no direct communication with the substance of the testicle has ever been seen ; neither does their occur- rence seem to interfere in any way with the successful treatment of this kind of dropsy, by injections, as prac- tised in hydrocele. In the fluid of ascites, when removed from the body, there may usually be observed a few epithelial scales from the serous layer of the abdomen, which are more abundant in some cases than in others. Occasionally blood and pus corpuscles may be detected in greater or less quantity. In ovarian dropsy, various products may be found in the evacuated fluid, according to the nature of the contents of the cyst. Pus and blood corpuscles are common elements, but more commonly epithelial cells and scales, which occasionally accumulate in the cysts of ovarian tumours. (Fig. 74.) At other times, masses of gelatinous or colloid matter are Fig. 72. Viscid greyish yellow S2mta of pneumonia, treated with dilute acetic acid, containing fibrinous mucin, pus corpuscles, and epithelial cells containing fatty and pigment granules. — {Afie?- Wedl.) 300 diam. Fig. 73. Spermatozoa as observed in the fluid of Spermatocele. 250 diam. EXAMINATION OF THE PATIENT. evacuated, whicli present various appearances, according to the time that has elapsed since its formation (see Colloid Cancer and Ovarian Dropsy). In the examination of dropsical fluids also, there can be little doubt that further research will lead to very important results in diagnosis. Urine. FifT. 74. Healthy human urine examined -with the microscope, when recently passed, is abso- lutely structureless. Allowed to repose for twelve hours, there is no precipitate; occasionally a slight cloudy deposition may be observed, in Avhich may be discovered a few epithelial scales from the bladder, a slight sediinent of granular urate of ammonia, or a few crystals of triple phosphate. In certain derangements of the constitution, however, various substances are found in the urine, which, in a diagnostic point of view, are highly important, and which we shall shortly notice in succession. To examine the deposits found in urine, this fluid should be poured, in the first instance, and left to stand for a time, in a tall glass jar ; the clear liquid should then be decanted, and the lower turbid portion put into a tall test tube, and the deposit again allowed to form. In this manner the structural elements are accumulated in the smallest possible compass, so that a large number of them are brought into the field of the microscope at once. The quantity of any salt or deposit in the urine can never be ascertained by the microscope. But in the great majority Fig. 75. of cases, the appearances observed with that instrument, are sufficient in themselves to distinguish the nature of the various kinds of sediment met with, and these consequently are all that need be described in this place. Uric Acid. — Uric acid crystals are almost always coloured, the tint varying from a light fawn to a deep orange red. The general colour is yellow; They present a great variety of forms, the most common being rhomboidal. "The lozenge-shaped and square crystals, which are more rarely met with, isolated and in groups, are represented. Fig. 75. Not unfrequently they present adhering masses or flat scales Avith transverse or longitudinal markings, as seen". Fig. 76. Occasionally they assume Fio-. 74. Cells in fluid, removed from an ovarian dropsy. Fit;;. 75. Lozenfj^e-sliaped and rhomboidal crystals of uric acid. Fig. 76. Aggregated and flat striated crystals of uric acid. 250 diam. USE OF THE MICROSCOPE. 89 the form of truncated rounded columns, as represented, ■with other struc- tures, Fig. 81. Urate of Ammonia most commonly assumes a molecular and granular form, occurring in irregularly aggregated amorphous masses. (Fig. 78.) This may be separated from a similardooking deposit of phosphate of lime by the action of dilute muriatic acid, which immediately dissolves the last-named salt, but acts slowly on urate of ammonia, setting free the uric acid. Some- times, however, it occurs in spherical bodies of a bistre brown colour, varying in size from the 5 0-Vot^ ^^ t^6 ¥ 0^*0 o'th of an inch in diame- 'c *:^/>^- '[/'- " O OOCO Fif. ter. The latter size rarely occurs. Occasion- ally they assume a stellate form, needle-like or spicular prolongations coming off from the spherical body. I have seen both these forms associated, and the former so curiously aggregated together as to assume the appearance of an organic membrane, for which by some observers it was mistaken, until it was found to dissolve under the action of dilute nitric acid. (Fig. 77.) Triple Phosphate or xhnmonio-Phosjihate of Magnesia. — These crys- tals are very commonly met with in urine, and are generally well defined, presenting the form of triangular prisms, sometimes trun- cated, at others having terminal facets. (Fig. 78.) If an excess of ammonia exist, or be added artificially, they present a star-like or foliaceous appearance, which, however, is sel- dom seen at the bed-side. Most of the forms of urate of ammonia are represented. Figs. 77 and 78, in the latter they are associated with the triple phosphate. Oxalate of Lime most commonly appears in the form of octahedra, varying in size, the smaller aggregated together in masses. Once seen, these bodies are readily recognised (Fig. 79). Very rarely thev present the form of dumb-bells, or of an oval body, the central transparent portion of which presents a dumb- Fig. 78. cr3 <&P \zz bell shape, while the sha- dowed dark portion fills up the concavities. Cystine takes the form of flat hexagonal plates, presenting on their surface marks of similar irregular crystals (Fig. 80). Occa- sionally their centre is opaque, having radiations more or less numerous, passing towards the circumference. Fig. 77. Urate of ammonia, in a granular membranous form, and in rounded masses, with spicula. Fig. 78. Triple phosphate, with various forms of urate of ammonia. Fig. 79. Octahedral and dumb-bell shaped crystals of oxalate of lime. Fig. 80. Flat and rosette-hke crystals of cystine. 250 dlam. Fig. 79. Fig. 90 EXAMINATION OF THE PATIENT. In addition to the various salts found in the urine, there may occasionally be found different organic yH P )'^ ^ fi^ Fig. 81. products, such as blood and pus corpuscles, sper- matozoa, vegetable fungi, exudation casts of the tubes, or epithelial scales from the bladder or mucous passages. Frequently one or more of these are found together, as in the annexed figure. Very rarely casts of the tubes, principally composed of oily granules, may be seen, or epithelial cells, more or less loaded with similar granules, several of which also float loose in the urine, as in the accompanying figure : — Although these casts of the tubes were at one time confounded together, they may now be separated into at least four distinct kinds, namely, — 1st, Fibrinous or exudative ; 2d, Desquamative ; 3d, Fatty ; and 4th, AVaxy casts. The inferences to be derived from the presence of one or more of these will be es- pecially dwelt on in the section which treats of urinary diseases. ■^> Fie. 62. Sy Fig. 83. Fig. 84 Fig. 81. Bodies observed in the urine of a scarlatina patient, 24 liours after being passed, a. Desquamated fragment of uriniferous tube, b, Exudation casts of uri- niferous tubes, c, Amorplious urate of ammonia, d, Columnar crystals of uric acid. e, Blood corpuscles. /, Pus corpuscles, g, Torulae and vegetable fungi, which had been formed since the urine was excreted. Fig. 82. Cast of a uriniferous tube, principally composed of oil granules, with fatty epithelial cell, and free oil granules, in urine of Bright's disease. 250 diam. Fig. 83. Fatty casts, at an early period of formation (/), with granule cells (e), and crystals of triple-phosphate. Fig. 84. Fragments of fatty and waxy casts. One of the latter is represented at the lower part of the figure. {Chrisiison.) 200 diam. USE OF THE MICE05C0PE. 91 Spermatozoa are occasionally fovind in the urine, but must not be con- sidered as of any importance, unless accompanied by the peculiar symp- toms of spermatorrhoea (see Fig. 73). The presence of torulje in con- siderable quantity (Fis:. 81, f/) is indicative of the existence of sugar, which requires, however, for its confirmation, the application of chemical tests. All the various appearances here noticed are only diagnostic when accompanied by concomitant symptoms. Alone, they are not to be depended on ; but, in combination with the history and accompanying phenomena, they are capable of aftording the greatest assistance in the detection of disease. CcTAXEOus Eruptions axd ITlcers. An examination of the various products thrown out upon the skin in the different forms of eruption, ulcer, and morbid growth, may in many cases be of high diagnostic value. Of these we shall speak separately. 1. Cutaneous Eruptions. — Tn the vesicular and pustular diseases, there may be observed below the epidermis all the stages of pus forma- tion, commencing in exudation of the liquor sanguinis, gradual deposi- tion of molecular and granular matter, and formation around them of cell-walls. The eruption produced artificially by tartar emetic ointment offers the best opportunity of examining the gradual formation of these bodies under the microscope. Pus taken from all kinds of eruptions and sores presents the same characters, there being no difference between the pus in impetigo and that in variola. "When a scab is formed, as in eczema or impetie;o, a small portion of it broken down, mixed with water and examined under the microscope, presents an amorphous collection of granules, oil globules, and epithelial scales. The squamous eruptions of the skin are three in number — namely, psoriasis, pityriasis, and ichthyosis. The dry incrustations which form on the surface in these diseases, essentially consist of epidermic scales more or less aggregated together. They are verv loose in pityriasis,and occasionally mingled with debris of vegetable confervse, similar to what grows on the mucous membrane of the mouth (Figs. 26 and 27). The scales are more aggregated together in psoriasis, and greatly condensed in ichthyosis — occasionally in the latter disease presenting the hardness and structure of horn. The epidermic tumours of the skin assume the form of corns, callosities, condylomatous warts, and what has been called Verruca achrocordon. They all consist, in like manner, of epidermic scales more or less con- densed together ; in the latter growth they surround a canal furnished with blood-vessels. Sometimes thev assume a regular form, their interior Fig. 35. Epidermic cells from crust of Psoriasis. 92 EXAMINATION OF THE PATIENT. being more or less hard, fibrous, and vascular — in short, a prolongation of the epidermis (Fig. 85). At other times they soften on their summits, and assume the structural peculiarities of the epithelial ulcer afterwards to be described. Tis. sr. Fig. 89. Fig. 86. The favus crust is composed of a capsule of epidermis scales, lined by a finely granular mass, from which millions of cryptogramic plants spring up and fructify. Tlie presence of these paVasittc vegetations constitutes the pathognomonic character of the disease (See Favus). Other forms of vegetable parasite are occasionally found in connexion with the skin, of which that described by Mayer and Grove, in the nieatus of the ear, is a good example. The latte"r, as figured by Beale, is given Fig. 86. The skin is also attacked by certain animal parasites. Of these the pediculi, or lice, are too well known to need description. The Acarus scabiei and the Entozoon follicu- lorum are described and figured in the section on skin diseases. 2. Cutaneous Ulcers. — In healthy granulating sores, whilst the sur- 'dV.-^ Q ■ 0^ ^i\0( ^(J) face oo is covered with normal pus \ n -^ b corpuscles (Fig. 39), thegranulations J ^\^J themselves present fibre cells in all V^J stages of development passing into '■^'"-.A ''.'^■''^■ifliW fibres. In scrofulous and unhealthy ^'^- -^- ^'S- 90- sores, the pus is more or less broken down, or resembles tubercle corpuscles (Fig. 42). The epithelial ulcer is very common on the under lip, commencing in Pig. 86. Tlialli of the fungus found in the ear by Mr. Grove {Beak). See also Trans, of the Microscopical Society, vol. v. p. 16], and plate vii. Fig. 87. The fungus {Achorion SchonMni) from a favus crust. Fig. 88. The same, magnified 500 diameters linear. Fig. 89. Epithelial cells, from the surface of an ulcer of the lip. Fig. 90. The same, after the addition of acetic acid. 250 diam. USE OF THE MICROSCOPE. 93 the form of a small induration or wart, but rapidly softening in the centre, it assumes a cup-shaped depression, with indurated margins, which extend in a circular form more or less over the cheek and chin. An examination of the softened matter sometimes exhibits epithelial cells, in various stages of development, as in Fig. 89. At other times the cells are enlarged, flattened out, and more or less loaded with fat molecules and granules, or compressed concentrically round a centre, forming what have been called nest-cells. These growths, though generally denominated cancer, are at once distinguished by a microscopic examination. The so-called chimney-sweep's cancer of the scrotum is essentially a similar formation (See Epithelioma). The cancerous ulcer of the skin is often difiicult to distinguish micro- scopically from the epithelial ulcer, because the external layer, like it, is often composed of softened epidermis. "When, however, a drop of can- cerous juice can be squeezed from the surtace, it is found to contain ■4 R\\>i-i \ ^1^/ groups of cancer cells, which, from their general appearance, mav for the most part be easily distinguished. Considerable experience, however. Fig. 91. Epidermic cells from the edge of a softened epithelioma. Fig. 92. Other ceUs from the centre of the softened portion. Fig. 93. Appearance of section of cancerous ulcer of the skin, — a, Epidermic scales and fusiform corpuscles on the external surface, b, Group of epidermic scales. c, Fibrous tissue of the dermis, d. Cancer-cells infiltrated into the fibrous tissue, and filling up the locuU of the dermis. 250 diam. 94 EXAMINATION OF THE PATIENT. in the knowledge, and skill in the demonstration, of cancerons and can- croid growths, are necessary in order to pronounce confidently on this point, and to this end an acquaintance with the whole subject of the histolog)' of morbid growths is essential.* USE OF CHEMICAL TESTS. The chemical examination of urine, blood, milk, and other animal fluids, as well as the detection of poisons in vomited matters, or other organic mixtures and tissues, constitutes an extensive field of inquiry, — for a description of which, I must refer to works on chemistry and medi- cal jurisprudence. At the bed-side much of this kind of investigation is now superseded by the use of the microscope, which at a glance enables us to detect the poverty and adulterations of milk, the spissitude and altered condition of blood, the natures of various salts and precipi- tates in urine, etc. The action of chemical re-agents on the corpuscles, made visible by this instrument, has already been alluded to. Chemical tests are most valuable at the bed-side to determine the presence of albumen, bile, sugar, or chlorides in the urine, to which points alone I shall in this place direct your attention. Before proceeding to test the urine for particular substances, notice should be taken of its general properties ; such as its colour, odour, density, and re-action. The naked-eye characters of the cloud or pre- cipitate which appears in almost every kind of urine, when allowed to remain at rest for some time after emission, should also be observed, and its morphological constituents determined by means of the micro- scope. The observation of one or more such properties may lead at once to the establishment of a correct diagnosis, and will certainly direct the path we should take in the subsequent chemical investigation of the fluid. The Specific Gravitij of the Urine is at once obtained by means of a urinometer, and should always be noted at the commencement of the examination of this fluid, as it furnishes important indications for further proceedings. Thus the specific gravity is generally diminished in chronic cases of Bright's disease, and increased in cases of Diabetes. To detect Albumen in the Urine. — Boil a portion of urine in a test tube over the flame of a spirit lamp, and observe the result. If the urine, which has in the preliminary examination proved to be acid, become hazy or coagulate, the presence of albumen is certain ; but if it be neutral or alkaline in its reaction, the cloudiness may be occasioned by the deposition of eai-thy phosphates. One drop of nitric acid should therefore, in the latter instance, be added, which will immediately clear up the opacity of the fluid if due to phosphates, but serve to increase its turbidity if depending solely on coagulated albumen. To detect Bile in the Urine. — The test for bile-pigment is nitric acid, which changes the fluid containing it in any quantity, first into a grass green, and then, if the test be added in excess, into a ruby-red or reddish brown tint. If the urine be very much loaded with bile, as sometimes * See the author's Treatise ou Cancerous and Cancroid Growths. Edin. 1849. USE OF CHEMICAL TESTS. 95 happens in cases of jaundice, so that it resembles porter in appearance, it is better to dikite it with water before adding the acid. If the test be applied to the urine, placed in a clean white plate, so as to form a thin laver over the surface, the plav of colours may often be distinctly seen a^uming green, violet, pink, and yellow hues. The same succession of tints may "be induce(i by nitric acid acting upon urine containing an excess of indican (Schunck), in consequence of this substance being resolved into blue and red indigo, which are subsequently destroyed by the continued action of the acid. There is, however, little chance of fallacy arisinar from this source, as a marked excess of indican has hitherto only been observed in two cases (Carter), and never in connexion with urine presenting a bilious appearance. Pettenkofers test. — Pettenkofer's test for bilin, or, rather, for the choleic acid of the bUe, is applied in the following manner. A few drops of simple syrup are mixed with a small quantitv of urine contained in a test-tube, or still better, in a porcelain capsule'; concentrated sulphuric acid is then graduaUy added in con- siderable quantity. If choleic acid be present, the mixture will exhibit a most intense and beautiful purple colour. The vessel employed should be placed in cold water before the acid is added, in order to prevent the suo-ar beino- decomposed into certain brown compounds, which would tend to obscure the development of the reaction which has been described. True bile is seldom found in urine, even when large quanti- ties of the colouring matters exist. To detect Sugar in the Urine. — The three best tests for sugar in urine are those known as Moore's test, Trommer's test, and the Fermen- tation test. Moore's test consists in boiling urine for five minutes in a tube, with half its bulk of liquor potassse. If sugar be present, the liquid assumes a brownish bistre colour. Trommer^s test consists in adding a few drops of a solution of sulphate of copper, so as to give the urine a pale blue colour ; liquor potassa? is then added until the hydrated oxide of copper thrown down is again dissolved, which will happen if the urine be saccharine. Tlie clear deep blue solution which is formed must now be boiled ; when, if sugar be present in very minute quantity, it will be indicated by the mixture assuming a yellowish-red opalescent tint ; but if in large amount, by its becoming pertectly opaque from the formation and precipitation of the yellow sub-oxide of copper. If the urine contain no sugar, a dark-green precipitate only is formed on ebul- lition. Fermentation test. — A few drops of yeast should be added to urine, and a test tube completely filled with the mixture inverted and allowed to remain in a saucer, containing a little more of the urine. The whole should then be put in a warm place, of about 70 or 80 de- grees, for 24 hours. Fermentation ensues, and carbonic acid is formed, which collects at the top of the tube, displacing the fluid. This test is now but seldom employed, being tedious of application, and not giving such accurate results as was at one time supposed. The following solution is very useful when many observations are to be made for the detection of grape sugar in the urine. Take of bitar- trate of potash and crystallized carbonate of soda, of each 150 parts, of caustic potash 80 parts, of sulphate of copper 50 parts, and of water 1000 parts ; dissolve the carbonate of soda and potash in part ot the water boiling, then add the sulphate of copper powdered. ^^ hen all 96 EXAMINATION OF THE PATIENT. the bitartrate is dissolved, add the rest of the water, and fiher. A few drops of this solution added to a little urine in a test tube will, under the action of heat, throw down a dirty green or yellow precipitate of sub-oxide of copper, if sugar be present. To detect Chlorides in the Urine. — Add to urine in a test tube, about a sixth part of its bulk, of strong nitric acid, and then a few drops of a solution of nitrate of silver. If any soluble chloride be present, the chlorine will be thrown down in combination with the silver as a white precipitate ; but if none exist, the fluid will remain clear. From the degree of turbidity or haziness occasioned by the addition of the silver solution, a rough estimate may be made of the amount of chlorides con- tained in the urine. In concluding this subject, allow me to impress upon you the great importance of making yourselves acquainted with all the modes of ex- amination I have brought before you, rather than one or more of them. It too frequently happens that exclusive attention to a particular method of exploration, has rendered some medical men good observers of symp- toms, whilst they are unacquainted with physical diagnosis ; and again, among those who have cultivated the latter, there are some who can percuss and use the stethoscope with skill, who are ignorant of the use of the microscope. Now you should regard all instruments only as a means to an end. In themselves they are nothing, and can no more confer the power of observing, reflecting, or of advancing knowledge, than a cutting instrument can give the judgment and skill necessary tor performing a great operation. We should learn to distinguish between the mechanical means necessary for arriving at truths, and those powers of observation and mental processes which enable us to recognise, com- pare, and arrange the truths themselves. In short, rather endeavour to observe carefully and reason correctly on the facts presented to you, than waste your time in altering the fashion and improving the physical properties of the means by which facts are ascertained. At the same time, these means are absolutely necessary in order to arrive at the facts on which all correct reasoning is based ; and perhaps no kind of know- ledge has been so much advanced in modern times by the introduction of instruments, and by physical means of investigation, as that of medi- cine. These enable the practitioner to extend the limits to which other- wise his senses would be confined. Chest measurers, pleximeters, ste- thoscopes, microscopes, specula, probes, etc. etc., are all useful, and in particular cases indispensable. I do not say employ one to the exclu- sion of the other, but be equally dexterous in the use of each. Do not endeavour to gain a reputation as a microscopist, as a stethoscopist, or as a chemist ; but by the appropriate application of everi/ instrument and means of research, seek to arrive at the most exact diagnosis and knowledge of disease, so as to earn for yourselves the title of enlightened medical practitioners. x\bove all, do not be led away by the notion that any kind of reasoning or theory will enable you to dispense with the careful observation of facts. What is called tact and skill is not a peculiar intuition, or a superior power of intelligence possessed by cer- tain persons, but is always the result of constant and laborious examina- tion of symptoms and signs in the living, combined with careful research into the nature of morbid changes discovered in the dead. SECTION 11. PRINCIPLES OF MEDICINE. Every animated being lias a limited period of existence, during ^vliich it is constantly undergoing a change. So long, however, as this change takes place uniformly in the ditferent parts ot^ which it is composed, its physiological or healthy condition is preserved. But immediately the action of one organ becomes excessive or weak in proportion to the others, disease, of a pathological state, is occasioned. This state may be induced by direct mechanical violence, but may also occur from the continued or irregular influence of several physical agents upon^ the bodv, such as temperature, moisture or dryness, certain qualities of the atmosphere, kinds of food, etc. etc. These are always acting upon the vital powers of the individual as a whole, as well as incessantly stimu- latino- the various organs to perform their functions. Life, then, may be defined in the wordsof Beclard — " organization in action." Health is the regular or normal, and disease the disturbed or abnormal condition of that action. While such mav be assumed to he our notion of disease in the abstract, what constitutes disease in particular has been much disputed. From the time of Hippocrates to that of Cullen and his followers, the external manifestation or symptoms constituted the only means of recognising diseased action, and gradually came to be regarded as the disease itself. Then these symptoms were arranged into groups, divided, subdivided, and named, according to the predominance of one or more of them, or the mode in which they presented themselves. These artificial arrange- ments are the nosologies of former writers. All philosophical phy- sicians, however, have "recognised that the true end of medical inquiry is, if possible, to determine rather the altered condition of the organs which produces the disordered function, than to be contented with the study of the eftects it occasions. But the difliculty of this inquh'v has been so great, and a knowledge of the means of prosecuting it so limited, that it is only within the last "thirty years that medicine has been enabled to build up for herself anything like a solid scientific foundation. "\^ hat has hitherto been accomplished in this way has been brought about by 7 VQ PRINCIPLES OF MEDICINE. the conjoined cultivation of morbid anatomy, patlioloijy, and clinical observation, greatly assisted, however, by the advance of numerous col- lateral branches of science, and especially in recent times by chemical and histological investigation. The result has been a complete over- throw of nosological systems. We now attempt to trace all maladies to their organic cause; and just in proportion as this has been successfully accomplished has medicine become less empirical and more exact. The organic changes, however, which produce or accompany manv diseases have not yet been discovered, and consequently a classilication of all maladies on this basis cannot be strictly carried out. The organic cause of epilepsy, hydrophobia, and of many fevers, for example, is as yet unknown. In the present state of medicine, therefore, when the morbid change in an organ is unequivocally tlie origin of the symptoms, we employ the name of the lesion to designate the disease ; but when there is disturbance of function, without any obvious lesion of a part, we still make use of the principal derangement to characterise the malady. Thus as regards the stomach we say a cancer or an ulcer of that viscus, and thereby express all the phenomena occasioned. But if we are unable to detect such cancer or ulcer, we denominate the affection after its leading symptom, dyspepsia, or difficulty of digestion. In endeavouring to carry out this distinction, however, modern 2^hv- sicians have fallen into a great error, inasmuch as they have continued to employ the nomenclature of our forefathers, and use words simph* expressive of the presence of symptoms to indicate the altered condition of organs which are the cause of those symptoms. Formerly the term inflammation meant the existence of pain, heat, redness, and swellino-; it now^ represents to us certain changes in the ner\'ous, vascular, and parenchymatous tissues of a part. Formerly, apoplexy meant sudden unconsciousness origiuating in the brain ; now, it is frequently used to express lifiemorrhage into an organ, and hence the terms apoplexy of the lung and of the spinal cord. The two ideas are essentially distinct, and bear no reference to each other, because the same word may be, and often is, employed under circumstances where its original meaning is altogether inapplicable. Hence it is incumbent on every one who ap- plies to organic changes, terms which liave been long employed in medicine, to define exactly what he means by them. In this way old indefinite expressions, though still retained, Avill have a more precise meaning attached to them. If, for instance, it be asserted that bleeding- cuts short an inflammation, let it be explained what is cut short — whether the symptoms, the physical signs, a congestion of the vessels, or an exu- dation of the liquor sanguinis. But notwithstanding the confusion in our nosological systems, and the frequent change of ideas with regard to the nature of morbid actions, which have necessarily resulted from the rapid advance of medicine in late years, it still follows that disease is only an alteration in the healthy function of organs. Hence all scientific classification of maladies must be founded on physiology, which teaches us the laws that regulate those functions. Therefore I venture to divide all diseases, in the first place, into two great classes, viz. — 1, Diseases of nutrition ; and 2, Diseases of innervation. HEALTHY AND DISEASED NUTRITION. 99 ON THE GENERAL LAWS OF NUTRITION AND OF INNERVATION IN HEALTH AND DISEASE. There have not been wanting some pathologists who have ascribed the origin of all diseases to an altered condition of nutrition and of the blood, whilst others have rcgaixled even this function as subservient to that of innervation. In man, it is true, we find them inextricabl}- united, and it becomes exceedingly difficult at all times to separate with exacti- tude what are the purely mrtritive, and what the purely nervous pheno- mena. But a consideration of animated nature at large must satisfy us, that in the vegetable world, as well as in some forms of animal life, nutri- tion may proceed independcntl}' of a nervous system. We also feel satisfied that in theory as well as in fact, the function of nutrition is capa- ble of being separated from that of innervation. Doubtless there is no lesion whatever which does not in the higher class of animals involve both nutritive and nervous changes, but the only method of arriving at a knowledge of their conjoint action, of their mutual influence, or the manner in which sometimes one predominates over or mingles with the other, is by studying in the first instance tlie laws by which each seems to be governed. FuXCTION OF NuTRITIOX. The various modes in Avhich nutrition becomes impaired, and the blood diseased, can only be understood by passing in review the different steps of the nutritive process. "We have already pointed out how patho- looT and practical medicine must be based upon anatomy and physiology, and there is no one subject perhaps which is so well capable of illustrat- ing; this proposition as the one we are about to consider. For ages medical men have been in the habit of considering the blood to be the primary source of numerous maladies. It will be our endeavour to shew, bv an analysis of the process of nutrition, that the changes of the blood, and the diseases which accompany them, are for the most part not pri- marv, but secondary — that is to say, they are dependent on previously existing circumstances, to the removal of which the medical practitioner must look for the means of curing his patient. For the sake of convenience of description and reference, we shall di- vide the process of nutrition in man into five stages. 1. The introduction into the stomach and intestinal canal of appropriate alimentary matters, 2. The foi'mation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs. 3. Passage of fluid fi'om the blood to be transformed into the tissues. 4. The disappearance of the trans- formed tissues and their re-absorption into the blood. 5. The excretion of these effete matters from the body, in various forms and by different channels. These different stages comprehend not only growth, but the processes of assimilation, absorption, secretion, and excretion ; and we believe that it is only bv understandino- the function in this enlarged sense that we 100 PRINCIPLES OF MEDICINE. can obtain a correct explanation of those important affections, whicliniay appropriately be called diseases of nutrition. We shall first, however, consider each of these stages separately. 1 . The introduction into the stomach and intestinal canal of appropri- ate alimentary matters. — Alimentary matters have been divided into several groups. The chemist has divided them into azotized and non- azotized substances. The most important azotized principles are fibrin, albumen, and caseine ; the most important non-azotized are fat, starch, gum, and sugar. Both animal and vegetable aliments are capable of yielding similar proximate principles, although in ditl'erent proportions. Those which are most subservient to nutrition are albumen and oil. Dr. Ascherson of Berlin was the fii-st to point out the effects produced by a union of these, and their importance in the formation of every organized tissue. When we regard the proportions in which these principles enter into our food, their presence in milk (the natural food of young animals), tlieir univei-sality in every blastema and organized tisiue, and the nume- rous experiments which prove that they are capable, when united, although not alone, of furnishing the conditions necessary for the support of living- animals, we are at once led to the conviction that albumen and oil are the cliief alimentary mattei-s destined for nutrition. Whilst albumen and oil may be considered as types of the chemical division of nutritive substances into nitrogenized and non-nitrogenize'D DISEASED NUTRITIOX, 103 continually being formed, the old ones disappear. The manner in Avbifh this is accomplished in certain adult tissues, such as muscle, bone, and areolar texture, has not yet been demonstrated, as the intermediate stages of growth have in them only been seen in the embryo. There is every reason to believe that individual particles, as they are dissolved and 'absorbed, are replaced by other particles derived from the blood, without necessarily passing through the stage of cell formation. Secret- ing surfaces, however, are continually producing new cells, in which the especial secretion is elaborated, and this either serves some definite pur- pose in the economy, as in the case of the gastric juice, or is separated from the body, as is the case with urea. The result is, that a large quantity of matter which has answered its purpose, breaks doAvn, is dis- solved, and again passes into the blood. A quantity of effete matter is thus continually entering the circulation, arising from the decay of all the tissues, but more especially from the muscular, osseous, nervous, adi- pose, and areolar tissues. The blood globules themselves dissolve after having performed their functions, and serve to swell the amount of effete matter in the blood. So long as the matters absorbed from the tissues correspond in quan- tity and quality to tlie matters exuded and transformed, the physiolo- gical or healthy state of the blood is preserved. We know, however, that this is continually liable to be disordered from any of the causes we have formerly noticed which derange nutrition. In some cases, ab- sorption takes place with great rapidity, as is occasionally observed after starvation or the formation of large abscesses. In others, this process is in no way proportionate to the quantity of matters exuded, as in ple- thora, hypertrophy, and morbid growths. The effete matters thus absorbed into the blood circulate with it, and always form an inherent part of its composition. It Avas first main- tained by Zimmermann that they constitute the fibrin of the blood, which, instead of being exuded to form the tissues, as has been generally sup- posed, is excreted from the body by the difierent glands. It may be well to recapitulate some of the arguments in favour of this opinion. There is no fibrin in chyme, and very little in the chyle, and what is remarkable, much less in the chyle of carnivorous than of herbivorous animals, as horses and sheep. Ilunger does not diminish its quantity in the chyle of horses, but, on the contrary, rather increases it, if we can rely upon the experiments of Tiedemann and Gmelin, who concluded that the fibrin must get into the chyle through the lymphatics. Since, then, there is no fibrin in the chyme of carnivorous animals, whilst it consti- tutes so large a portion of their food, the object of digestion must be the transformation of fibrin into albumen. Further, the blood of carnivora contains less fibrin than the blood of herbivora, and in the egg there is no fibrin, although organization is proceeding rapidly in it. These facts are sufficient to prove that fibrin is in no way necessary to cell develop- ment and formation of the tissues. On the other hand, all those circum- stances that cause exhaustion of the textures, or increase the amount of absorption from them, augment the amount of fibrin in the blood, as after inflammatory or other exudations, starvation, violent fatigue, preg- nancy, and frequent bleeding or hfemorrhage. Both Xasse and Zim- mermann found the fibrin far more abundant in weak lymphatic persons, 10-i PRINCIPLES OF MEDICINE. than in those who are strong and vigorous. Again, 'fthile there is little fibrin in the chyle of the lacteals, it exists in great quantity in the lymph of the lymphatics, as determined by Xasse in man, and by Miiller in frogs.* It follows from these facts, that the pi-imary digestion must transform fibrin into albumen, rather than the latter into the former ; and such is very probably also the result of the secondary digestion. flow otherwise could so small a quantity of fibrin as from one and a half to three parts in a thousand, exist in healthy blood — an amount altogether disproportionate to what would be requii-ed, did this consti- tuent as such build up the tissues? It appears, therefore, probable that the fibrin is formed partly from a solution of blood corpuscles, and partly from the effete matters of the tissues. Hence we may understand why absorption of exudations, or of the textures from exhausting causes, as well as anything that favours the disintegrating process of the blood corpuscles themselves, will produce an increase of this constituent in the blood. It has been maintained by some that fibrin is secreted by the blood corpuscles. Dr. Carpenter supposed this to be the especial function of the colourless ce]ls,f and Mr. Wharton Jones of the coloui'ed nuclei.^ But there are facts proving that fibrin must have a double origin, as I have stated, one in the solution of both kinds of corpuscles, another from the tissues, of which its increase during inflammation and in rheu- matism are examples, although in these morbid states, increase of the colourless or coloured corpuscles is certainly not essential. Hence fibrin must be referred in its origin to a process of disintegration, rather than to one of evolution, — but even in this capacity, it may serve to produce higher elaboration of that complex fluid, the blood.§ The pathological changes which take place in the blood, as far as they have been ascertained by Andral and Gavarret, Simon, and numerous other investigators, may be summed up in the words of Becquerel and Rodier, who ascertained — 1st, That the simple fact of the development of a disease almost always modifies in a notable manner the composition of that fluid. 2d, That venesection exercises a remarkable influence on the composition of the blood — the more marked the oftener it is re- peated. Under these circumstances the blood is impoverished and ren- dered more watery — the albumen is slightly diminished — the fibrin, extractive matters, and free salts, are not influenced, but there is a decided diminution of the blood corpuscles. 3d, That in a plethoric condition of the system there is no relative increase in the number of the corpuscles, or, in fact, any other change in the composition of the blood ; it is simply the mass of the blood that is increased. 4th, That anemia is characterized by a diminution in the amount of the corpuscles. 5th, That inflammation induces an increase of the fibrin and of the cho- * Zur Analysis und Synthesis des pseudoplastischen Processe. Berlin, 1844. P. 19. ■f- British and Foreign Medical Review, vol. xv., jjp. 272, 278. :j: Ibid, vol. xiv. p 597. g I have carefully read the argument of an able writer in the British and Foreign Medical Review, vol. vii. pp. 153, 473, and vol. x. p. 200, in opposition to the view of Ziminermann, and in favour of the old doctrine ; but I beheve that all the facts he adduces may readily be shewn to favour, rather than overthrow, what appears to me the correct theor3% HEALTHY AND DISEASED NUTRITION. 105 lesterine — the former varying from 4 to 10, and tlie latter being almost doubled. The albumen is diminished. 6th, That the amount of fibrin is diminished, and possibly its physical conditions altered under two classes of circumstances — the first embraces fevers, exanthematous disease, and intoxication ; the second starvation and purpura haemor- rhagica. 7th, That when any of the secretions are checked, their essen- tial principles are contained in the blood in excess. For instance, when the secretion of the urine is suppressed, urea is found in the blood ; when the bile is not excreted, it also abounds in the blood, etc. 8th, That there are three diseases in which the albumen of the blood is notably diminished, viz., in Bright's disease, in certain aft'ections of the heart accompanied b}' dropsy, and in severe cases of puerperal fever. 5. The excretion of the effete matters from the body in various forms and by d[ferent channels. — The circulating fluid having received the effete matters in the manner we have described, again parts with them through the agency of the glands, in the form of certain secretions and excretions. Glands are nourished like all other textures, but their cells are endowed with the property of secreting difterent substances from the blood. Thus the cells of the liver secrete bile ; those of the kidney, urea ; those of the mamma, milk ; those of the testis, the spermatic fluid, etc., etc. In this way the carbonized and nitrogenized matters, as well as the albuminous and fatty principles, whether received from the assimilation of alimentary substances, or from the transformation of the tissues themselves, are again excreted from the system, as bile, urea, carbonic acid, etc. The mineral matters received into the blood pass through the same process. The lime and phosphorus absorbed from the alimentary canal, unite to form the constituents of bone, and when re-absorbed are ex- creted under new combinations in the urine and foeccs. The muriate of soda is decomposed in the tissues. The acid is found in the gastric juice or is exhaled by the skin, Avhile the soda is excreted largely with the bile by the liver. Sulphur, phosphorus, and the other minerals, also pass out of the system in various states of combination. To complete the physiological changes connected with the function of nutrition, it is only necessary to remember that carbonic acid gas, the result of decompositions in the tissues, and water, are contiiuially given off by the lungs and skin ; and that oxygen, which enters the blood through the lungs, is continually entering into new combinations with the bases of the solids and fluids. These chemical combinations and ex- changes are accompanied by the evolution of heat, whereby the animal temperature is kept up. Thus we may consider that there are two kinds of digestion continu- ally going on in the body — one in the stomach and intestines, the other in the tissues ; that the blood is the recipient of both, distributing the results of the first to build up the tissues, and of the second to consti- tute the various excretions. In this manner the circulation of the blood may be compared to a river flowing through a populous city, which serves at the same time to supply the wants of its inhabitants, and to remove all the impurities that fi'om numerous channels find their way into its stream. 106 PKIXCIPLES OF MEDICINE. From the foregoing considerations, it follows that an eliminative func- tion is to a certain extent brought about by all the processes of growth referred to, and that there can be no change, however limited, that is not necessarily associated with a general one in the system at large. As all the nutritive functions are connected with one another, an excess or diminution of local growth, by subtracting from or adding to the consti- tuents of the blood, must produce an alteration in that fluid both as to quantity and quality. The idea of Treviranus, viz., "that each single part of the body, in respect of its nutrition, stands to the whole body in the relation of an excreted substance," has been ably shewn by Mr. Paget to account for various processes in health, under the name of " complemental nutrition."* The same notion has been still further extended by Dr. William Addison, who correctly points out, thatin the distinctive eruptive fevers, such as small-pox, the numerous minute abscesses in the skin eliminate the morbid poison, which formerly existed in the blood, and are in this way essential to the cure. This provident action he denominates " cell therapeutics."! Hence there are fixed pro- cesses in abnormal as in normal nutrition, with which it is essential for the medical practitioner to be acquainted, in order that, instead of ope- rating blindly or empirically, he may act scientifically, or in accordance ■with natural laws. Further, we cannot avoid observing that the process of nutrition is a continuous round, which in the natural world may be said to commence "with the reception and terminate with the preparation of aliment, vege- table or animal; that this is observable not only in the "chemical balance of organic nature," so beautifully described by Dumas, but in the incessant cliemical compositions and decompositions, as well as structural formations and disintegrations, which are peculiar to all vital entities. If so, it must be apparent that our knowledge of the animal economy and of the diseases to which it is liable, can only be elucidated by investigating the nature of such chemical and structural changes, together with the necessary relations that each one bears to the others, and that it is on such kind of knowledge alone that medicine, as a scientific art, can ever repose in security. We can noAv readily understand how derangement in one stage of the nutritive process more or less affects the others, Tlius, if alimentary matters are not furnished in sufiicient quantity, and of a proper quality, the blood is rendered abnormal, and it necessarily follows that the matters it gives off will be abnormal also, and its subse- quent transformations more or less modified. Again, if secretion be checked, the blood is not drained of its effete matter ; and if excretion be prevented, the secretions themselves may enter the blood, and act upon it as a poison. A diseased or morbid state of the blood, therefore, may arise from either of the stages of nutrition which we have described, being rendered irregular, or otherwise abnormal. In Avhatever part of the circle inter- ruption takes place, it will, if long continued, aftect the whole. Thus, a * Lectures on Surgical Pathology. Lecture 2. f Addison on Cell Therapeutics. 1856. HEALTHY AND DISEASED NUTRITION. 107 bad assimilation of food produces througli tlic lilood bad secretions and excretions, whilst an accidental arrest of one of the latter reacts through the blood on the assimilating jjowers. The forms of disease thus arising may be endless, but as regards nutrition, they may all be traced to the following causes : — 1. An improper quantity or quality of the food. 2. Circumstances preventing assimilation or impeding respiration. 3. Altered quantity or quality of nutritive mattei's passing out of the blood. 4. The accumulation of effete matters in the blood. 5. Obstacles to the excretion of these from the body. Examples in which each of these causes, separately or combined. Las occasioned disease, must have occui'red to every pi'actitioner. It is true that all general diseases are accompanied by certiiin changes in the blood, but "these changes are to be removed, not by operating on that fluid directly, but by obviating or removing those circumstances which liave deranged the stage of nutrition primarily affected. For instance, a very intense form of disease may be produced in infants, through improper lactation. The remedy is obvious ; we procure a healthy nurse. Ischuria is followed by coma, in consequence of the accumulation of urea in the blood ; we give diuretics to increase the flow of urine, and the symptoms subside. In the one case we furnish the elementary principles necessary for nutrition ; in the other, we remove the residue of the process. In both cases the blood is dis- eased, but its restoration to health is produced by acting on a know- ledge of the causes which led to its derangement. In the same manner we might illustrate the indications for correct practice in the other classes, of causes tending to derange the blood. Thus, although there be a proper quantity or quality of food, there may be circumstances which impede its assimilation ; for instance, a too great acidity or irritability of the stomach — the use of alcoholic drinks — inflammation or cancer of the organ. It is the discovery and removal of these that constitute the chief indications for the scientific practitioner. Again, the capillary vessels become over-distended with blood, and the "exudation of liquor sanguinis to an unusual amount takes place, constituting inflammation, llow is this to be treated ? In the early stage topicat bleeding, if directly applied to the part, may diminish the congestion, and the application of cold will check the amount of exudatton. But the exudation having once coagulated out- side the vessels, acts as a foreign body, and the treatment must then be directed to furthering the transformations which take place in it, and facilitating the absorption and excretion of effete matter. This is accomplished by the local application of heat and moisture — the inter- nal use of neutral salts to dissolve the increase of fibrin in the blood, and the employment of diuretics and purgatives to assist its excretion by urine or stool. The general principle we are anxious to establish from this general^ sketch of the nutritive functions is— that diseases of nutrition and of the blood are only to be combated by an endeavour to restore the deranged processes to their healthy state, in the order in which they were impaired ; that a knowledge of the process of nutrition is a pre- 108 PRINCIPLES OF MEDICINE. liminary step to the proper treatment of these affections ; that the theory of acting directly on the blood is incorrect; and that an expect- ant system is as bad as a purely empirical one. Function of Innervation. The function of innervation is also made up of the performance of various actions, widely ditfercnt from each other, although associated together. These actions lead to the manifestation of intelligence, sensa- tion, and combined motion. But as the connection between these is not capable of exhibiting such an order of sequence, as has been made appa- rent among the nutritive processes, it Avill be necessary to describe them in a different manner. General Anaiomi/ and PhysioJogi/ of the Nervous System. Structure and Arrangement of the Nervous System. — To the eye, the nervous system appears to be composed of two structures — the grey or ganglionic,, and the white or fibrous. The ganglionic, when examined under high powers, may be seen to be composed of nucleated cells, varying greatly in size and shape, mingled with a greater or less number of nerve tubes, also varying in calibre. One important fact, with regard to these corpuscles, is, that many of them may be demonsti-ated to throw out prolongations, which are in direct con",munication with, or constitute, the central band or axis of Remak and Purkinje witliin the fibres. The fibres, indeed,, may be shewn to consist of minute tubes, which are smallest towards the periphery of the cerebrum, larger towards its base, and largest in the nerves. They are of three kinds — 1st, Finely cylin- drical, as observed in the optic and auditory nerves ; 2d, Varicose, as in the white substance of the cerebral lobes and of the spinal cord ; and 3d, Larger and of regular size throughout, as in the nerves. There are also bundles of gelatinous or flat fibres, the nature of which is much dis- puted, very common in the olfactory nerve and sympathetic system of nerves. There can be no doubt that some nerve tubes run into the ganglionic corpuscles, whilst others originate from them. (Wagner, Kolliker.) It is also now rendered certain that the same ganglionic cell may receive and give off nerve tubes, each having distinct properties, the one of conveying the influence of impressions to, and the other of conveying influences from, the nervous centres. The peripheral termi- nation of the nerves is in loops or arcs. The general arrangement of the two kinds of structures should be known. By cerebrum, or brain proper, ought to be understood that part of the encephalon constituting the cerebral lobes, situated above and outside the corpus callosum ; by the spinal cord all the parts situ- ated below this great commissure, consisting of the corpora-striata, optic thalami, corpora quadrigemina, cerebellum, pons varolii, medulla oblongata, and medulla spinalis. In this way, we have a cranial and a vertebral portion of the spinal cord. In the cerebrum, or brain proper, the ganglionic or corpuscular HEALTHY AND DISEASED IXNERVATIOX, 109 structure is external to tlie fibrous or tubular. It presents on the sur- face numerous anfractuosities, -whereby a large quantity of matter is capable of being contained in a small space. This crumpled up sheet of grev substauce has beeu appropriately called the hemispherical ganglion. (Solly.) In the cranial portion of the spinal cord, the grey matter exists in masses, constituting a chain of ganglia at the base of the ence- phalon, more or less connected with each other and with the white mat- ter of the brain proper above, and the vertebral portion of the cord below. In this last part of the nervous system the grey matter is inter- nal to the white, and on a transverse section presents the form of the letter x, having two posterior and two anterior cornua, — an arrangement which allows the latter to be distributed in the form of nerve tubes to all parts of the frame. The white tubular structure of the vertebral portion of the cord is divided by the anterior and posterior horns of grey matter, together with the anterior and posterior sulci, into three divisions or columns on each side. On tracing these upwards into the medulla oblongata, the anterior and middle ones may be seen to decussate there with each Fig. 94 Transverse section of the spinal cord of the Sahno salar, about two inches from the brain. — A, anterior ; B. posterior groove ; C, central canal lined with epi- thelium ; D. areolar tissue surrounding the central canal, continuous with tlie ante- rior and posterior grooves; E, anterior root: F, commissural fi))res; G. po-sterior root : H, areolar tissue ; I, vertical fibres of the white substance cut acros.s in the transverse section ; K. openings of blood-vessels cut across : L, ganglionic cells. — ( Owsjannikow.) 100 dium. 110 PEIXCIPLES OF MEDICINE. other, whilst the posterior columns do not decussate. On tracing the columns up into the cerebral lobes, we observe that the anterior, or pyramidal tracts, send oiF a bundle of fibres, which passes below the olivary body, and is lost in the cerebellum — {Arciform hand of Solly). The principal portion of the tract passes through the coipns striatum, and anterior portion of the optic thalamus, and is ultimately lost in the white substance of the cerebral hemispheres. The middle colunm, or olivary tract, may be traced through the substance of the optic thalamus and corpoia quadrigemina, to be in like manner lost in the cerebral Fig. 95. Longitudinal section of the spinal cord of the Salmo solar cut obhqueh- from before inwards, in tlie course of the fibres of the anterior root. — A, blood-ves- sels filled with blood corpuscles ; B, areolar texture ; C, central canal ; D, ganglionic cells ; E, fibres of the white substance originating in the cells and going to the brain : F, fibres of the anterior root which pass througli the white substance and pass into the cells: G, pia mater. — {Owsjannikoic) lOO diam. Fig. 96. Longitudinal section of the spinal cord of the Pdromyzon fluviatilis. The right half — A, areolar tissue between the broad fibres of the cord ; B, areolar tissue between the ganglionic cells, which exist in large numbers ; C, broad fibres ; D, bipolar ganglionic cells on a level with the broad fibres, the extremities of which divide into a countless number of minute branches. The upper one is seen to commu- nicate Avith a spindle-shaped cell by a continuous fibre; E, fibres of medium width ; F. spindle-shaped ganglionic cells, containing a nucleus and nucleolus; longitudinal fibres of the white substance, passing upwards; a, a fibre going from the cell into the posterior root ; h, a fibre cut across which passes into the anterior root ; c, com- missural fibre ; d. a fibre very difficult to follow, which was once seen to communi- cate with a round ganglionic cell in the centre of the cord ; e, a fibre passing out of the cell and running upwards. — {Oicsjannikow.) 100 diam. HEALTHY AND DISEASED INNERVATION. Ill hemispheres. The posterior cohimn, or restiform tract, passes ahnost entirely to the cerebelhun. In addition to the diverging fibres in the cerebral hemispheres which may be traced from below upwards, connecting the hemispberical ganglion with the structures below, the brain proper also possesses bands of transverse fibres, constituting the commissures connecting the two hemi- spheres of the brain together, as well as longitudinal fibres connecting the anterior with the posterior lobes. In the spinal cord it results from the investigations of Lockhart Clarke, that there is a decussation of various bundles of fibres throughout its whole extent. It is now also determined, that many of the fibres in the nei'ves may be traced directly into the grey substance of the cord— a fact originally stated by Grainger, but confirmed by Budge and Kulliker. Furtlier, it has recently been shewn that by means of these fibres an anastoiuosis is kept up between the various columns, even those on both sides of the cord, through the medium of nerve cells in the grey matter, an important fact principally demonstrated by the labours of Stilling, Remak, Van der Kolk, Schilling, Kupifer, and Owsjannikow. These later observations indeed open up to us the probability that the numerous actions hitherto called reflex, are truly direct, and are carried on by a series of nervous filaments running in ditFerent directions, which have yet to be described. There can be no doubt that they pass and operate through the cord, and hence the term diastaltic proposed by Marshall Hall instead of reflex, is in every way more appropriate. The importance of this view appears to me so great, that I would refer to the figures, pp. 109, 110, from the Thesis of Owsjannikow,* showing what he thinks to be the connection of nerves and ganglionic cells in the spinal cord of certain fishes, as indicative of probably similar relations yet to be discovered in man. Functions of the N^ervous Si/stem. — The great difterence in structure existing between the grey and white matter of the neiwous sytem would d priori lead to the supposition that they performed separate functions. The theory at present entertained on this point is, that, while the grey matter eliminates or evolves nervous power, the white matter simply conducts to and from this ganglionic structure the influences which are sent or originate there. The brain proper furnishes the conditions necessary for the manifesta- tion of the intellectual faculties properly so called, of the emotions, pas- sions, and volition, and is essential to sensation. That the evolution of the power especially connected with mind is dependent on the hemi- spherical ganglia is rendered probable by the following facts: — 1. In the animal kingdom generally, a correspondence is observed between the quantity of grey matter, depth of convolutions, and the sagacity of the animal. 2. At birth, the grey matter of the cerebrum is very defec- tive, so much so, indeed, that the convolutions are, as it were, in the first stage of their fonuation, being only marked out by superficial fissures almost confined to the surface of the brain. As the cineritious substance increases, the intelligence becomes developed. 3. The results of experiments by Flourens, Rolando, Hertwig, and others, have shewn * Disquisitiones microscopical de medullte spinalis textura, 1854. 112 PRINCIPLES OF MEDICIXE. that, on slicing away the brain, the animal becomes more dull and stupid in proportion to the quantity of cortical substance removed. 4. Clinical observation points out, that in those cases in which the disease has been afterwards found to commence at the circumference of the brain and proceed towards the centre, the mental faculties are affected first; whereas in those diseases which commence at the central parts of the organ and proceed towards the circumference, they are affected last. The white tubular matter of the brain proper serves, by means of the diverging fibres, to conduct the influences originating in the two hemispherical ganglia to the nerves of the head and trunk, whilst they also conduct the influence of impressions made on the trunk, in an inverse manner, up to the cerebral convolutions. The other transverse and longitudinal fibres which connect together tlie two hemispheres, and various parts of the hemispherical ganglia, are proba- bly subservient to that combination of the mental faculties which cha- racterises thought. The spinal cord, both in its cranial and vertebral portions, furnishes the conditions necessary for combined movements ; and that the nervous power necessary for that purpose depends upon the grey matter, is rendered probable by the following facts: — 1st, Its universal connection with all motor nerves. 2d, Its increased quantity in those portions of the spinal cord from whence issue large nervous trunks. 3d, Its collection in masses at the origin of such nerves in the lower animals as furnish peculiar organs requiring a large quantity of nervous power, as in the triglia volitans, raia torpedo, silurus, etc. 4th, Clinical observation points out that, in cases where the central portion of the cord is afl"ected previous to the external portion, an individual retains the sensibility of, and power of moving, the limbs, but wants the power to stand, walk, or keep himself erect, when the eyes are shut ; whereas, when diseases commence in the meninges of the cord or externally — pain, twitchings, spasms, numbness, or paralysis, are the symptoms present, dependent on lesion of the white conducting matter. The white matter of the cord acts as a conductor, in the same manner that it does in the brain proper, and there can be no doubt that the influence arising from impressions is carried not only along the fibres, formerly noticed, which connect the brain and two portions of the spinal cord together, but along those more recently discovered, "which decussate or anastomose in the cord itself (Brown-Sequard), and are connected with the ganglionic cells of the grey matter. The various nerves of the body consist for the most part of nerve tubes, running in parallel lines. Yet some contain ganglionic corpuscles, as the olfactory and the ultimate expansion of the optic and auditoi-y nerves, whilst the sympathetic nerve contains in various places, not only ganglia, but gelatinous flat fibres. The posterior roots of the spinal nerves possess a ganglion, the function of which is quite unknown. These roots are connected with the posterior horn of grey matter in the cord, while the anterior roots are connected with the anterior horns. As regards function, the nerves may be considered as — 1st, Nerves of special sensation, such as the olfactory, optic, auditory, part of the glosso-pharyngeal and lingual branch of the fifth. 2d, HEALTHY AND DISEASED INNERVATION. 113 Nerves of common sensation, such as tlie greater portion of the fifth, and part of the glosso-pharyngeal. 3d, Nerves of motion, such as the third, fourth, lesser division' of the fifth, sixth, facial, or portio dura of the seventh, and the hypo-glossal. 4th, Senso-motory or mixed nerves, such as the pneumo-gastric, the accessory, and the spinal nerves. 5th, Sympathetic nerves, including the numerous ganglionic nerves of the head, thorax, and ahdomen, — the exact function of which has not been determined, although they seem to influence nutrition and the pro- duction of animal heat, through their connection with the blood-vessels. All nerves are endowed with a peculiar vital property called sensi- bility, inherent in their structure, by virtue of which they may be excited on the application of appropriate stimuli, so as to transmit the influence of the impressions they receive to or from the brain, spinal cord, or certain ganglia, which may be considered as nervous centres. The nerves of special sensation convey to their nervous centres the influence of impressions caused by odoriferous bodies, by light, sound, and by sapid substances. The nerves of common sensation convey to their nervous centres the influence of impressions caused by mechanical or chemical substances. The nerves of motion c&ny from the nervous centres the influence of impressions, whether psychical or physical. (Todd.) The mixed nerves carry the influence of stimuli both to and from, combining in themselves the functions of common sensation and of motion. Although the sympathetic nerves also undoubtedly carry the influences of impressions, the direction of these cannot be ascer- tained, from their numerous anastomoses, as well as from the ganglia scattered over them, all of which act as minute nervous centres. But there are cases where certain psychical stimuli (as the emotions) act on organs through these nerves, and where certain diseases (as colic, gallstones, etc.) excite through them sensations of pain. Sensation may be defined to be the consciousness of an impression, and that it may take place, it is necessary, — 1st, That a stimulus should be applied to a sensitive nerve, which receives an impression ; 2d, That, in consequence of this impression, a something which we designate an influence, should be generated, and conducted along the nerve to the hemispherical ganghon ; 3d, On arriving there, it calls into action that faculty of the mind called consciousness or perception, and sensation is the result. It follows that sensation may be lost by any circumstance which destroys the sensibility of the nerve to impres- sions; — which impedes the progress of the influence generated by these impressions, or, lastly, which renders the mind unconscious of them. Illustrations of how sensation may be affected in all these ways must be familiar to you, from circumstances influencing the ultimate extremity of a nerve, as on exposing the foot to cold, — from injury to the spinal cord, by which the communication with the brain is cut off", or from the mind being inattentive, excited, or suspended. The independent endowment of nerves is remarkably well illustrated by the fact, that whatever be the stimulus which calls their sensibility into action, the same result is occasioned. Mechanical, chemical, gal- vanic, or other 2)ki/sical stimuli, when applied to the course or the extre- mities of a nerve, cause the very same results as may originate from suggestive ideas, perverted imagination, or other psychical stimuli. Thus 114 PEIXCIPLES OF MEDICIXE. a chemical irritant, galvanism, or pricking and pinching a nerve of mo- tion, will cause convulsion and spasms of the muscles to which it is dis- tributed. The same stimuli applied to a nerve of common sensation -will cause pain, to the optic nerve Hashes of light, to the auditory nerve ring- ing sounds, and to the tip of the tongue peculiar tastes. Again, we have lately had abundant opportunities of seeing that suggestive ideas, or stimuli arising in the mind, may induce peculiar effects on the muscles, give rise to pain or insensibility, and cause perversion of all the special senses. — (See Diseases of the Nervous System.) Motion is accomplished through the agency of muscles, which are endowed with a peculiar vital property, called contractility, in the same way that nerve is endowed with the property of sensibility. Contractility may be called into action altogether independent of the nerves (Haller), as by stimulating an isolated muscular fasciculus directly. (AYeber.) It may also be excited by a physical or psychical stimulus, operating through the nerves. Physical stimuli (as pricking, pinching, galvanism, etc.) applied to the extremities or course of a nerve, may cause convulsion of the parts to which the motor filaments are distributed directly, or they may induce combined movements in other pails of the hody diastalti- cally (Marshall Hall), — that is, through the spinal cord. In 'this latter case the following series of actions take place : — 1st, The influence of the impression is conducted to the spinal cord by the afferent or enoclic fila- ments which enter the grey matter, 2d, A motor influence is transmitted outwards by one or more efferent or exodic nerves. 3d, This stimu- lates the contractility of the muscles to which the latter are distributed, and motion is the result. Lastly, contractility may be called into action by 'psychical stimuli or mental acts — such as by the will and by certain emotions. Integrity of the muscular structure is necessary for contractile movements; of the spinal cord, for diastaltic or reflex movements; and of the brain proper, for voluntary or emotional movements.* * Diagram illustrative of voluntary and reflex motions. Fig. 97 refers to volun- tary motion and sensation. Tlie first originates in a psychical stimulus — the wiU — in the liemispherical ganglion, the influence of which is propagated downwards through the fibres of the brain, a, to the spinal cord, and outwards by a motor filament in a com- pound nerve, b, to the muscles. The last originates in aphysical stimulus, say the prick of a needle, at the extremity of the nerve, b, the influence of which travels in the op- posite direction, along a sensitive filament of that compound nerve, through the spinal cord, up to the hemispherical ganglion, there ex- citing the mental act of consciousness, and, as a result, sensation. In both cases the nerve fibres are continuous. Fig. 98 explains reflex or more properly diastaltic motions {Sta, through, oteXAu, I contract). They originate in a physical sti- mulus applied to the extremity of a sensitive filament, a, the influence of which travels in- wards to the spinal cord, and through its grey matter again outwards along a motor filament, b, to the muscles, without neces- \ Fig. 97. \ Pig. 9S. sarily being propagated to the hemispherical ganglion, and thereby exciting con- HEALTHY A^D DISEASED INNERVATION". 115 Thus, tben, we may consider that the brain acting alone furnishes the conditions necessary for intelligence ; the spinal cord acting alone fur- nishes the conditions essential for the co-ordinate movements necessary to tlie vital functions; and the brain and spinal cord acting together fur- nish the conditions necessaiy for voluntary motion and sensation. The following aphorisms will be found useful, in endeavouring to rea- son correctly on the functions of the nervous system : — 1. The brain proper is that portion of the encej^halon situated above the Corpus Callosum. 2. The spinal cord is divided into a cranial and a vertebral portion. 3. The grey matter evolves and the white conducts nervous power. 4. ContructiUty is the property peculiar to fibrous texture, whereby it is capable of shortening its fibres. Motion is of three kinds, contrac- tile, dependent on muscle — diastalttc, dependent on muscle and spinal cord — voluntary, dependent on muscle, spinal cord, and brain. 5. Sensibility is the property peculiar to nervous texture, whereby it is capable of receiving impressions. Sensation is the consciousness of receiving such impressions. A more detailed account of the various cerebral, spinal, and cerebro- spinal functions, as they are performed separately or coujointl}', belongs to the course of the Institutes of Medicine, and with these you are sup- posed to be familiar. It is important, however, that we dwell more at length on the General Pathology of the Nervous System. For the purposes of diagnosis and treatment, it is a matter of great importance to attend to the following pathological laws which regulate diseased action of the nervous centres. (1.) The amount of fluids tvithin the cranium must always be the same so long as its osseous walls are co'pable of resisting the j^ressure of the atmosphere. There are few principles in medicine of greater prac- tical importance than the one we are about to consider, — the more so, as many able .practitioners have lately abandoned their former opinions on this head, and on what I consider to be very insufticient grounds. On this point, therefore, I cannot do better than condense and endeavour to put clearly before you the forcible arguments of the late Dr. John Reid, with such other considerations as have occurred to myself. That the circulation within the cranium is different from that in other parts of the body, was first pointed out by the second Monro. It was tested experimentally by Dr. Kellie of Leith, ably illustrated by Dr. Abercrombie, and successfully defended by Dr. John Reid. The views adopted by these distinguished men were, that the cranium forms a spherical bony case capable of resisting the atmospheric pressure, the only openings into it being the difterent foramina by which the vessels, nerves, and spinal cord pass. The encephalon, its membranes, and blood-vessels, Avith perhaps a small portion of the cerebro-spinal fluid, sciousness and sensation. The nature of the communication through the grey matter instead of being broken or reflected, we have seen to be probably continuous and direct through the medium of ganglionic cells. (Fig. 94.) 116 PRIXCIPLES OF MEDICINE. completely fill up the interior of the cranium, so that no substance can be dislodged from it without some equivalent in bulk takino; its place. Dr. Monro used to point out, that a jar, or other vessel similar to the cranium, with unyielding walls, if filled with any substance, cannot be emptied without air or some substance taking its place. To use the illustration of Dr. "Watson, the contents of the cranium are like beer in a barrel, which will not flow out of one opening unless provision be made at the same time that air rushes in. The same kind of reasoning applies to the spinal canal, which, with the interior of the cranium, may be said to constitute one large cavity, incompressible by the atmospheric air. Before proceeding furthei-, we must draw a distinction between pres- sure on, and compression of, an organ. Many bodies are capable of sus- taining a great amount of pressure without undergoing any sensible decrease in bulk. By compression must be understood, that a substance occupies less space from the application of external force, as when we squeeze a sponge, or compress a bladder filled with air. Fluids gene- rally are not absolutely incompressible, yet it requires the weight of one atmosphere, or fifteen pounds in the square inch, to produce a diminu- tion equal to 2 o.Wotli part of the whole. Now this is so exceedingly small a change upon a mass equal in bulk to the brain, as not to be appreciable to our senses. Besides, the pressure on the internal surface of the blood-vessels never exceeds ten or twelve pounds on the square inch, during the most violent exertion, so that, under no possible circum- stances, can the contents of the cranium be diminished even the jo.Wotti part. When the brain is taken out of the ci'anium, it may, like a sponge, be compressed, by squeezing fluid out of the blood-vessels ; but during life, surrounded, as it is, by unyielding walls, this is impossible. For let us, with Abercrombie, say, that the whole quantity of blood cir- culating within the cranium is equal to 10, this is 5 in the veins, and 5 in the arteries ; if one of these be increased to 6, the other must be diminished to 4, so that the same amount, 10, shall always be preserved. It follows, that when fluids are eft'used, blood extravasated, or tumours grow within the cranium, a corresponding amount of fluid must be pressed out, or of brain absorbed, from the physical impossibility of the cranium holding more matter. At the same time, it must be evident that an increased or diminished amount of pressure may be exerted on the brain, proportioned to the power of the heart's contraction, the eftect of which will be, not to alter the amount of fluids within the cranium, but to cause, using the words of Abercrombie, " a change of circulation" there. This is all, it seems to me, that is shown by the ingenious experi- ments of Donders, who saw venous congestion through glass plates, fixed in the crania of rabbits.* Dr. Kellie performed numerous experiments on cats and dogs, in order to elucidate this subject. Some of these animals were bled to death by opening the carotid or femoral arteries, others by opening the jugular veins. In some the carotids were first tied, to diminish the quantity of blood sent to the brain, and the jugulars were then opened, with "the view of emptying the vessels of the brain to the greatest possible extent ; while, in others, the jugulars were first secured, to prevent as much as * Nederlandeche. — Laucet, 1850. HEALTHY AND DISEASED INNERVATION. 117 possible the return of the blood from the brahi, and one of the carotids was then opened. He inferred, from the whole inquiry, which was con- ducted with extreme care, " That we cannot, in fact, lessen, to any con- siderable extent, the quantity of blood within the cranium by arterio- tomy or venesection ; and that when, by profuse haemorrhages, destruc- tive of life, we do succeed in draining the vessels within the cranium of any sensible portion of red blood, there is commonly found an equivalent to this spoliation in the increased circulation or effusion of serum, serv- ing to maintain the plenitude of the cranium." Dr. Kellie made other experiments upon the effects of position imme- diately after death from strangulation or hanging. He also removed a portion of the unyielding walls of the cranium in some animals, by means of a trephine, and then bled them to death ; and the difference between the appearances of the brain in these cases, and in those where the cranium was entire, was very great. One of the most remark- able of these differences was its shrunk appearance, in those animals in which a portion of the skull was removed, and the air allowed to gravitate upon its inner surface. He says: — "The brain was sensibly depressed below the cranium, and a space left, which was found capable of containing a teaspoonful of water." It results from these inqiiiries, that there must always be the same amount of fluids within the cranium so long as it is uninjured. In morbid conditions these fluids may be blood, serum, or pus ; but in health, as blood is almost the only fluid present (the cerebro-spinal fluid being verj^ trifling), its quantity can undergo only very slight alterations. There are many circumstances, however, which occasion local congestions in the brain, and consequently unequal pressure on its structure, in which case another portion of its substance must contain less blood, so that the amount of the whole as to quantity, is always preserved. These circum- stances are mental emotions, haemorrhages, eftusions of serum, and mor- bid growths. Such congestions, or local hyperhemias, in themselves constitute morbid conditions ; and nature has, to a great extent, provided against their occurrence under ordinary circumstances, by the tortuosity of the arteries and the presence of the cerebro-spinal fluid, described by Magendie. The views now detailed, had been very extensively admitted into patho- logy, when Dr. Burrows, of St. Bartholomew's Hospital, endeavoured to controvert them, first in the Lumleian Lectures of 1843, and subse- quently in a work published in 1846, entitled " On Disorders of the Cere- bral Circulation, and on the connections between Affections of the Brain and Diseases of the Heart." Dr. Burrows, however, evidently misunder- stood the doctrine we are advocating. Thus, he is always combating the itlea that blood-letting, position, strangulation, etc., cannot affect the hlood in the brain ; whereas the real proposition is, that they cannot alter the fluids within the cranium. By thus confounding blood with fluid, and brain with cranium, he has only contrived to overthrow a doc- trine of his own creation. Dr. Burrows has brought forward several observations and experi- ments, which he considers opposed to the theory now advocated. His facts are perfectly correct. I myself have repeated his experiments on rabbits, and can confirm his descriptions. It is the inferences he draws 118 PRINCIPLES OF MEDICINE. from them that are erroneous. For the paleness which results from haemorrhage, and the dift'erence observable in the colour of the brain, when animals, immediately after death, are suspended by their ears or by their heels, is explicable by the diminished number of coloured blood particles in the one case, and by their gravitation downwards in the other. That the amount of fluid within the cranium was in no way affected, is proved by the plump appearance of the brains figured by Dr. Burrows, and the total absence of that shrunken appearance so well described by Dr. Kellie. Neither does our observation of what occurs in asphyxia or apna?a, oppose the doctrine in question, as Dr. Burrows imagines, but rather con- firms it. On this point the following observations by Dr. John Reid are valuable. He says : — If any circumstance could produce congestion of the vessels within the cranium, it would be that of death by hanging; for then the vessels going to and coming from the brain are, with the ex- ception of the vertebral arteries, compressed and then obsti'ucted. These two ai'teries, which are protected by the peculiarity of their course through the foramina of the transverse processes of the cervical vertebra?, must continue for a time to force their blood upon the brain, while a comparatively small quantity only can escape by the veins. Indeed, the greater quantity of blood carried to the encephalon by the vertebrals returns by the internal jugulars and not by the vertebral veins, which are supplied from the occipital veins of the spinal cord ; and the anasto- moses, between the cranial and vertebral sinuses, could carry off a small quantity of the blood only, transmitted along such large arteries as the vertebrals. And yet it is well known that there is no congestion of the vessels within the cranium after death by hanging, however gorged the external parts of the head may be by blood and serum." This is admitted by Dr. Burrows, although he endeavours to get rid of so troublesome a fact by a gratuitous hypothesis, which will not bear a moment's exami- nation, but for the refutation of which I must refer to the works of Dr. Reid.* On the whole, whether we adopt the terms of local congestion, of change of circulation within the cranium (Abercrombie), or of unequal pressure (Burrows), our explanation of the pathological phenomena may be made equally correct, because each of these modes of expression im- plies pretty much the same thing. But if we imagine that venesection will enable us to diminish the amount of blood in the cerebral vessels, the theory points out that this is impossible, and that the eftects of bleeding- are explained by the influence produced on the heart, the altered pres- sure on the brain, exercised by its diminished contractions, and the change of circulation within the cranium thereby occasioned. I have entered somewhat fully into this theory, because, independent of its vast importance in a practical point of view, it is one which origi- nated in the Edinburgh School of Medicine. Singular to say, notwith- standing the obvious errors and fallacies in Dr. Burrows' work, no sooner did it appear, than the whole medical press of England and Ireland adopted its conclusions, and even Dr. Watson, in the two last editions of his excellent work, also abandoned the theory of Monro, Kelly, and * Physiological, Anatomical, and Pathological Researches, No. XXV. HEALTHY AND DISEASED INNERVATION. 119 Abercrombie. But so far is this theory concerning the circnlation with- in the cranium from being shaken by the attack of Dr. Burrows, that it may be said now to stand on a firmer basis than ever, owing to that attack having drawn forth the convincing reasoning and unanswerable arguments of so sound an anatomist, physiologist, and pathologist, as the late Dr. John Reid. (2.) A.II the functions of the nervous system may be increased, per- verted, or destroyed, accordiay to the degree of stinialus or disease ope- rating on its various parts. — Thus, as a general rule it may be said, that a sligiit stimulus produces increased or perverted action; whilst the same stimulus, long continued or much augmented, causes loss of function. All the various stimuli, whether mechanical, chemical, electrical, or psychical, produce the same effects, and in ditferent degrees. Circum- stances influencing the heart's action, stimulating drinks or food, act in a like manner. Thus if we take the effects of alcoholic drink, for the purpose of illustration, we observe that, as regards combined movements, a slight amount causes increased vigour and activity in the muscular system. As the stimulus augments in intensity, we see irregular move- ments occasioned, staggering, and loss of control over the limbs. Lastly, when the stimuhis is excessive, there is complete inability to move, and the power of doing so is temporarily annihilated. With regard to sen- sibility and sensation, we observe cephalalgia, tingling, and heat of skin, tinnitus aurium, confusion of vision, muscte volitantes, double sight, and lastly, complete insensibility and coma. As regards intelligence, we observe at first rapid flow of ideas, then confusion of mind, delirium, and lastly, sopor and perfect unconsciousness. In the same manner pressure, mechanical irritation, and the various organic diseases, produce aug- mented, perverted, or diminished function, according to the intensity of the stimulus applied, or amount of structure destroyed. Then it has been shewn that excess or diminution of stimulus, too much or too little blood, very violent or very weak cardiac contractions, and plethora or extreme exhaustion, will, so far as the nervous functions are concerned, produce similar alterations of motion, sensation, and intel- ligence. Excessive haemorrhage causes muscular weakness, convulsions, and loss of motor power, perversions of all the sensations, and lastly, unconsciousness from syncope. Hence the general strength of the frame cannot be judged of by the nervous symptoms, although the treatment of these will be altogether difterent, according as the individual is robust or weak, has a full or small pulse, etc. These similar effects on the nervous centres from apparently such opposite exciting causes, can, it seems to me, only be explained by the peculiarity of the circulation previously noticed. A change of circulation within the cranium takes place, and, whether arterial or venous congestion occurs, pressure on some portion of the organ is equally the i-esult. The impoilance of paying attention to this point in the treatment must be obvious. (3.) The seat of the disease in the nervous system influences the nature of the jyhenomena or symptoms produced. — It is a matter of very great importance to ascertain how far certitude in diagnosis may be arrived at, and the seat of the disease ascertained. On this subject it may be 120 PRINCIPLES OF MEDICINE. affirmed that, altliongh clinical observation combined with pathology has done much, more reqnires to be accomplished. As a general rule, it may be stated, that disease or injury of one side of the encephalon, especially influences the opposite side of the body. It is said that some very striking exceptions have occurred to this rule, but these at any rate are remaikably rare. Besides, it has always appeared to me probable that, inasmuch as extensive organic disease, if occurring slowlv, may exist without producing sj-mptoms, whilst it is certain most important symp- toms may be occasioned without organic disease, even these few excep- tional eases are really not opposed to the general law. Then, as a s'eneral rule, it may be said that diseases of the brain proper are more especially connected with perversion and alteration of the intelligence ; whilst disease of the cranial portion of the spinal cord and base of the cranium, are more particularly evinced by alterations of sensation and motion. In the vertebral portion of the cord, the intensity of pain and of spasm, or else the want of conducting power, necessary to sensation and voluntary motion, indicates the amount to which the motor and sensitive fibres are atFected. Further than this we can scarcely generalise with prudence, although there are some cases, as we shall subsequently see, where careful observation has enabled us to arrive at more positive results. The fatality of lesions afliecting various parts of the nervous centres varies greatly. Thus the hemispheres may be extensively diseased, often without injury to life, or even permanent alteration of function. Convulsions and paralysis are the common results of disease of the ganglia, in the cranial portion of the cord. The same results from lesion of the pons varolii. But if the medulla oblongata, where the eighth pair originates, be aflfected, or injury to this centre itself occur, it is almost always immediately fatal. (4.) The rapidity or slowness with tvhich the lesion occurs influences the phenomena or symptoms produced. — It may be said as a general rule, that a small lesion {for instance, a small hemorrhagic extravasation), occurring suddenly, and with force, produces, even in the same situation, more violent etfects than a very extensive organic disease which comes on slowly. This, however, will depend much upon the seat of the lesion. Very extraordinary cases are on record, where large portions of the nervous centres have been much disorganized, without producing any- thing like the violent symptoms which have been occasioned at other times by a small extravasation in the same place. Here again the nature of the circulation within the cranium otters the only explanation, for the encephalon must undergo a certain amount of pressure, if no time be allowed for it to adapt itself to a foreign body ; whereas any lesion coming on slowly enables the amount of blood in the vessels to be diminished according to circumstances, whereby pressure is avoided. (5.) The various lesions and injuries of the nervous system produce p)henomena similar in kind. — The injuries which may be inflicted on the nervous system, asAvell as the morbid appearances discovered after death, are various. For instance, there may be an extravasation of blood, exudation of lymph, a softening, a cancerous tumour, or tubercular deposit, and yet they give rise to the same nervous phenomena, and HEALTHY AND DISEASED INNERVATION. 121 are modified only by the circumstances formerly mentioned, of degree, seat suddenness, etc. Certain nervous phenomena also are of a parox- ysmal character, whilst the lesions supposed to occasion them are sta- tionary or slowly increasing. It follows, that the effects cannot be explained by the nature of the lesions, but by something which they all have in common; and this, it appears to me, may consist of— 1st, Pressure with or without organic change ; 2d, more or less destruction or disorganization of nervous texture. Further, wlien we consider that the same nervous symptoms arise from irregularities in the circulation ; from increased as well as diminished action ; sometimes when no appre- ciable change is found, as well as v^'hen disorganization has occurred — the theory of local congestions to explain functional alterations of the nervous centres seems to me the most consistent with known facts. That such local congestions do frequently occur during life, without leaving traces detectable after death, is certain ; whilst the occurrence of mole- cular changes, or other hypothetical conditions which have been sup- posed to exist, has never yet been shown to take place under any circumstances. While such appear to me to be some of the generalizations which are important to the physician with regard to the nutritive and nervous functions, viewed separately, it should never be forgotten that he has constantly to do with their conjoint action. Indeed, the derangement of one order of functions exercises a constant influence over the other, so that in every disease the effects of disordered nutrition are visiblein perverted innervation, and the converse. Thus an improper quantity or quality of food produces sometimes excitement, at others dulness of intellect. Various articles of diet have been known to cause violent headache, and different kinds of nervous phenomena ; while starvation, if long continued, excites delirium, paroxysms of mania, and lastly, stupor. In "children, derangement of the alimentary canal is the most common cause of spasm and convulsion, and in the aged it often leads to apo- plexies and palsy. Again, impeded respiration, poverty of the blood, accumulation of "^effete matters in the system, suppressed secretions and obstructed excretions, are all accompanied or followed by disorders of innervation. On the other hand, the influence of the nervous system on nutrition is equally apparent. Syncope and even death itself have been occasioned by mental emotions. Anxiety and suppressed grief predispose to diseases of the stomach, and thereby to altered nutrition, terminating in various maladies. The reception of joyful or distressing intelligence, it is well known, invigorates or depresses the bodily energies. Various organs are excited to action by particular trains of thought or desires, and the countenance is reddened by modesty, and blanched by fear. As a general rule, it may be said, while slight emotions increase the secre- tions, very violent ones, particularly if suppressed, completely suspend them, and are most dangerous to life.* Direct mechanical injury to the large nervous trunks, in addition to causing paralysis, is now recognised in some cases to produce increased heat and redness in parts, often fol- * " Give sorrow words ; the grief that will not speak, Whispers the o'erfraught heart, and bids it hveak."—Shaks2)eare. 122 PRINCIPLES OF MEDICINE. lowed by exudation and ulceration. In chronic cases, such paralysis leads to atrophy, and withering of a limb, or some other portion of "the body. Very rarely, injuiy of a great sympathetic trunk produces similar loss of nutrition without impairment of sensibility or motion, of Avhich the most remarkable example I am acquainted with is recorded by Pro- fessor Romberg of Berlin. It was that of an unmarried woman, ao-ed 28, in whom, as the result of extensive suppuration on the left side of the neck, which burst through the tonsil, the features on the correspond- ing side of the face gradually became atrophied, without any diminution Fig. 99. of sensibility or motion. Looking at the two halves of the face sepa- rately, it appeared as if the one belonged to a young, and the other to an old woman. By some it was supposed that the diseased side was sound, and that the other was swollen. The hair, eyebrows, and eye- lashes were very thin on the affected side, and she was in the habit of dividing her hair towards the right, so as to equalize the quantity. Every feature, including the brow, eye, nostril, lips, cheek, and chin, as well as the left half of the tongue and left palatine arch, was smaller than those on the opposite one,* Further illustrations of the general principles now detailed will be constantly met with under the head of special diseases. * Klinische Ergebnisse. Berlin, 18-16. Fig. 99. Remarkable atrophy of the left side of the face, in a woman aged 28, without loss of sensibility or motion in the affected parts. — (Romberg.) SIMPLE, CANCEROUS, AXD TUBERCULAR EXUDATIONS. 123 SIMPLE, CAXCEROUS, AXD TUBERCULAR EXUDATIONS— THEIR PATHOLOGY AXD GEXERAL TREATMEXT. Tliere are three varieties of exudation, which, occurring as they do in one or other of the textures, occasion the great majority of those diseases we are called upon to treat. A knowledge of the manner in which these are produced, of the characters of each, of their specific differences and natural progress, constitutes the foundation of modern medicine, I propose, then, in the first place, to describe them to you generally, and then to direct your attention to the special peculiarities which they present in individual cases. The term exudation has been introduced into pathology, not only to express the act of the liquor sanguinis passing through the walls of the blood-vessels, but also to denominate the coagulation of the fibrinous portion of the liquor sanguinis itself, upon the surface, or in the substance of any tissue or organ of tlie body. The use of this term removes a difficulty* which morbid anatomists have long experienced ; and hence it has of late years been extensively used to indicate various kinds of morbid deposits. Thus it has been applied to all those processes hitherto termed intiaramatorv, tubercular, and cancerous ; it may be associated with ever}- form of morbid growth ; it often gives rise to concretions, and frequently constitutes the soil in which grow those parasitic vegeta- tions or cryptogamic plants of a low type, which communicate essential characters to certain diseases. Under the head of exudation, indeed, considered as a morbid process, is comprised the greater part of organic, as distinguished from functional diseases ; of lesions of nutrition, as sepa- rated from lesions of innervation. I. Production of Exudatiox. Exudation is in every case preceded by a series of changes which have taken place in the capillary vessels, and in the blood contained in them. These changes, as we are enabled to follow them in the trans- parent parts of animals under the microscope, are seen to occur in the following oi'der : — 1st, The capillary vessels are narrowed, and the blood flows through them with greater rapidity. 2d, The same vessels become enlarged, and the current of blood is slower, although even. 3d, The * Of inflammation, Andral says. " created in the infancy of science, this expres- sion, altogether metaphorical, was destined to represent a morbid state, in wliich the parts appeared to bum, to be inflamed, etc. Received into general language without any precise idea having ever been attached to it, in the triple relation of symjrtoms wliich announce it, of the lesions which characterize it, and of its intimate nature, the expression inflammation is become so very vague, its interpretation is so very arbitrary, that it has really lost its value ; it is like an old coin without an impression, which ought to be removed from circulation, as it only causes error and confusion." On the other hand, exudation of the liquor sanguinis is a demonstra- tive fact, and gives rise to a definite idea. Hence, for all scientific and practical purposes, the expression '• exudation" may be substituted for that of inflammation. 124 PRINCIPLES OF MEDICINE. flow of blood becomes irregular. 4th, All motion of the blood ceases, and the vessel appears fully distended. 5th and lastly, The liquor san- guinis is exuded through the walls of the vessel ; and sometimes there is extravasation of blood corpuscles, owing to rupture of the capillaries. The first step in the process, viz., narrowing of the capillaries, is readily demonstrated on tlie application of acetic acid to the web of the frog's foot. If the acid be weak, the capillary contraction occurs more slowly and gradually. If it be very concentrated, the phenomenon is not observed, or it passes so quickly into complete stoppage of blood as to be imperceptible. Although we cannot see these changes in man under the microscope, certain facts indicate that the same phenomena occur. The operations of the mind, for instance, as fear and fright, and the appli- cation of cold, produce paleness of the skin, an effect which can only arise from contraction of the capillaries, and a diminution of the quantity of blood they contain. In the majority of instances, also, this paleness is succeeded by increased redness, the same result as follows from direct experiment on the web of the frog's foot, and which constitutes the second step of the process. In other cases, the redness may arise pri- marily from certain mental emotions, or from the application of heat ; and in both instances depends on the enlargement of the capillaries, and the greater quantity of blood which is thus admitted into them.* The variation in the size of the capillaries, and of the amount of blood in them, is conjoined with changes in the movement of that fluid. AVhilst the vessels are contracted, the blood may be seen to flow with increased velocity. After a time the blcod flows more and more slowly, without, however, the vessel being obstructed ; it then oscillates, that is, moves forwards and backwards, or makes a pause, which is evi- dently synchronous with the ventricular diastole of the heart. At length the vessel appears quite distended with yellow or coloured cor- puscles, and all movement ceases. Again, these changes in the movement of the blood induce variations in the relations which the blood corpuscles bear to each other, and to the walls of the vessel. In the natural circulation of the frog's foot, the yellow corpuscles may be seen rolling forward in the centre of the tube, a clear space being left on each side, which is filled only with liquor * It has been asserted that instead of contraction of the capillaries, the first changes observable are enlargement with an increased flow of blood. To determine positively the question of contraction or dilatation, I have recently made a series of careful observations on the web of a frog's foot. Having fixed the animal in such a way that it could not move, I carefully measured with Oberha^user's ej-e micro- meter the diameter of various vessels before, during, and after the application of stimuli. The results were, that immediately hot water was applied, a vessel that measured 13 spaces of the eye micrometer contracted to 10; another that measured 10 contracted to 7 ; a third that measured 7 contracted to 5 ; a fourth, which was a capillary carrying blood globules in single file, and measured 5, was contracted to 4 ; and another one of the smallest size which measured 4 was contracted to 3. "With regard to the ultimate capillaries, it was frequently observed that if filled with corpuscles, they contracted little, but if empty, the contraction took place from 4 to 2, so that no more corpuscles entered them, and they appeared obliterated. This was especially seen after the addition of acetic acid. It was also observed that minute vessels that contracted from 4 to 3, afterwards became dilated to 6 before congestion and stagnation occurred. The smaller veins were seen to contract as much as the arteries of the same size. PRODUCTIOX OF EXUDATION. 125 sanguinis and a few lymph corpuscles. There are evidently two cur- rents, one at the centre, which is very rapid, and one at the sides (in the lymph spaces, as they are called), much slower. The coloured cor- puscles are hurried forward in the centre of the vessel, occasionally mixed with some lymph corpuscles. These latter, however, may fre- quently be seen clinging to the sides of the vessel, or slowly proceeding a short distance along it in the lymph space, and then again stopping. Occasionally the lymph corpuscles get into the central torrent, whence they are carried off with great velocity, and accompany the yellow corpuscles. It has been said that these corpuscles augment in number, accumulate in the lymph spaces, and obstruct the flow of blood. In Fig. 100. young frogs their number is often very great ; but then they constitute a normal part of the blood, and in no way impede the circulation. In old frogs, on the other hand, all these, and subsequent changes, may be ob- Fig. 100. An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus ; the intermediate or capillary plexus run- niHg over them, and pigment cells of various sizes scattered over the whole. On the left of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has taken place. a, A deep-seated vein, partially out of focus. The current of blood is of a deeper colour, and not so rapid as that in the artery. It is running in the opposite direc- tion. The lymph space on each side, filled with slightly yellowish blood plasm, is very apparent, containing a number of colourless corpuscles, clinging to, or slowly movuig along, the sides of the vessel. 6, A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a reddish yellow broad streak, with lighter spaces at the sides. Opposite c, laceration of a capillary vessel has produced an extravasation of blood, which resembles a brownish-red spot. At fZ, congestion has occurred, and the blood corpuscles are apparently merged into one semi-transparent, reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only coats the vessel. 200 diam. 126 PRDfCIPLES OF MEDICIXE. served, without the presence of colourless corpuscles. When the capil- laries enlarge, however, the central coloured column in the smaller ves- sels maybe seen to enlarge also, and gradually approach the sides of the tube, thus encroaching on the lymph spaces. The slower the motion of the blood, the more the lymph spaces are encroached on, until at length the coloured corpuscles come in contact with the sides of the vessel, and are compressed and changed in form. The vessel is at length completely distended with coloured corpuscles, the original form of which can no longer be discovered, so that the tube appears to be filled with a homogeneous deep crimson fluid. This is congestion. If the morbid process continue, the vessel may burst, causing haemor- rhage, or the liquor sanguinis may transude through its walls, without rupture, into the surrounding texture. This last is exudation. II. Theory of Exudation. It is of the utmost importance in pathological inquiries to separate facts fi'om theories. Our facts may be correct, although the conclusions derived from them are wrong. This proposition, however generally admitted, is seldom adhered to in practice ; for, in medical writings and statements, we frequently find fact and hypothesis so mingled together, that it often requires considerable critical and anah*tical power to sepa- rate the one from the other. AVe are, however, in all cases, insensibly led to theorise — that is, to attempt an explanation of the phenomena observed, in order that we may derive from them some general principle for our guidance. Such speculation is always legitimate, so long as we consider opinions to be mere generalizations of known facts, and are ready to abandon them the moment other facts point them out to be erroneous. Tlie phenomena of exudation, previously described, may easily be demonstrated — they constitute the facts. Let us now examine how they have been attempted to be explained — in other w^ords, what is the theory. 1. The contraction and dilatation of the capillaries are explicable, by supposing them to be endowed with a power of contractility analogous to that existing in non-voluntary muscles. John Hunter thought they were muscular, from the results of his observations and experiments ; and they may be shown by the histologist to consist of a delicate mem- brane, in which permanent nuclei are imbedded. Mr. Lister has recent- ly shown that much of the contractility is dependent on fusiform cells, which have the property of shortening themselves, and which run trans- versely round the vessels. In structure, then, they possess elements closely resembling the muscular fibres of the intestine, and we know that, like them, they may be contracted or dilated by emotions of the mind (that is, through the nerves), or by local applications, that is di- rectly. The narrowing of these tubes, therefore, may be considered, as Cullen thought it was, analogous to spasm, while their dilatation may be referred either to the relaxation which follows such spasm, or to mus- cular paralysis. The recent observations of CI. Bernard and others as to the eftects produced by dividing the large nervous trunk of the sym- pathetic in the neck, have singularly confirmed this theory. THEORY OF EXUDATIOX, 127 2. The rapid and slow movement of the blood is explicable on the hydraulic principle, that when a certain quantity of fluid is driven for- ward with a certain force through a pervious tube, and the tube is nar- rowed or widened, while the propelling force remains the same, the fluid must necessarily flow quicker in the first case and slower in the second. It has been supposed, from the throbbing of large vessels leading to con- gested parts, that they pump a larger quantity of blood than usual into them. This was called " determination of blood " by the older patho- logists, and is now known not to be a cause, but a result, of the changes going on in the capillary vessels and tissues of the affected part. The oscillatory movement, seen later in the transparent parts of small ani- mals, has not been observed in man, and probably depends, in the former, on a weakened power of the heart. 3. It is the stoppage of the blood and exudation of the liquor sangui- nis, however, which it is most diflicult to explain ; for why, so long as there is no mechanical obstruction (and during thig process none has ever been seen) should the circulation through the capillaries of a part cease ? It has been endeavoured, indeed, of late years, to account for this stoppage by referring it to a mechanical obstruction, which is sup- posed to result from the formation of colourless corpuscles, which cling in large numbers to the sides of the capillaries, and so cause interruption of the stream. But this hypothesis is negatived by the following facts : — 1st, In young frogs, the vessels may be seen to be crowded witli colour- less corpuscles, while the circulation is in no way aftected. 2d, In old frogs, oscillation and gradual stoppage of the stream may be seen, without any colourless corpuscles being present. 3d. The colourless cor- puscles, as shown by Remak, are increased, after large venesections, in the horse, without ever causing active congestion,* And, 4th, In Leu- cocythemia all the vessels are crowded with colourless corpuscles, and yet no active congestion in these vessels, nor exudation of any kind, takes place. (See Leucocythemia.) We cannot ascribe the stoppage of the circulation in the capillaries to venous obstruction, or to mechanical pressure of any kind, because all observation proves that such causes, while they induce eft\ision of serum, never occasion exudation of liquor sanguinis. Neither can we suppose it to depend on endosmose, nor on a vis a tergo^ as such physical causes cannot be shewn to apply in all cases. We are compelled, there- fore, to attribute the vital force producing these changes, not to anything residing in the blood, or in the vessels, but to the tissues which lie out- side the vessels. That these do possess a power attractive and selective, whereby matters are drawn from the blood to carry on nutrition and secretion, is now generally admitted in physiology. A modification of this power, whereby the attractive property is augmented, and the selective one diminished, at least offers us an explanation consistent with all known facts, and seems to be the only active agency to Avhich we can ascribe the approach of the coloured particles to the capillary walls, and the passage through them of the exudation. * Diagnostische und Pathognetische Untersuchungen, &c., 1845. He also found that in man the colourless corpuscles of the blood were few iu number during inflam- mations, and were augmented during successive bleedings, so that he concluded the fewer there are of these the higher is the degree of inflammation. 128 PRINCIPLES OF MEDICINE. AMien the liquor sanguinis is exuded, it generally coagulates, and con- stitutes a foreign body in the texture of the parts affected ; and then it becomes the object of nature either to remove it from the system, or so to modify it that its presence may be rendered conducive to the wants of the economy. In order to accomplish this, two kinds of changes take place in it — 1st, The exudation serves as a blastema, in which new vital structures originate and are developed ; 2d, It exhibits no power of becoming organised, and the exuded matters, together with the textures involved in them, die. In the first case, corpuscles spring up in the exu- dation, which differ in form, size, constitution, and power of further deve- lopment, and give rise to these various appearances and changes which, in some cases, have been denominated the results of inflammation, iu others, various kinds of deposits. In the second case, death of the exu- dation takes place — slowly, constituting ulceration ; or rapidly, producing gangrene. III. Vital Transformations of the Exudation. "We find that the peculiar constitution of the blood, or the general vital power of the organism, exercises a very powerful influence on the development of the exudation. This has been long recognised by patho- logists in certain conditions, denominated respectively diathesis, dj'scrasia, or cachexia. I propose at present to direct your attention to some of the facts connected with exudation as it occurs in the body during health, as well as when connected with cancerous and scrofulous consti- tutions. I shall call the former simple exudation, to distinguish it from what may be denominated cancerous and tuboxulur exudation. Simple Exudation. Simple exudation presents four principal forms — 1, As it occurs on serous membranes, where it exhibits a finely fibrous structure, and has a strong tendency to be developed into molecular fibres ; 2, As it occurs on mucous membranes, or in areolar tissue, where it is generally converted into pus corpuscles ; 3, When it occurs in dense parenchymatous organs, such as the brain, where it assumes a granular form, and is associated with numerous compound gra- nular corpuscles ; 4, As it is poured out after wounds or injuries, and occurs on granulating sores. In this last case the superficial por- tion is transformed into pus corpuscles, while the deeper seated is converted, by means of nuclei and cells, into nucleus and '^' ^^ ■ cell fibres, which ultimately form the cicatrix. 1. On examining the minute structure of the exudation on a serous Fig. 101. Molecular fibres and plastic corpuscles, in simple exudation on a serous surface, a, The latter after the addition of acetic acid. 250 diam. VITAL TRANSFORMATIONS OF THE EXUDATION. 129 surfacG when recently formed, and when it presents a gelatinous semi- transparent appearance, it will be found to be made up of minute fila- ments mingled with corpuscles (Fig. 101). The filaments are not the result of the development of either a nucleus or a cell, but are formed by the simple precipitation of molecules, which arrange themselves in a linear manner, in the same way as they may be seen to form in the bufty coat of the blood. As the exudation becomes firm, the filaments appear more distinct and consolidated, varying from y^io gth to --i_^th of an inch in diameter. Bundles, or difterent layers of them, often cross each other; and as the lymph becomes older, they assume more and more the character of those in dense fibrous tissue. The corpuscles, when newly formed, are delicate and trans- parent, but in a short time become more distinct, and are then seen to be composed of a distinct cell-wall, enclosing from three to eight granules. They vary in size from yaVot^i to ToVot'i, and the enclosed granules from y^-io o^^^ to joio o^h of an inch in diameter. On the addition of water and acetic acid, the corpuscles undergo no change, although sometimes the latter re-agent causes the cell-wall to contract and thicken ; and at others, to be somewhat more transparent. In 1842, I separated these bodies from pus cells, and called them plastic corpuscles, from the frequency of their occurrence in plastic lymph. Lebert, in 1845, confirmed my description, and called iham 2)yoid, from their resemblance to pus. These corpuscles after a time melt away among the fibres, but seve- ral of them remain, constituting, as shown \y Dr. Drummond, perma- nent nuclei. After a time, blood-vessels grow in the exuded lymph 3- ' ■ ii«iii Y\:.'^^ -''H ^iSli Fig. 102. Fig. 103. Fig. 104. Fig. 105. Fig. 106. (see Vascular Growths), the surface of which becomes villous. Into the villi loops of vessels penetrate, and by these the fluid, contained in the interior of shut sacs, is absorbed. The fluid thus gradually diminishes, and, when the villous surfaces are brought into contact, they unite, and ultimately form the dense chronic adhesions so common between serous membranes. 2. Exudation poured out on a mucous membrane sometimes presents a fibrous mass, as in cases of croup and diphtheritis, but more gene- rally it passes into an opaque, unctuous, straw-coloured fluid, long known Fig. 103. A portion of recent Ij'mph from the pleura. Fig. 103. Another portion of the same, further developed. Fig. 104. Portion of firm pleural adhesion. Fig. 105. Another portion of the same, further developed. Fio-. 106. The last acted on by acetic acid. — {Drummond.) 180 dmm. 9 130 PRIXCIPLES OF MEDICINE. under the name of pus. "When poured into the meshes of areolar tissue, and occasionally into the substance of the brain, the same trans- formation occurs, and then forms an abscess. On examining the minute structure of pus, it is seen to be composed of numerous corpus- cles floating in a clear fluid. These corpuscles are perfectly globular in form, and vary in size from the g^oVo't'i to the y aVo^li ^^ 'I'l "^ch in diameter. Their surface is finely granular. They have a regular well- defined edge, and roll freely in the liquor puris upon each other. On the addition of water, they become much f^,^ A-^v i'pj^fS^! increased in size and more transparent, their ,Vf'"N^ ^^l^ '^^'^ finely granular surface disappearing. Weak '^^J^^ ^^^\' ^P%\'-^'-'-'' acetic acid partially, and the strong acid £0^^f^ ' ■■-'U^^ completely, dissolves the cell-wall, and brings n^* >ii- ■- jiito view an included body, generally com- Fig. loT. Fig. 108. poscd of two or three granules close toge- ther, and rarely four or five, each with a central shadowed spot. These are usually about the g oVo^li of an inch in diameter. (Figs. 107, 108, also Figs. '39, 40.) In some cases the pus corpuscles now described are surrounded by an albuminous layer closely resembling a delicate cell-wall (Fig. 41), which I first described in 1847. It is about the toVot^ or g^gth of an inch in diameter, and is highly elastic, assuming different shapes, according to the degree and direction of the pressure to which it is subjected. Water and acetic acid cause it at once to dissolve, whilst the included pus corpuscle exhibits the usual body composed of two or three granules. In what is called scrofulous pus, the corpuscles, instead of being round and rolling freely on each other, are misshapen and irregular .--7-,. „ _ (Fig. 42), and, on the addition of acetic acid, ;0\K<^^) '"-■'' ^'^ ■r^! the granular nuclei are found to be ill- ^y^\^ ('^^/p ^^ formed or absent (Figs. 109, 110). -^'''^■^'^'^^) y?'i /^i -P^^* cells, if not evacuated externally, ulti- '-^' '^ Vi°>^ ''^^ mately dissolve, their walls disappear, the Fig. 109. Fig. 110. included nuclei and granules separate, and are converted into a fluid. This passes into the blood, increases for a time its effete constituents, but is at length excreted by the emunctories. Meanwhile the original abscess, or collection of matter, is said to be resolved. 3. In parenchymatous organs, the exudation insinuates itself among the elementary tissues of which they are composed, so that, when it coagulates, these are imprisoned in a solid plasma, like stones in the mortar of a rough cast wall ; thus constituting a firm mass, and giving increased density to certain organs. This is Avell observed in the lung, where, however, a mucous surface extensively prevails, and where the exudation is commonly transformed into pus. In the brain, spinal cord, and placenta, we find the exudation deposited in the fonn of minute molecules and granules, which are frequently seen coating the Fig. 107. Pus cells. Four cells have been acted on by acetic acid. Fig. 108. Pus cells containing fatty molecules, after adding acetic acid. 250 di. Fig. 109. Scrofulous pus cells after the addition of acetic acid. Fig. 110. The same. In both specimens the nuclei are irregular or absent. VITAL TRANSFORMATIONS OF THE EXUDATION. 131 the 6 oVo^'^ *^^' ^^ ^'^*^^^ vessels externally, and filling up the intervascular spaces (Fig. Ill) The granules var}^ in size from the ja.oo o^^i to in diameter. They always contain among them round transparent globules, varying in size from the 5 oVo^^i to -soVot^ ^^ ^^ inch in diameter. These are the nuclei of round or oval cells which may frequently be observed in various stages of develop- ^j ment. When fully formed, the cells vary ff? greatly in size, for the most part measur- ing from the yoVo'th to the 7 jo^th of an inch in diameter. They sometimes con- tain a few oil granules only, at others they are so completely filled with them as to assume a brownish-black appearance. Water and acetic acid cause no change in them, although the latter re-agent, on some occasions, renders the cell- walls more transparent. They are readily soluble in a;ther, and break down into a mole- cular mass on the addition of potash and am- monia. These are granule cells (Fig. 112). Masses of these granules may be occasionally seen floating about, of ii-regular shape, without any cell-wall. They are produced either by the solution of the cell-wall in which they are contained, or from the separation, or peeling off of such masses from the external wall of the vessels; and form granular masses (Fig. 112 a). these granules to coalesce, or the oil to be forced through the cell-wall. Occasionally also the cell-wall is ruptured. The granules, masses, and cells just described are found in the colos- trum secreted by the mammary glands ; in the exudative softening of parenchymatous organs ; on the surface of granulations and pj^ogenic membranes ; in the pus of chronic abscesses ; combined with cancerous, tubercular, and all other forms of exudation; in the tubes of the kidney when affected with Bright's disease ; and in the contents of encysted tumours. In fact, there is no form of cell-growth, whether healthy or morbid, that may not, under certain conditions, accumulate oil or fatty granules in its interior, become a compound granular corpuscle, and thus be rendered abortive. The granule cells in an exudation, however, are the results of a vital transformation of that exudation, and not of a mere fatty degeneration of the vessels, as some have supposed. In some instances I have seen them in all stages of development coating the blood-vessels, as in Fig. 113. That softening from the formation of granules and granular cells may occasionally disappear, and the new structures be absorbed, is rendered probable by the history of several well-recorded cases; but the changes Fig. 112. Pressure causes Fig. 111. Granular exudation and granular masses, from cerebral softening. 250 di. Fig. 112. Granular cells and masses from cerebral softening. « 132 PEINCIPLES OF MEDICINE. thereby produced, especially in nervous textures, have not hitherto been made the subject of special investigation. 4. If a recently-formed granulation on the surface of a healing sore be examined, nume- rous cells will be observed, of various shapes, and in different stages of development. Some are round, others caudate, spindle-shaped, elon- gated, or splitting into fibres, as originally described by Schwann (Fig. 114). In many cases there may be seen a number of free nuclei, imbedded in a slightly fibrous blastema, elongating at both ends, becoming fusiform, and splitting up the surrounding exudation, as de- scribed by Henle. Not unfrequently the nuclei may be seen developing themselves into elastic fibres, in the same exudation which contains cells that are passing into white fibres. Indeed, the process of cicatrization in its various stages, and in different tissues, offers the best means of studying the manner in which nucleus and cell fibres are respectively formed. As these fibres - ii"^- are developed in the deeper layers of the exuda- tion, a villous vascular basis is formed, and the superficial pus-corpus- I .s,- un- cles, after having served to protect the more permanent growths, are thrown off in the form of discharge. When the fibrous structiire becomes more consistent and dense, the amount of pus diminishes, and a greater tendency is manifested by the exudation to pass into per- manent tissue. At length pus ceases to be developed ; the whole re- Fig. 113. Two vessels coated with exudation from softening of the spinal cord. Granular cells may be seen forming in it. 250 diam. Fig. 114. Vertical section of a granulating sore. Externally, pus corpuscles, deeper, fibre cells in various stages of development into fibre. The looped blood- vessels are seen enlarged at their extremities, magnified 100 diameters linear. On the left, the cells are magnified 250 diameters linear. CANCEROUS EXUDATION". 133 maining exudatioB is transformed into fibres ; a new surface is produced, ■which, after a time, contracts and forms the permanent cicatrix. Cancerous Exudation. Cancerous exudation presents three principal forms, which result from the relative amount and arrangement of the cells and fibres forming it. 1, A very hard structure, principally formed of fibres ( scirrhus). 2, A soft structure containing a copious milky fluid, in which numerous corpuscles swim ( encephaloma). 3, A structure having a fibrous basis, so arranged as to form areolse or loculi, which contain a gelatinous gum or glue-like matter (colloid cancer). 1. Scirrhus presents to the naked eye a whitish or slightly yellowish tinge ; is dense and hard to the feel, and oflers considerable resistance Fig. 116. Fig. 117. F-. i.-. to, and often crunches under, the knife. On making a thin section of the growth, it is seen to be principally composed of filaments, which vary in size, and run in different directions, sometimes forming waved bands, at others an inextricable plexus, among which, however, nucleated cells (cancer cells) may be seen to be infiltrated. Occasionally the fibrous structure forms loculi or cysts, enclosino- similar cells. The so-called cancer-cells may be round, oval, caudate, spindle-shaped, oblong, square, heart-shaped, or of various indescribable forms, produced by pressure on their sides. In size they vary from the ToVot^i to the ^j-L^th of an inch in diameter. The cell-wall, when young, is smooth and distended ; when old, it is more or less corrugated and flaccid. Each cell contains at least one nucleus, often two, and sometimes as Fig. 115. Section showing the arrangement of cells and fibres in scirrhus of the mamma Fig. 116. The same, after the addition of acetic acid. Fig. 117. Isolated cancer-cells, from the same growth. Fig. 118. The same, after the addition of acetic acid. 250 diam. * 134 PEIXCIPLES OF MEDICINE. many as nine. Most commonly there is only one, wliicli is round, or more generally oval, and contains one or two granules or nucleoli. The nucleus also varies in size, and may occupy from one-sixth to four-fifths - r R r?\ Fig. 119. Fig. 120. Fig. 121. Fig. 122. of the volume of the cell. Between the nucleus and cell-wall there is a colourless fluid, which, at first transparent, becomes afterwards opalescent, from the presence of molecules and granules. On the addition of water, the cell-wall becomes distended by endosmose, and is enlarged. "When acetic acid is added, the cell-wall is rendered more transparent, and in young cells is entirely dissolved (Fig. 120), whilst the nucleus, on the other hand, either remains unafl:ected, or its margin becomes thicker, and its substance more or less contracted. 2. Uncephaloma also presents a fibrous texture, which, however, is very loose when compared with that of scirrhus. In the denser parts of the growth, indeed, it closely resembles the scirrhus form of cancer, but often where it is pulpy and broken down, no traces of fibres, or at most only some fragments of them, are visible to the naked eve. The whitish cut surface is often more or less mottled,* with a pinkish, ■m '■ . A' ' ^ i^^f-: Fig. 123. Fig. 124. Fig. 125. reddish, greyish, yellowish, or black colour. The two first colours are owing to different degrees of vascularity. The reddish spots are owing to extravasations of blood, and are of greater or less extent ; when very Fig. 119. Young cancer-cells from the lung. Fig. 120. The same, after the addition of acetic acid. Fig. 121. Somewhat older cells from the testicle. Fig. 122. The same, after the addition of acetic acid. Fig. 123. Still older cancer-ceUs from a tumour in the duodeniun. Fig. 124. The same, after the addition of acetic acid. Fig. 125. Highest development of cancer-cells, mcluding secondary cells, from a tumour of the toe. 250 diam. CANCEROUS EXUDATION. 135 '~y'f larcje tliev constitute what has been called /'^Hr/us hcematodes. The yel- lowish colour, when it surrounds extravasations of blood, is owinor to imbibition of its colouring matter ; but when the colour is spread in a reticulated form over the surface, or over the masses, it generally results from fatty degeneration of the cancerous tissue, and forms the so-called reticulum {cancer retkulare of MiiUer). This yellow matter is usually of cheese-like consistence, friable, and often resembles tubercle, for which it has been mistaken. The blackish tinge is owing to black pigment infil- trated among the cancerous elements, or existing within the cells, and con- stitutes the malignant mela- nosis, or raelanic cancer, of " @*'1^ """^ authors. (See Fatty and Pig- j^^^sF^\ mentary Degenerations.) A small portion of the cream-like fluid obtained from cancer-masses, when examined with a microscope presents a large number of the cancer cells formerly described ; in some speci- mens of encephaloraa these cells reach a higher degree of development than in N^j^ - -rl_ other forms of cancerous ••.""<_" - ^ _j^^ growth (Figs. 125, 126). '" -•■^^:^^:5-.;;>r4T^;rv^c;v^: -^ "^ They are mingled with a large number of molecules ^'e- 126. and granules, granular cells, blood corpuscles, and more or less of the fibrous element. The fibrous structure is the same as that in scirrhus, but the filaments are often finer, and always more widely sepa- rated, while the pulpy matter and cells, contained in the in- terstices, are correspondingly in- creased. The yellow reticulum is sometimes composed of loose granules and granular cells, at others of granules alone. Xot unfrequently it contains nuclei, disintegrated and altered in shape with crystals of margarine or of cholesterine. In some instances the encephaloma is more or less impregnated with irregular masses of mineral mat- ter, and occasionally is almost entirely converted into a calcareous sub- Fig. 126. Simple and compound cancer-cells from the duodenum. — Several contain fluid from endosmose. which strongly refracts light. Fig. 127. Colloid tissue, with the loeuli tilled with molecular matter, in which cells are commencing to form. On the left of the figure, one of the molecular masses has been squeezed from the fibrous matrLs. Below ai'e masses of mineral matter. 250 diam. O®'^ pV^ ^^<& 136 PRINCIPLES OF MEDICINE. stance. In this way cancer is liable to undergo the fatty and calcareous degenerations. (See Fatty and Mineral Degenerations.) 3. Colloid cancer consists of a fibrous structure so arranged as to form areolae or loculi, which are filled with a gTey or amber-coloured glutinous matter, sometimes transparent, at others opalescent or semi- opaque. This matter is occasionally found quite structureless, or exhibits ouly a finely molecular appearance (Fig. 127) ; and in consequence the term colloid tissue has been applied to it. At other times nu- merous nucleated cells, presenting all the characters of cancer-cells, in Fig. 128. Tig. 131. A, .■-^■•>. \ . ><< Fig. 129. various stages of development, are found in it as a blastema ; and Ave observe that the growth has a tendency to spread. In this colloid can- cer, when it is formed on a free surface, as on the peritoneum, there are often present small grains of a grey colour, resembling coagulated gum- arabic. When collected in masses, these grains have an iiTCgularly nodulated aspect. I have never seen the fibrous structure of colloid con- tain permanent nuclei, or atford any evidence of being developed from nuclei or cells. All the three forms of cancer now described are vascular, but in differ- ent degrees. Scirrhus is least so, but is still rich in blood-vessels. En- cephaloma is alwavs very vascular, and often to such a degree, that it readily bleeds during life (furu/us hcEmatodes). Colloid cancer is also Avell supplied with vessels, which ramify among the fibrous tissue. I have already stated that these forms pass into each other, and need only Fig. 128. Colloid cancer. Appearance of the fibrous areolae filled with cancer- cells. Fig. 129. The same, after the addition of acetic acid. Fig. 130. Some of the cells isolated. Fig. 131. Fibrous stroma deprived of the cells by pressure and washing. 250 diam. TUBERCULAR EXUDATION. 137 remark here, tliat this is often so gradual in many specimens, as to ren- der their classitication very difficult. This is especially the case Avith scirrhus and encephaloma. Tubercular Exudation. Tubercular exudation has been spoken of as presenting itself under a miliary, infiltrated, or encysted form ; those distinctions, however, have no reference to structure, but merely to the extent and age of the exuda- tion. It generally presents a yellowish or dii'ty-white colour, and varies in consistence from a substance resembling tough cheese to that of cream. m n^^ ^A v\-(P.-}^. .0 -..yi:':'. ft Flsr. 132. Fie It^ Sometimes it is soft at one place, and indurated at another. On section, Avhen tough, it presents a smooth or waxy, and Avhen soft, a slightly granular surface. On pressure it is friable, and ma}' break down into a pulpy matter, but never yields a milky juice. A small portion squeezed between glasses, and examined under the Fiar. 135. Fig. 132. Corpuscles from firm tubercular exudation into the lung, a, After the addition of acetic acid. Fig. 133. Corpuscles, granules, and debris, from soft tubercular exudation into the lung. Fig. 134. The same, from tubercular infiltration of a mesenteric gland. Fig. 135. Section of a grey granulation in the lung, showing the pulmonary vesi- cles filled with tubercle corpuscles. Fig. 136. Section of a firm mihary tubercle of the lung. 250 diam. ^ 138 PRINCIPLES OF MEDICINE. microscope, presents a number of irregularly shaped bodies approaching a round, oval, or triangular form, varying in their longest diameters from the ? oVot'i to yTrVot^^ of an inch. These bodies contain from one to seven granules, are unaffected by water, but rendered very transparent by acetic acid. They are what have been called tubercle-corpuscles. They are always mingled with a multitude of molecules and granules, which are more numerous the softer the tubercle. Occasionally, when softened tubercle resembles pus, constituting scrofulous purulent matter, we find the corpuscles more rounded, and approaching the character of pus cells (Fig. 42). They do not always, however, on the addition of acetic acid, exhibit the peculiar granular nuclei of pus-cells (Figs. 10*7, 108). The grey granulations described by Bayle may be seen, on careful management of the light, and after the addition of acetic acid, to con- tain similar bodies to those described as tubercle corpuscles, being close- ly aggregated together, having indistinct edges, and containing few granules. Cretaceous and calcareous tubercles, on the other hand, contain very few corpuscles, their substance being principally made up of numerous irregular masses of phosphate of lime, and a greater or less number of crystals of cholesterine. (See Mineral Degeneration.) Tubercle corpuscles may be associated with pus and granular cells, as well as with cells peculiar to glandular organs or mucous surfaces in vari- ous stages of fatty transformation and disintegration. AYith all these they have frequently been confounded. TV. PATnOLOGT OF THE ThREE KiNDS OF ExUDATIOX. We have seen that the liquor sanguinis transudes through the coats of the capillaries, and, coagulating outside the vessels, constitutes an exudation more or less solid. Much of the serum, which accompanied it, is rapidly absorbed, but what remains constitutes a blastema, which becomes organised in the various ways described, according to the seat and nature of the exuded matter. In simple exudation we find diff"er- ences according as it is poured out on a serous, mucous, or granulating surface, or into a dense parenchyma. These diflferences are dependent on the seat of the exudation. But in cancerous or tubercular exudations, we observe no such distinctions, although it has been observed that fibrous cancer or scirrhus is most common in fibrous organs, and cell cancer or enccphaloma is most common in cellular organs. The more important characters of the three kinds of exudation may be shortly stated as follows : — A simple or inflammatory exudation may occur at all epochs in life ; it may attack all tissues, and is most commonly found in those which are very vascular; it may be poured out in large or small quantities, and with greater or less rapidity — whence the terms acute and chi'onic. Further, acute exudations are generally attended with symptoms of a peculiar character (inflammatory), and have a great tendency to cell or temporary formations, which rapidly breaking down, are absorbed and excreted by the emuuctories. Chronic simple exudations, on the other PATHOLOGY OF THE THREE KINDS OF EXUDATION. 139 laand, have a tendency to fibrous or permanent formations, producing adhesions, strictures, indurations, etc. Cancerous exudation occurs for the most part in persons of adult or advanced life ; it may also attack every tissue, but is by far most common in ijlandalar or fatty organs, such as the liver or female mamma, and is verv apt to occur in the lymphatic glands secondarily ; its progress, although sometimes slow when very fibrous, becomes rapid when cor- puscles abound in it ; there is in it a great tendency to the formation of the most perfect forms of cell life, having the power of self-development, and thereby of spreading to neighbouring tissues ; and lastly, when, by pressure, ulceration is produced on free surfaces, it bursts through them in exuberant fungoid excrescences (Fig. 27.3). Tubercular exudation occurs for the most part in young subjects, between the periods of dentition and of adult age ; it may occur in all tissues, but is by far most common primarihj in the lymphatic glands, and afterwards in fibrous or albuminous textures, as the lungs and serous surfaces ; its progress is in general exceedingly slow ; there is no dispo- sition in it to the formation of perfect cell-formation, but abortive cor- puscles are formed in it slowly, and slowly break down ; there is little tendency in it to absoi'ption, but great liability to disintegration and ulceration ; and finally the local changes which it occasions are almost always preceded by derangement of the primse vice, and a group of symptoms known under the name of dyspepsia. Taking, then, the products of simple exudation (say pus) as a standard, we may remark, that whilst the cell-development of tubercle is below, that of cancer is above, this standard. Of the three kinds of exudation, tubercle is the lowest, and cancer the highest, in the scale. Of the ultimate cause producing this difterence in the formative power of the exudation we are ignorant, but legitimate reasoning leads us to the conclusion, that these changes and effects depend, not upon the vas- cular system, which is the mere apparatus for the production of exuda- tion ; nor upon the nervous system, which conducts impressions to or from this apparatus; and not on the texture, which is the seat of the exudation, as that varies whilst the cancerous or tubercular fonnation is the same — but upon the inherent composition or constitution of the exudation itself. On this point most pathologists are agreed, and hence the supposed existence of various kinds of dyscrasise, which originate in the blood, and as it is imagined, explain the difterent results produced. And here pathologists pause — having traced the disease back to the blood, they are content ; but they have not sufficiently taken into con- sideration, that the blood itself is dependent for its constitution on the results of the primary digestion in the alimentary canal on the one hand, and the secondary digestion in the tissues on the other. Yet it must be evident to every physiologist, that if it be the constitution of the blood which determines the constitution of the exudation, the causes which produce the latter must be sought in those circumstances which operate on the composition of the former fluid. Xumerous facts render it probable, that while the blood is normal in simple exudation, it contains an excess of nutritive materials in cancer- ous, and a deficiency of them in tubercular, exudation ; but these are points which can only be established after examining instances of such 1-iO PRINCIPLES OF MEDICINE. exudations in detail. But it must not be forgotten, however, that as the blood is continually undergoing changes, and is receiving and giving off new matters, it can scarcely remain the same for many'hours together. An exudation at one time may be very diflferent from what it was at another ; abounding in elements at one period which do not exist in it at the next. Hence, therefore, it may often happen that a concurrence of circumstances is necessary to occasion a certain result. A cancer once formed, may remain local until such a concurrence of events arises, comprising, iirst, the phenomena leading to and producing an exudation ; secondly, the occurrence of this exudation in some other tissue or organ sufficiently predisposed for the purpose ; and thirdly, a peculiar consti- tution of the blood. Hence the histologist continually finds many varieties of intermediate formations between the three leading kinds of exudation ; and even when the constitution is thoroughlj- cancerous or tubercular, simple exudations may be poured into tissues as the result of recent wounds or injuries. But, whilst a recent cancerous or a tuber- cular exudation may be found to accompany or alternate with a simple exudation, the two former are seldom nict with together — a circumstance Tvhich still further points out the wide difference between the constitu- tional causes producing them. The termination of all kinds of exudation may be the same, but each has its peculiarities. We have noticed the tendencies of simple exuda- tion to be transformed into pus or fibres, according to its seat. In the one case, the pus cells break down, and are re-absorbed in a disintegrated and fluid condition into the blood ; in the other, permanent fibrous tis- sue is produced, constituting chronic adhesions or cicatrices. The cells of a cancerous growth may also degenerate or decay, but this rarely takes place throughout the whole structure. But it is not uncommon to find in certain encephalomatous tumours, yellow matter eitlier in masses or reticulated through its substance — {Cancer Heticulare of Mailer). This is generally owing to fatty degeneration of the cancer cells. (See Fatty Degeneration.) The fibrous structure of cancer may also increase, so as occasionally to produce cicatrization. Tubercle pos- sesses no such fibrous stroma, but is infiltrated among the elements of various organs, the vascularity of which it tends to destroy. This, indeed, is the reason why a cancerous tumour increases by growth, which tubercle cannot be said to do ; the former is vascular, the latter is not : in the one, cells are formed which have the power of re-development ; in the other, no reproductive cells are produced. In cancer, the morbid matter, whatever it be, circulating in the blood, is concentrated or attracted to the cancerous part ; and even should no such matter be present, the healthy blood is made subservient to the purpose of nou- rishing a foreign growth. In tubercle, successive fresh exudations only occur, which, by their accumulation, augment the volume or amount of the morbid product. All three forms of exudation may be rendered abortive, the animal matter of them being broken down and absorbed, while the mineral matter remains, constituting a cretaceous or calcareous concretion. This is not unfrequently seen as the result of simple exudation ; it rarely hap- pens in cancerous, but is very common in tubercular exudations. During the disintegration of simple, cancerous, and tubercular exuda- DEATH OF THE EXUDATION. 141 tions, the animal matter broken down is again rendered fluid, repasses into the blood, and then constitutes that excess of fibrin detected by chemists. (See p. 103.) The quantity of this will, of course, vary according to the amount of the exudation and the activity of the disin- tegrating process. In the blood this etfete matter undergoes a series of chemical changes, preparatory to its excretion by the different emunc- tories, especially by the kidneys, in the form of various sediments. The resolution of simple exudation is generally accompanied by the presence of urinary sediments, whose nature indicates in what way the exudation, after it has passed through the phases of development described, is at length discharged from the body. In the same manner the amount of these sediments frequently points out the extent of absorption going on in cancerous and tubercular exudations. Another theory has been advanced regarding the various products of exudation as we have described them, viz., that instead of being new formations in an exuded blood plasma, they are only modifications of pre-existing texture. According to this view, pus cells are only altered epithelial ones, cancer cells are an increased development, and tubercle corpuscles are a degeneration or " necrosis," of gland or other cells. The fallacy of this theory, though it has many facts which seem to give it support, is easily demonstrated. For instance, pus cells may occur in tissues where there are no epithelial cells, as among muscles ; and can- cer, pus and tubercle are all found in the white substance of the brain, where no cells have been demonstrated to exist, capable of increasing on the one hand or deo-eneratincr on the other. T. Death of the Exudation-. The exudation, instead of passing through the vital transformations we have previously described, may die, and in two ways — 1st, Rapidly — constituting what has been called Mortification or Moist Gangrene ; and, 2d, Slowly — causing gradual disintegration and loss of texture, and thereby forming what has been denominated ulceration. Mortification or Moist Gangrene. Occasionally a very large amount of blood plasma is thrown out ; a greater or smaller number of capillaries are also ruptured, and blood corpuscles more or less mixed up with the liquor sam/uinis exuded. The exudation thus formed compresses the part into which it is thrown out, paralyses the nerves, obstructs the blood-vessels, and arrests the circula- tion in them. Under these circumstances, instead of forming a blastema for the production of new structures, it undergoes chemical changes, whereby decomposition is induced, and then the part is said to be mor- tified, or to be affected with moist gangrene. This change commences first in the blood extravasated, which becomes of a purple colour more or less deep ; the corpuscles break down and become disintegrated ; their hsematozine dissolves and colonic the serum ; and, should the exudation have coagulated, it forms brown, rust-coloured, purple, or blackish masses. An acid matter is now formed, which, acting on the 142 PRINCIPLES OF MEDICINE. neighbouring tissues, produces fcetid gases, that are abundantly given off from the atfected part. Sulphuretted hydrogen is evolved, which causes the blackish sloughs usually ol:)served in such cases, and disco- . lours silver probes and the preparations of lead. After a time, the ele- mentary tissues surrounding or involved in the exudation, become more or less atfected. The transverse stria3 in the fasciculi of voluntary muscles first become pale, and are then obliterated. Celhilar tissue, fat, and other soft substances lose their connection, and fall into an undefined granular mass. The tendons and fibrous tissues retain their characteristic structure for a long time after the other soft parts have been reduced to a softened pulp. The bones resist the action longest, Fig. 137. but at length, commencing externally, they become rougli, soft, and are more and more broken down, and reduced to the same pulpy consistence and granular structure as the surrounding parts. As the tissues thus become broken down and fluid, they are dis- charged from the system in the form of an ichorous matter, which, examined microscopically, presents numerous granules, imperfect or broken dow"n cells, blood corpuscles, and fragments of filamentous tissue or of the other structures involved. If the morbid action be seated in the subcutaneous tissue, the skin soon becomes aft'ected ; and an open- ing is formed, which rapidly enlarges, and gives vent to the discharge. In a similar manner, gangrene of internal organs, by destroying the intermediate parts, at length enables the fluid to reach the surface, or to find its way into the excretory passages, such as tlie bronchi, the intes- tinal canal, the meatus auditorius, etc. In this manner, life may be endangered, by the destruction of organs necessary for its continuance ; by the exhaustion resulting from the discharge ; and sometimes by the absorption of the ichorous matter, which, entering the circulation, acts as a poison to the economy. On the other hand, a favourable termina- tion may take place, either by the dead substance breaking down, and being evacuated externally, or by its being separated en masHe in the form of a slough. In such case a process of regeneration and healing may be set up in the exposed living texture, which may produce a cica- trix in the manner formerly spoken of. It may be asked, whether mortification is the result merely of a greater amount of the exudation ? or whether it is dependent besides on other circumstances, such as a peculiar state of the atmosphere, which favours Fig. 137. Moist gangrene, following compound fracture — all the injured parts infiltrated with exudation, which has died and mortified. — Llston. MORTIFICATION. 1^3 tlie decomposition of the exudation poured out ? In order to answer these questions, we must distinguish between ordinary mortification arising from a variety of circumstances, and moist gangrene properly so called^ which is undoubtedly the rarest of all the terminations of exuda- tion. ' Mortification may be produced by the application of chemical or mechanical agents, which directly destroy the tissues. It also often arises through" severe and complicated injuries, in which arteries leading to the portions of structure aft'ected have been divided or crushed. In old persons it follows obstruction in the blood-vessels, or is dependent on circumstances not yet ascertained. In none of these cases is it a result of exudation. But when stasis of the capillaries is produced to a considerable extent, followed by the exudation of a large quantity of blood-plasma, which, instead of passing into organization, undergoes the changes previously described, then moist gangrene, properly so called, is produced. We sec this take place after burns, after long exposure to frost, and in certain cases of erysipelas. Here the amount of exudation is considerable, the pressure caused by it extreme, the obstruction to the circulation in the neighbouring parts correspondingly great, so that these, as well as the exudation itself, is destroyed. In this sense, there- fore, it may be said to depend on the rapidity and amount of the exuda- tion ; but not in the sense of those, who consider adhesion, suppuration, and gangrene as different stages of one process. Suppuration, as w^e now know, has no connection with adhesion ; it is opposed to it ; nor is it in any way related to mortification, which must be considered as a primary alteration of the exudation. In mortification the vitality of the exudation is lost, and instead of passing into organization, it becomes subject to the chemical laws of dead matter, and undergoes putrefaction. Now^, in order that organic substances may enter rapidly into putre- faction, it is necessary that they find sufficient oxygen and water for all their carbon to be transformed into carbonic acid, all their hydrogen into water, and all their azote into ammonia. When these conditions are not completely fulfilled, transition or intermediate substances are formed. If there is not sufficient oxygen, for instance, an excess of car- bon is produced in the debris. There is also often developed a species of destruction by contact, which causes parts undergoing decomposition to excite it in neighbouring ones (eremacausis of Liebig) ; which does not take place in dry gangrene. A gangrenous stomatitis [Cancrum Fig. 138. Dry gangrene from debility — being death of the pre-existing tissues, unconnected with exudation. — Liston. 144 PEIXCIPLES OF MEDICINE. oris) will tlius destroy, in a short time, a large portion of the soft parts of the lips and face, and JVoma the genitals of young female children. This appears to depend upon the quantity of destructive fluid or mixture generated in the process. On the other hand, several weeks may occur before a dry gangrenous foot is completely separated by decomposition. There are sometimes external causes also which seem to produce mortification, independent of the amount of exudation, or the rapidity with which it is thrown out. During the summer of 1836, I watched with great care the progress of a sloughing gangrene, prevalent, not onlv in the Infirmary of Edinburgh, but throughout the city generally. All kinds of sores and wounds were atfected by it, even those of a speci- fic nature, such as chancres, etc. Neither youth nor age was exempted from it. It affected not only those who were debilitated from disease, through intemperance or bad diet, but those also apparently in the most robust health. Thus a servant girl, aged 16, who had never suffered from illness, and was of a robust constitution, fell down upon some glass bottles, and slightly cut her left thumb. A week after, she entered the Infirmary with an ulcer the size of a shilling, filled with a brownish- black slough, discharging a foetid and sanguineous fluid. In this, as well as other cases which occurred, it became impossible to attribute the gangrene to the violence of the injury, the amount of exudation, a state of cachexia, or indeed to any circumstances connected with the individual. It could not arise from contagion, as it originated simul- taneously in difi"erent parts of the citv in individuals who had no com- munication with each other, and was not confined to the Infirmary, where the system of dressing wounds precluded the possibility of such an occurrence. We are, therefore, compelled to ascribe the cause to something in the atmosphere. Most writers have noticed the connection between a certain state of the atmosphere and the prevalence of hospital gangrene and of dysen- tery, as well as their more frequent occurrence in summer and autumn — that is, at a period of the year when increased temperature favours the decomposition of animal matter. The good eflfects which result from change of air, when every kind of treatment fails, still further point out its connection with some atmospheric changes. These may proba- bly depend upon some peculiar electrical state not yet explained, power- fully influencing the chemical combinations of the diseased part, and preventing ceil growth. At least such is what we may reasonably sup- pose, from all the facts with which we are acquainted on this head. The disease is similar to blight among vegetables, or the potato disease. Ulceration. The process of ulceration is somewhat similar to that of mortification, but is more chronic in its progress ; the exudation, instead of undergo- ing decomposition, exhibits an indisposition to pass into cell formation. In this case the exudation is poured out slowly, it coagulates and presses upon the surrounding parts, more or less obstructing the flow of blood to them, and acts as a foreign body. By means of the continued pres- sure, the circulation is obstructed, and death of the portion aftected results. This dead portion is sometimes imprisoned in fresh exudation, ULCERATION. 145 as the ulceration extends, and the whole part affected at length becomes disintegrated. x\ll this time the exudation exhibits little of that ten- dency,"so conspicuous in healthy persons, to undergo changes in itself, and when examined microscopically, is found to consist principally of very minute granules. These are occasionally mixed with irregularly formed cells, usually more or less angular, containing one or more granules. The cells are more numerous in proportion to the stage of the ulceration, and the healthy powers of the constitution. The different granules and imperfect cells, with the structures they involve, at length become broken down, and separated from each other, constituting a serai-fluid mass, wdiich has a tendency to point where it can most readily be discharged, that is, towards the surface of the skin or mucous mem- branes. Ilere, on account of the less degree of resistance offered, the continued pressure and disintegration of tissue first causes an aperture to be formed. Another portion of solid exudation is now broken down, with the tissues involved in it, and in this way the opening is enlarged. If the morbid process continue, a fresh exudation is slowly poured out below the already coagulated blood-plasma, which supplies the loss thrown off in the form of discharge, and thus chronic ulcers may be continued indefinitely. The whole of this process may be well observed in scrofulous and syphilitic ulcers, or in the callous sores of the legs in weavers and others of a cachectic constitution. Indeed, the general powers of the constitution are almost always in such cases enfeebled, and hence the indisposition of the exudation to be transformed into cells. Ulcers produced by direct pressure are occasioned in a similar manner; only in such cases the pressure is not derived in the first instance from the solid exudation poured out. Thus, in stumps not sufficiently covered by soft parts, in places long pressed npon by lying, or by the growth of tumours, the vitality of the part is slowly destroyed. At the same time an exudation is poured out from the neighbouring vessels, which becomes broken up, and assists in disintegrating the textures whose vitality is destroyed. The finely molecular particles are thus absorbed, whilst the grosser portions are thrown oft' in the form of discharge. All ulcerated surfaces are covered with a fluid, which varies in character according to the nature of the sore. Healthy granulations are covered with laudable puruleut matter, the corpuscles in it present- ing their normal character. In chronic, scrofulous, and syphilitic sores, the corpuscles are generally of an irregular form, constituting Avhat has been denominated unhealthy purulent matter. Not unfre- quently the ulcer is covered with a discharge, either of a thin dirty yellowish tint, or more or less sanguinolent and foetid. In the latter case the discharge has received the name of sanies, and is similar in character and constitution to that observed in the fluid accompanying moist gangrene — that is to say, there are in it traces of imperfect cell formation,"mixed with numerous molecules, and the shreds or debris of the structures involved. Ulceration has by most writers, since the time of Hunter, been regarded as the result of a peculiar operation, which he denominated ulcerative absorption. No doubt the process, such as w^e have described 10 146 PRINCIPLES OF MEDICIXE. it, is peculiarly favonrable to the production of a fluid containing molecules so minute that they may readily permeate the neighbouring vessels bv endosmosis. But it must not be overlooked that much of the substance lost in ulceration, especially of the more consistent and tough structures, after having been more or less broken up, is thrown oft' from the surface in the form of discharge. This is proved by direct observation. In either case all such parts fiist lose their vitality, from the pressure to -which they are subjected, and then, being disintegrated, the fluid and finer parts may be absorbed, whilst the coarser are thrown ofl' from the surface. In bones the processes corresponding to mortification and ulceration in soft parts, are generally denominated JVecrosis and Caries. \1. General Treatment of Exudation. The foregoing facts and considerations must lead us to the conclusion, that practically the medical man may be called upon — 1st, To prevent or diminish the extent of an exudation ; 2d, When it has coagulated, to further its removal from the economy ; or, 3d, If this cannot be accomplished, to render its products as little injurious to the system as possible. In each case, we can only proceed correctly by knowing the manner in which nature operates, and assisting those curative changes which she invariably attempts to bring about. We have seen that exu- dation follows certain preliminary alterations in the capillary vessels, and is immediately dependent on relaxation or paralysis of their coats, and transudation through them of the liquor sanguinis. Once formed, it passes through certain changes or developments, which vary according to the nature of the texture in which it occurs, its amount, the rapidity with which it is formed, and its inherent constitution. The exudation, bv means of these changes, is rendered soft, is more or less disintegrated, and is absorbed into the blood to be excreted from the economy. A correct treatment, therefore, will be influenced by the stage and nature of the exudation. 1. To prevent or diminish the extent of an exudation, we must adopt measures to overcome the dilatation of the capillaries, their distension with blood, and the attractive power (whatever that is) which draws the liquor sano-uinis into the surrounding textures. This is accomplished — 1st, Bv local applications of cold and astringents, which stimulate the capillaries to contraction ; 2d, By soothing topical applications, such as warm fomentations, opiates, etc., which relieve the irritation of the nerves in the part. Blood-letting, local or general, has long been supposed capable of meeting this indication, but theoretically it can no longer be defended, and practically the use of the former has much diminished, while that of the latter has of late years been almost confined to active congestion of the external tissues. 2. When the exudation has coagulated, it constitutes a foreign body, which either becomes organised, or is removed by its dying. In the one case it acts as a blastema, in which cells are developed that ulti- mately break down, and so render it capable of being absorbed (resolu- tion), or they are converted into a tissue that becomes permanent. In CLASSinCATIOX OF MORBID GROWTHS. 1-47 the other case, it disintegrates slowly, constituting ulceration — or putre- fies, forming moist gangrene, when it is separated from the economy in discliarge or as a slough. It is by regulating the formative power of the exudation that we check or favour resolution ; and we can only do this bv employing those means which lessen or advance cell growth in all living organisms. Thus locally, cold, dryness, and pressure check — while heat, moisture, and room for expansion favour, — growth. And as reirards the general system, the increase or diminution of food, nutrients and stimuli, act for or against this object. With a view of diminishing the general excitement that prevails, tar- tar emetic has been recommended, and to assist the absoi-ption of the exuded matter, calomel has been a favourite remedy ; but the manner in which these act has been disputed, and whether it be as a solvent of the etfete matters in the blood, or by operating on the excretions, is yet undetermined. The former probably acts in both these ways — the use of the latter, as an antiphlogistic, has of late years been almost aban- doned. The action of counter-irritants, although undoubtedly useful in removinor pain and in causing absorption of chronic exudations, is little understood, and belongs to the most mysterious department of thera- peutics. 3. In order to favour the excretion of the effete matters in the blood, purgatives, diaphoretics, and diuretics, alone or combined, will be found very useful. The influence of these remedies, indeed, is not confined merely to removing matters which have been absorbed as the result of the secondary digestion ; but, by their depurating qualities, they favour indirectly the rapid absorption of the exudation. -4. In cancerous exudations we must endeavour to restrain the advance of cell growth, by local cold, dryness, and pressure ; we must attempt its eradication by excision or caustics, if this can be appropriately prac- tised ; and diminish the tendency to accumulation of nutritive materials in the system, by keeping the excretory functions in full activity. 5. In tubercular exudation, the cell development of wliich is imper- fect, and tends to ulceration and wasting, we have to combat the preli- minary phenomena of exudation locally, whilst we improve the nutri- tive powers of the economy generally. To meet the first indication, counter-irritation and an equable climate are useful; whilst for the second, we must overcome the dyspepsia so hostile to a correct primary digestion, and in addition to exercise and free air, supply the system wi^th easily assimilable animal oils, without which nutrition cannot pro- ceed. The general indications for treatment now alluded to, of couree admit of infinite variations and modifications in individual cases. In the mean- time, what I have to tell you with respect to these, will, I think, be more readily comprehended from the preceding considerations. 14:8 PRINCIPLES OF MEDICIXE. MORBID GROWTHS OF TEXTURE— THEIR GENERAL PATHOLOGY AND TREATMENT. The exclusive study of morbid growtlis, according as tliej^ aifect inter- nal or external parts, has led to limited views of the subject. The sur- gical tendenc}' to speak of them as tumours, and to regard them in refer- ence to the great practical question of excision, has interfered with the true pathological doctrine, namely, that, however or wherever produced, they are essentially the same. No doubt they are veiy common in exter- nal parts, simply because all growth proceeds best on surfaces where there is room for expansion, but this accidental circumstance should not induce us to suppose that they are peculiarly matters for surgical consi- deration. In truth, their study belongs to pathology — that science which constitutes the basis of all branches of the medical art. The line which separates health from disease is not always to be deter- mined, when certain tissues or organs have increased in size dispropor- tioned to the rest of the body. Exercise, within certain limits, may cause the size of particular parts to be relatively increased, as the legs of the dancer, and arms of the blacksmith. In these cases, however, such enlargement is consistent with health. So when the uterus enlarges and its walls thicken during pregnancy, we recognise that the departure from the normal type is absolutely necessary for the purpose it is required to carry out ; and when this is accomplished, it returns to its natural con- dition. In like manner, other hollow viscera enlarge when they have an obstruction to overcome. Thus the urinary bladder becomes greatly thickened, in consequence of a stricture in the urethra; and the left ven- tricle of the heart becomes hypertrophied from disease of the aortic valves. But in these last cases the increased growth, though a wise adaptation of nature, and even necessary for the continuance of life, must be regarded as evidence of permanent disease. Again, a blow on the breast, on the skin, or over a bone, may cause the injured parts slowly to enlarge, inducing swellings, which may produce inconvenience from their size, or from their pressure on neighboui'ing nerves. In this manner no tissue or organ of the body is exempt from more or less increase of its extent or magnitude, and there are none, consequently, which may not occasionally present morbid or excessive growth. Increased growth of tissues may assume various forms. The organ or structure may gradually become enlarged in whole or in part, still maintaining more or less of its original texture, shape, and function, con- stituting hijpertropluj. Membranes may become preternaturally thick- ened, causing more or less induration, whereby the movements of parts may be affected, or the calibre of tubes and ducts may be diminished, producing stricture. The results of the healing process may give rise to new tissues exactly resembling those previously existing in other parts of the body, as in cicatrices, callus, etc. *, or such growths may assume the form of tumour. Lastly, we must not overlook the fact that certain transformations in the exudation, formerly noticed, lead to increase of texture, and produce morbid growths altogether foreign to the healthy frame. CLASSIFICATION OF MORBID GROWTHS, 149 A cultivation of histology excited the hope that, by stnclyino- the ultimate structure and mode of development of morbid gi'owths, distinc- tive elements, and thereby a new foundation for their classification, would be discovered. But extensive researches long ago convinced me that this hope was vain, and in a special work, published in ] 849,* I pointed out what were the ultimate elements of all morbid growths, and that no one of these was characteristic of any special kind of organic formation. The structural elements of morbid growths may be reduced to six, viz. — 1st, molecules and granules ; 2d, nuclei ; 3d, cells ; 4th, fibres ; 5th, tubes (especially vascular ones) ; and 6th, crystals or irregular masses of mineral matter. Now no combination of these elements will serve to characterize morbid growths, such as fibro-molecular, fibro-nucleated, fibro-celiular, fibro-vascular, etc., for the simple reason that tumours very unlike in their external characters and natures may be composed of the same elements. For instance, cystic, glandular, cartilaginous, and cancerous growths, are all fibro-cellular. It is not then from its showing the existence of one or more elementary structures, but from its pointing at their mode of arranf/ement, that the microscope is destined to be of infinite impoi'tance in pathology and diagnosis. Neither will chemical composition furnish us with trustworthy means of distinguishing morbid gi'owths, as many of them contain albuminous, fatty, pigmentary, and mineral principles conjoined, although in variable proportions. The best classification, therefore, is one founded on our knowledge of the compound textures of the growths themselves, assisted as far as varieties are concerned by their similitude to well known objects, which have long been received in pathology as standards of comparison. Thus the following arrangement appears to me capable of embracing all the known primary classes of morbid growth : — I. Fibrous growths . . . Fibroma f or Inoma. II. Fatty growths .... Lipoma. III. Cystic growths .... Cystoma. IV. Glandular growths . . . Andenoma. V. Epithelial grow^ths . . . Epithelioma. YI. Avascular growths . . . Angionoma. YII. Cartilaginous growths . . Enchondroma. yill. Osseous growths . . . Osteoma. IX. Cancerous growths . . . Carcinoma. All these primary divisions are susceptible of being subdivided ac- cording to the presence of particular substances, or to fancied resem- blances which have received names. Thus the varieties of the above kinds of growth have long been determined by their substance present- ing greater or less similitude to well-known objects, such as water, lard, flesh, brain, etc. etc., as follows : — * On Cancerous and Cancroid Growths. Edinburgh, 1849. f The word Fibroma, though composed of a Latin root with a Greek termination, and therefore barbarous, is here given in consequence of its having been already employed in medicine. Those, however, who may object to it on this ground, can employ the more correct Hovel term of Inoma, from I's-iVos , a fibre. 150 PRINCIPLES OF ilEDICIXE, 1. Like water ..... . Hygroma. 2. n black pigment Melanoma. 3. 5) green pigment Chloroma. 4. 5J blood ..... . Httmatoma. 5. » gl"e Colloma. 6. 5? lard Steatoma. / . ?J gruel ..... Atheroma. 8. r honer ..... Meliceroma. 9. » cholesterine Cholesteatoma 3 0. ?5 flesh ..... Sarcoma. 11. ?5 nerve ..... Neuroma. 12. ?? brain ..... Encephaloma. 13. J) marrow .... Myeloma. 14. 5> marble . . . . . Scirrhoma, etc It is easy to understand how varieties may in this way be multiplied, and how new names may be scientifically given to rare forms of tumour, for instance Sijphonomu, or tubular growth, described by Henle ;* Cy- lindroma, by Billroth ;t Heteradenoma by Eobin,| etc. etc. Further varieties have been made to express one or more combina- tions of these elements, and hence the terms Fihro-cijstk, Fibro-cartila- (/inous, Fibro- Sarcoma, Osfeo-Sarcoma, and so on. Indeed, this kind of nomenclature admits of further extension, and such terms as Fihro-ejn- thelial, Anyio-cy^tic, Cystk-aJcnoma^ Osteo-fibrous, and so on, might be employed with advantage. When, also, growths have a certain resem- blance to, or largely partake of the character of the structures and sub- stances referred to, while their real nature is not absolutely or altogether the same, the words Fibroid, Cystoid, Adenoid, Chondroid, Osteoid, Col- loid, Heematoid, Fungoid, Fncep}ialoid, Myeloid, Cancroid, etc., have been employed. All these words and modes of expression, as they are founded on anatomical facts, may, if carefully applied, be useful in designating the structure and nature of morbid growths. But other distinctions founded on presumed vital properties, are objectionable. "What ideas, for instance, can be attached to the terras innocent and malignant ? A fibrous growth has been generally classed among innocent ones, yet the terms recurrent and malignant have also been applied to it. In fact, we shall aftei'wards see that almost every kind of growth may be innocent in some cases, and malignant in others. The distinctions, therefore, sought to be esta- blished from such theoretical considerations are not only erroneous, but have proved — as we shall subsequently show — most injurious in prac- tice. I have known innocent growths never operated on bv the sur- geon, and allowed to kill, in consequence of his believing them to be malignant, and really malignant ones not touched at that early period when their removal was likely to be beneficial, in the hope that they would go away of themselves. This point will be more especially dwelt upon, after giving, as it is now proposed to do, a short sketch of the nine distinct kinds of morbid growths. * Zeit. fiir Ration. Med. 3 Bd. 1 Heft. f Ueber die Entwickelung der Blutgefasse, Berlin, 1856. \ Traite d'Anat Pathologique, par Lebert, p. 339, et seq. FIBROUS GROWTHS. 151 Fibrous Growths. — Fibroma or Inoma. The patholoo;ical formation of fibrous growths is the most common and universal which occurs in the bod3^ It is essentially of two kinds — ls<, a simple increase by division or enlargement of pre-existing fibrous tissue ; 2K^" ^N Fi- 16-.' oval form, frequently embedded in a cyst, composed of the indurated - structures in whicli they lie. They are ^^ of considerable density, varying from -'-'^ -~^ that of tendon to that of ligament or 'V;i^ fibro-cartilage, and on section present "*^ numerous white glistening fibres, inti- mately interwoven together, or arranged .-■^^\ in bundles constituting circles, or loops intercrossing Avith each other. Occa- sionally they have a calcareous centre or nucleus. Their colour is generally white, but sometimes they have a vellow- ish tinge. They are for the most part not very vascular, although there is great difference in this respect, some approaching the pinkish colour of sarcomatous growths, and others being of dead white and of extreme density, containing scarcely any ves- sels. They vary greatly in size, from that of a pin's head to a volume measuring several feet in circum- ference. These tumours may be situated in various tissues and organs, as in the subcutaneous and submucous cellular tissue, in the mamma, and uterus, in which last-named organ Fig- 163. they are most common. When de- veloped in the uterus, they often push the mucous membrane before Fig. 1.58. Fibre cells and fibres from the pulpy interior of a poljpus removed by Mr. Syme. Fig. 159. The same, after the addition of acetic acid. Fig. 160. Ciliated epithelial and pus cells from the exterior of the tumour. Fig. 161. The same, after the addition of the acetic acid. Fig. 162. Section of a dermoid fibrous tumour, embedded in the uterine waUs. One-fourth of the entire growth is represented. Natural size. Fig. 163. Section of a dermoid fibrous tissue from the uterus, afler the addition of acetic acid, showing the concentric direction of the fibres. 250 diam. FIBROUS GEOWTHS. 157 them. In this way they grow outwards, forming what are called hard Ijoliipi. At other times they grow towards the serous or internal cavitv, pushing the membrane before them in a similar manner, so that it ulti- mately constitutes a neck or pedicle, by which they are attached to the uterus. Such pedunculated fibrous tumoui-s are sometimes found in the peritoneum, growing from the uterus. Occasionally the pedicle breaks across, and the tumour becomes free in the serous cavitv. To the same cause are owing the small fibrous, oval or round bodies, called loose cartilages, found in the joints, more especially that of the knee, some of which are truly osteo-cartilaginous. Others are found in the veins, and denominated phhbolites. The minute structure of these dermoid tumours is found to consist of fusiform cells more or less aggregated together. In the softer portions of the gi-owth they can easily be separated by needles, but in the indu- rated portions they are so ^^ dense that this is impossible. / '.i^^'<:i''ii ^J U i / / a Uiir'* '/r.^/'y<^> 4 Sometimes the filamLs are |^^^Ml^^^^%f^^^C more or less waved, as in or- \''S'^^-^^'^Ai.'-*i -''f'-^'^^'j/'^^^ih^ dinary nbrous tissue ; at others, '^"jT- they are curled and brittle, ^-^V, as in elastic tissue. On raak- ^/'r, _ -v-W ing a thin section, they may >^/, . • i . ;^£%0 often be seen to form a con- ..^^il^l^'-f - "£r;> ^ / ' ''^ '^^.P centric fibrous structure, and ^^^f '^'^ . J?^//jy^c^4i on the addition of acetic acid, 0f^''' ^ ^^ V^ '^'^^ -p^^f ^ the nuclei, scattered through- ^/ , \\^^^'' ^ out the tissue, are made very '' ', .„. iv apparent (Fig. 163). Xo't Fig. 164 unfrequently these latter are collected together in masses (Fiij. 164). and sometimes they are isolated, as in the sarcomatous tumours ; but then the proportion of them to the fibrous element is generally small. The bony nuclei of such tumours are composed of amorphous mineral matter, not of tnie bone (see Fig. 345), although Lebert says that on two occasions he has seen true bone produced. ^Vedl also has figured true bone in the inte- rior of these growths. (See Fig. 270.) The two forms of fibrous growth now spoken of may frequently be found associated together in one f:^-. ic\ tumour. Some are composed of several rounded or oval masses varying in size, enclosed and separated from each other by a cvst, or layer of areolar tissue. The external surface, under such circum- Fig. 164. Section of hard uterine polvpus, which had been boiled in dilute acetic acid and dried ; a, groups of nuclei, surrounded bv bundles of fusitbrm fibres — ( Wedl). 250 diam. Fig. 165. Section of Neuroma connected with three nervous tnmks. — Xatural size.— {Smith.) 153 PKINCIPLES OF MEDICINE. stances, is more or less nodulated. It may frequently be observed that some of these nodules are soft and pulpy — semi-gelatinous, with a very sparing laver of fibrous tissue ; whilst others may be seen more or less touo-h, gradually passing into a fibro-caitilaginous density, grating under the knife. Xay, even in the same nodule I have frequently ob- served some parts of it soft and others hard, and have shown that the softer parts are mostly cellular, and the harder fibrous, and that between the two there are many degrees of variation. Neuromatous Fibrous Tumours. — This form of fibrous tumour is developed in the nerves, sometimes spontaneously, at others as the result of injuries, and especially of amputation. In the museum of the Rich- mond Hospital, Dublin, I examined a most remarkable series of prepara- tions, taken from two individuals, in whom almost every nerve of the bodv presented knotty swellings. In some places these were developed into tumours, which varied in size from a pea to that of the human head.* A subcutaneous tumour, described by the late Mr. W. "Wood of Edinburgh, must be referred to this class of tumours.+ All these neuromata, on being minutely examined, are found to con- sist of fibrous texture, more or less dense, the filaments often arranged in wavv bundles running parallel to each other, but occasionally assum- ino- a looped form, or intercrossing with each other, as in Fig. 162. I have also found them to contain groups of cells, so that, on the addition of acetic acid, they closely resemble the structure represented in Fig. 164. Fig. 166. Fig. 167. Not unfrequently they are fibro-cartilaginous, sometimes with the cells closelv ao:frregated together, at others widely scattered (Fig. 166). In some "of ■the neuromatous swellings described by Dr. Smith of Dublin,* I found the fibrous tissue to present wavy bundles, among which a few * See Smith's Treatise on Xeuroma. — Dublin, 1849. f Edin. iled. and Surg. Journal, 1812. Fiff. 166. Thin section of a subcutaneous tubercle, composed of fibro-cartilage. Fig. 167. Fibrous structure of a neuromatous swelling, given to me by Dr. Smith, &om one of the cases he has described. 250 diam. FATTY GROWTHS, 159 grannie and cartilage cells were scattered and shrivelled, apparently from the action of spirit (Fig. 167). Fatty Growths. — Lipoma. The morbid increase of fat is frequently so imperceptible, that it is impossible to separate the pathological from the phvsioloo-ical state. Obesity may gradually increase, either locally or generally, internally or externally, so as to cause, not only inconvenience, but actual disease. Some individuals have become celebrated from their excessive fatness, (See Polysarcia.) Fat sometimes occurs in masses, being only an exaggeration of the normal texture of the part, as when it collects about the heart, in the omentum, or on the serous membranes, in which case it takes the exact form of the included viscera. Fat may also be aggregated in masses in unusual situations, and then form the so-called fatty tumour. Fis. 163. Fatty tumours vary in size ; they may reach a growth weighing upAvards of 30 lbs. Sometimes their surface is lobulated, at others smooth. They are of a yellow colour, resembling adipose tissue, and Fig. 168. Lobulated Lipoma of the nose. —(Bickersitth.) 160 PRINCIPLES OF MEDICINE. are occasionallv divided into bands by -white fibrous tissue. The rela- tive amount ol' these two elements varies greatly in different specimens, some being soft, oily, containing few fibres, others being hard and dense, the areolar tissue preponderating. For the most part they are very sparingly supplied with blood-vessels ; the vessels abound most in the fibrous varieties. In the latter case they are liable to ulcerate, and, under such circumstances, have frequently been mistaken for cancer. Some of these growths, indeed, may be con- sidered as fibrous or sarcomatous tumours, combined with an unusual quantity of fat. Occasionally they are connected with the ordinary adipose tissue of the body. We see this in fatty tumours so common in the sub- cutaneous tissue. They are often surrounded by a delicate cyst or envelope ; but in others this is not perceptible. It is when the collec- tion of fat resembles the ordinary adipose tis- sue, that the tumour has received the name o^ Lipoma. "When it is more lardaceous, some have applied to it the term Steaioma, in the ■ '• same manner as when the substance is en- cysted. ~\\'hen firm, and largely mingled with fibres, it may be called Fibro-Lipomatous^ as in the lobulated tumours that constitute so fright- ful a deformity of the nose (Fig. 168) . The minute structure of these tumours varies according to the amount of adipose or fibrous tissue in their composition. The adipose Fis. 170. Fiir. 171. matter is composed of vesicles of a round or oval form, more or less liable to undergo alterations in shape from pressure (Fig. 170). They vary Fig. 169. Smooth Lipoma, removed from under the tongue, one-half the natural size. — [Liston.) Fig. 170. Two layers of voluminous fat cells, varying in size, from a i/powia. 200 rfj. Fig. 171. Fat ceils from the same Lipoma, dried, showing crystalline bundles of Margaric acid. 250 diam. CYSTIC GEOWTHS. 161 from the y oVot^^ to jj^tli of an incli in diameter ; are composed of a diaphanous cell-wall, which frequently includes a nucleus. The nucleus is crenerally round or oval, about the 2 oVoth or y gVo^'h of an inch in diameter. ' Occasionally it is stellate or penniform, of a crystalline appearance, from the formation of crystals of margarine or margaric acid around it (Figs. 171, 172 a). On rupture of the cell- wall the oil may be made to" flow out, and the cell-wall puckers or shrinks up. Such collapsed cells may frequently be seen among the more perfect formations, mixed with glo- bules of oil and fat granules. The fibrous tissue presents the usual appearance of areolar texture running between groups of the adipose cells, being denser, and occu- pying greater space, according to the pro- portion in which it enters the tumour. Steatomatous and melicerous fatty matter may consist of the cells just described, minified in various proportions with granu- lar matter. In some melicerous encysted growths, we have found the whole to be composed of granular matter, in which faint traces of deli- cate cell-walls were seen more or less compressed together. In all such productions the relative amount of the vesicular and granular elements varies greatly. An excess of fat may cause the entire disappearance of the usual structure of a part, and its conversion into adipose tissue. The muscular system is very liable to this fatty transformation or degeneration, which often occurs in the heart, and in muscles which have not been much exercised, owing to local disease or paralysis. In this case adipose tissue o-enerallv springs up in the cellular substance surrounding the muscular lisciculi," and by its increase and pressure upon them, causes the trans- verse striffi to disappear, and the whole to assume a granular appearance — (See Fatty Degeneration, Fig. 304). Fis. 1T2. Ci/stic Groicths. — Cystoma. The different crypts and follicles of the skin and mucous membrane, as well as several of the excretory ducts of internal organs, may become obstructed, and as a consequence enlarged and hypertrophied. It is true such growths usually consist of one or more elementary tissues, and do not therefore properly constitute a class of themselves. Their impor- tance in a practical point of view, however, as well perhaps as the diffi- cultv of knowing under what head to describe such compound growths, warrants our speaking of them separately. Encysted growths are composed of a cyst or envelope, enclosing various kinds of contents. They differ greatly in size, situation, and structure, which renders their arrangement somewhat difficult. By some Fig. 172. Structure' of a Fibro-Lipornaious tumour; a, isolated cells, showing stel- late crvstals of Margaric acid. 2-40 diam. 11 162 PRINCIPLES OF MEDICINE. they have been divided into simple and com])ound, according as the tumonr is formed of one cyst, or is composed of several. By others they have been arranged, according to the nature of their contents, into hygromatous, atheromatous, melicefoiis, and steatomatous growths. The latter mode of division is very faulty, as many of these varieties are only altered forms of one substance — ftit; whilst some compound encysted tumours contain various kinds of contents in separate cysts. But as there can be no doubt that the peculiar contents give to these growths a distinctive character, we shall first speak of them as simple or com- pound, and then describe their different kinds of contents. Simple cystic grotvths. — These growths are formed of a cyst generally composed of fibrous tissue, lined by a smooth membrane. Sometimes the membrane is structureless, or only composed of areolar tissue. At other times it is covered with a distinct layer of epithelial cells, the nuclei of which are very apparent on the addition of acetic acid. The former kind con- stitute the vesicles so fre- quently found in the plexus ch oroides, in the kidneys, ovaries, etc., and vary in size from a pin's head to that of a hazel nut, or even walnut, and usually have aqueous contents. The lat- ter kind constitute the cys- tic o-rowths which arise in the follicles of the skin, in the mamma, ovaries, testicles, etc. ; these frequently reach the size of an orang-e, and are sometimes much larger, and vary greatly as to the nature of their contents. For the most part they are only sparingly supplied with blood-vessels, and seldom cause inconvenience except from the deformity they occasion when situated externally. Compound cystic groivths are of two kinds. _ 1st, The external sac may contain on its internal surface second- ary or even tertiary cysts, which may be sessile or pedunculated — or the growth may be divided into numerous compart- ments by divisions of the fibrous sac. These are the true multilocular encysted Fig. 1T4. Fig. 175. tumours. The external cyst in every case is formed of fibrous tissue. The intenvil surface is smooth, sometimes with, at others without an epithelial layer. The primary, as well as the Fig. 173. Simple cyst of the broad ligament of the uterus, with very vascular walls, a, New vessels; &, broad ligament. — {Wedl.) 30 diam. Fig. 174. Diagram of compound cj'stic growth, containing secondary and tertiary cysts, developing themselves endogenously. Fig. 175. Diagram of compound cystic growth, in which the included cysts are formed by irregular divisions of the fibrous sac. CYSTIC GROWTHS. 163 secondary cysts, are for the most part richly supplied with blood-vessels, and hence they are peculiarly prone to - contain exudation which may undergo ^ various kinds of development. They may also ulcerate. In the ovary these growths . a frequently attain an enormous size, mea- suring several feet in circumference ; the \ cystic internal membranes often secreting more or less rapidly even gallons of tluid. 2d, Numerous cysts may be pedunculated from one stock, and more or less crowded " „^^ together, with a tendency to grow out- ^"'' W wards instead of inwards ; as happens in " ■ ^..b,,^'' the case of so-called uterine hydatids, Fig. 1T6. which is a cystic disease of the chorion, as described by Mittenheimer. Fijr. ITT. The contents of cystic growths are very various, and give, as we have previously stated, a peculiar character to them. 1, The contents may be a perfectly colourless fluid, resembling water, * Mailer's Archiv. fiir Anatomie, etc., 1850, p. 41 T. Fig. 176. Compound cystic sarcoma of the mamma. The cysts are more nume- rous at a than at h. — {Miller.) One-fourth the natural size. Fig. 177. Structure of a cystic chorion belonging to an ovum,^ at the eighth or tenth week. — ( Wedl.) a, An enlarged villus, covered with epithelium, having a globular and a retort-shaped prolongation at its extremity; h and d, outlines of other enlarged villi, containing hyaline spaces c and e ; /, nuclei and cells in the interstitial substance ; g and ft, roots of villi undergoing fatty degeneration. 250 diam. 164 PRIXCIPLES OF MEDICINE. or the limpid serum so frequently secreted in the lateral ventricles of the brain. It is structureless, and chemically contains a minute proportion of salts, and a small amount of albumen, -vshich coagulates on boiling. Such are frequently the contents of so called serous cysts, or false hydatids of the plexus choroides, kidneys, ovaries, etc. A Hydrocele, and other dropsies of shut serous sacs, may be looked on pathologically, as constituting a form of hygromatous encysted growth. 2. The contained fluid may have an amber or golden yellow colour, and resemble the serum formed after the coagulation of the blood. It is still structureless, but contains a large amount of albumen, as is proved by the action of heat and nitric acid, 3. The contents are more or less gelatinous, sometimes slightly so, like weak gelatine, at others they are firm, and capable of being cut with a knife like tolerably strong glue or firm calves-foot jelly. The colour of the gelatinous matter may vary fi'om a slight yellowish tinge, to a deep amber, or brownish-yel- low colour. Sometimes this matter is structureless, at others it may be seen to con- tain very delicate filaments, combined with pale oval bodies, the outlines of which become stronger on the addi- tion of acetic acid (Fig. 179). Tliis re-agent frequently causes the gelati- nous mass to coagulate into a fimi white fibrous structure, capable of being separated by neeclles, and pre- senting the appearance of fila- mentous tissue. This kind of contents is common in the cysts of the thyroid gland and ovary, and I have seen it in the kidney and other organs. On one occa- sion the gelatinous matter in the kidney contained numerous granules ; and more than once I have found in the centre of the clear amber masses a creamy white substance, either wholly granular (Fig. 298), or in the process of formation into pus corpuscles. 4. The cyst may be distended with epithelial cells, which have evi- dently been thrown ofi" from its internal surface, and been compressed Fig. 173. Tig. 179. Fie. ISO. Fig. 178. Colloid cystic growths in three lobules of the thyroid gland.- — ( Wedl.) 15 di. Fig. 179. Delicate oval corpuscles in amber-coloured, transparent colloid matter 01 the ovary. Fig. 180. Eound and oval corpuscles with filaments in light yellow, semi-transparent gelatinous coUoid matter in the ovary. 250 diam. CYSTIC GROWTHS. 165 too-ctlicr, and partially broken down. Hence on examination, clusters of such scales may be found mixed with numerous debris, and fat Sjranules and globules, sometimes with crystals of cholesterine. (Fiij. 185.) The contents of the cysts are usually of a white or slightly yellow colour, some- times fluid, at others semi-solid. The molluscum contagiosum of dermatologists is thus constitut- ^'S- l^i. ed. A small pedunculated simple cyst, dependent from the peritoneal surface of the ovary, was found by Wedl to contain the structures repre- sented Fior. 184,. Fig. 1S2. Fig. 184. 5. The contents may consist principally of fat, either amorphous, crystallized, or organized, that is cellular. If amorphous, they resemble honey, constituting the melicerous growths of morbid anatomists. In many cases, however, where the yellow colour is uniform, and the con- tents, closely resembling honey to the naked eye, break down under the finger, faint cell-walls, more or less compressed together, may be observed by the microscope in them. At other times the fatty contents are of a whitish colour, forming masses of a pearly aspect and smooth surface, and are mingled with a roughened yellowish, and more granular fatty matter. This is the cholesteatoma of Miiller. This white matter con- sists of numerous crystals of cholesterine placed in a close juxta-position, — the granular fatty matter of oil globules and granules mixed with broken up crystals, epithelial scales, and sometimes the products of Fig. 181. Oval epithelial cells from the lining membrane of an ovarian cyst. Fig. 182. Polygonal epithelial cells from the same lining membrane. Fig. 183. Section of the wall of the same cyst, showing the epithelial cells in situ. Fig. 184. Cells from the interior of a simple cyst, a, b, c, Cells developing endo- genously, independent of the nucleus, which is embedded in the wall of the parent cell : d, e, the same, undergoing the fatty degeneration ; /, g, cylindrical epithelium, seen sideways and from above ; h, polygonal epithelium cells ; i, fibre cells. — ( Wedl.) 250 diam. 166 PRIXCIPLES OF MEDICINE. fibrinous exudation (Fig. 185, 187). Such is the general structure of the atheromatous encvsted frrowths of various authors. Fig. 185. Fig. 1S6. Again, the fatty matter may be more or less lardaceous in character, and consists of beautiful round or oval cells, some of which are distinctly "r, Fiff. 1S7. l^ Fifr. ISS. nucleated. Mixed with these may be a granular matter, combined with Fig. 185. Structure of cholesteatoma, consisting of disintegrated fat vesicles and epithelial scales, with numerous crystals of cholesteruie. — [Beak.) 215 diam. Fig. 186. Encysted tumour, with fatty steatomatous contents. Natural size. — (Listen.) Fig. 187. Contents of a large atheromatous cyst, opened by Mr. Syme, consisting of numerous crystals of cholesterine, oily granules, granule and pus cells, with en- closed cysts containing oil granules. — {ATurchison.) 200 diam. Fig. 188. Adipose cells, embedded in fatty granular matter, from a steatomatous encysted tumour of the ovary. 250 diam. CYSTIC GROWTHS. 167 epithelial cells or their debris (Fig. 188). At other times no distinct cells can be observed, only a granular or amorphous mass, the greater part of which is soluble in ether. This constitutes the steatomatous encysted growth (Fig. 186). 6. Many encysted growths contain hair and teeth. The hair is occa- sionally inserted into the walls of the cyst, at other times lies loose in it, mixed with the fatty or other contents. The hair has exactly the same structure as the hairs in other parts of the body, having distinct bulbous roots. When attached they are surrounded by a follicle in the lining membrane ; when loose they have been evidently grown in follicles, and been afterwards separated. Their apices are frequently split up into several fibres in the longitudinal direction. The teeth belong sometimes to the first, and sometimes to the second dentition. They present on section the usual structure of cavity, with ivory, enamel, and bone. Sometimes they are found embedded in a follicle of the lining membrane, at others, like the hairs, they are quite unattached. 7. Occasionally the cysts contain lymph, softened fibrin, and purulent matter, presenting the structure of molecules (Fig. 189), or of pus and granule cells — this is the result of exudation into their cavities. Occasionally there is a sei'ous fluid more or less mixed up with extravasated blood, giving to the contained liquid various colours and appearances, according to the age of the extravasation. Thus it may be red, dark brown (re- sembling cotfee), of a dark-green- "' ish tinge, etc. etc. Sometimes it is of a dark-bluish or blackish tint from excess of pigmentary deposit. 8. Sometimes the contents of a cystic growth are formed of a solid exudation, which has undergone the sarcomatous transformation as previously described, and wholly liilA^4'-SM 4 consists of fusiform cells (Fig. 190). The exuda- Jll(s?rlp*lff|f'-] tion poured into such cysts may pass into the can- ^'/Ji^-H^V cerous formation, and then the characters we have *°-'-i"'!i-°'n' :^ described will be associated with those which dis- tinguish cancer. 9. Some cysts contain the peculiar secretion of >, , . -aj^'^ the organ in which they are found. Thus cysts in " " "" ° the liver may be full of bile, and those in the kid- *'^" ^^^' ney of urine. 10. Lastly, cysts may contain a greater or smaller amount of mineral matter. The mode in which encysted growths are developed is — 1st, By the hypertrophy of pre-existing tissues, whereby, from the accumulation of Fig. 189. Cysts in cystic-sarcoma of the mamma, filled with molecular matter. Fig. 190. Fibrous tissue composed of fusiform corpuscles, from a sarcoiuatous encjsted growth in the kidney. 250 diaia. 168 PRINCIPLES OF MEDICINE. materials Avitliin, canals are distended, follicles or vesicles enlarged, and their -walls thickened. Thus the simple cysts in the plexus choroides are owing to effusion of serum into the areolar spaces in the villi of the membrane, and their subsequent distension. Those in the kidney may be owing to the dilatation of uiiniferous tubes above an accidental obstruction in the same manner that the -whole kidney may become encysted from obstruction of the ureter. The Malpighian capsules also, or the shut sacs of the thyroid, may be distended with fluid, which thus forms cysts. In like manner the crypts of the skin, the blind sacs of conglobate glands, or of the follicles of mucous membranes, become obstructed at their orifice ; and their contents gradually accumulating, distend the walls, which become enlarged and thickened. Simple cysts in the ovary become dilated by enlargement of isolated Graafian vesicles, either deep in the stroma of the organ, or on the surface, when they grow outwards, and become pedunculated. This mode of cystic formation, ti'om distension by material that cannot readily find an escape, is remarkably well observed in bones, in which cysts are some- times produced in conse- quence of accumulated pus. In the Edinburgh University Museum is a remarkable pre- j)aration, in which a large osseous cyst has been deve- loped in this manner, at the lower end of the Femur (Fig. 191) ; and in the Edinburgh College of Surgeons' Mu- seum, is another, which has formed in a similar manner in the head of the tibia (Fig. 192). In the first spe- cimen the osseous cystic Avails are thin, in the second they are greatly thickened. In this respect they resemble the cranial bones, which in some cases are expanded and rendered thin, and. under other circumstances become preternaturally thick through disease. 2d, The origin of compound encysted tumours is not so well de- termined. It is very probable, how-ever, that in most cases they consist of clusters of simple cysts, which become compressed together, assume an increased power of groAvth, and are at length surrounded by a cap- sule. They are most common in the ovary ; and here we can readily understand how successive growths of Graafian vesicles may give rise Fis. 191 192. Fig. 191. Cystic-osteoma of the femur. One-eighth (he natural size. — {Miller.) Fig. 192. Cystic-osteoma of tlie tibia. One-eighth the natural size. — {Miller, copied from the preparations above referred to.) CYSTIC GROWTHS. 169 either to tlie appearance of secondary or tertiary cysts, or to the mul- tilocnlar form we have described. Once produced, the compound cyst enlarges, the individual ones grov? sometimes inwards and sometimes outwards, according as there is more room for expansion in the one direction or the other. In the former case they open into each other by ulceration. Hence, in very old compound cystic growths, we find one large cavity with the traces on its internal wall of previously existing cysts, or bands and divisions with pouches between them. In the latter case they grow outwards, forming clusters of cysts more or less pe- dunculated, as in the so-called hydatid moles of the chorion (Fig. 177, a). These endogenous and exogenous modes of growth are sometimes found in the same specimen. 3d, Another mode in which compound cysts are formed is by the gradual enlargement of the areolae in newly-formed fibrous tissue. On examining thin sections of sarcomatous growths, we observe the fila- Fig. 193. Fitr. 194. mentous tissue arranged in a circular form, enclosing spaces varying m size. These spaces are often lined by a distinct epithelial membrane, and" sometimes contain serum, blood, or exudation, either in a granular or fibrous state. Such growths have long been known under the name of cystic sarcoma (Figs. 193, 194, and also Figs. lV6, 189). 4th, The glandular or epithelial cells of an organ assume an increased power of development, and become scattered through its tissue in great numbers. In the kidney especially, a cystic disease is not unfrequently met with, in which the 'cysts vary from the size of a pea down to the __i__th of an inch in diam'eter, as may be accurately traced with the aid of the microscope. The diao-nosis and treatment of encysted growths belongs to the spe- cial pathoTogy of each organ affected by them. It need only be men- tioned here that a knowledge of the structure of these tumours is not unimportant, as an examination of the fluids discharged from them fre- quently enables us to speak with certainty regarding their nature. Fio-. 193. Cysts in cystic-sarcoma of the mamma, crowded with cells ; a, the cells after the addition of acetic acid. . Y\^. 194. Fibrous stroma from another part of the same tumour, with commenc- ing enlargement of the areolar spaces, after the addition of acetic acid. 250 diam. 170 PRINCIPLES OF MEDICINE. Glandular Groivths. — Adenoma. Glandular growths are essentially hypertrophies of gland texture, in the same manner that fibrous or fatty growths are an increase of fibrous or fatty tissues. But the structure of a gland is compound, and em- braces two kinds of growth. Strictly speaking, the growths are fibro- epithelial, but of a kind so peculiar as to warrant Lebert and Birkett in constituting them into separate groups. Glandular growths may be regular or irregular, that is, they may involve the entire gland or only a portion of it, and in the latter case they may assume the form of tumour. They may also be perfect or imperfect, in the first case closely resembling the gland structure, in the second difi"ering from it in various degrees, and passing into fibrous, cystic, fatty, and other forms of growth. It is not our intention to enter .'S?^^^'^/? Fig. 195. into minute descriptions of the various appearances and modifications of structure they present in the several glands. Under the names of chro- nic mammary tumour, bronchocele, enlarged prostate, and hypertro- phied, indurated, or swollen glands, their existence was recognised be- fore their structure was known. While now it has become apparent that growths, which are truly glandular in their nature, have frequently been mistaken for fibrous and even for cancerous formations. These growths are sometimes lobulated, with the lobes more or less compressed, and the interlobular fibrous tissue varying in density and amount. They may reach a considerable size. One, removed from the female breast by Mr. Syme, which I carefully examined, was larger than Fig. 195. Structure of a cjstic glandular tumour of the neck, in the neighbour- hood of the thyroid gland, a, Appearance of a portion slightly separated and viewed by a simi^le lens, presenting a grape-like bunch of lobules ; h, c, d, ultimate lobules, composed of single or branched CiBcal tubes, distended with epithelial cells ; e, dis- tended condition of these on tlie addition of water ; / alteration of their shape on pressure; g, fusiform cells found in small numbers. — {Redfern.) 250 diam. GLANDULAR GROWTHS. 171 the human adult head, aud weighed upwards of eight pounds. To the feel they vary in density, are lobular or smooth externally, and in the latter case are not unfrequently surrounded by a fibrous capsule. On section they are sometimes smooth and glistening, at others somewhat granular and dull. The cut surface varies in colour, sometimes being almost white, at others of a pale yellow, pink, or fawn colour, apparently from the greater or less amount of vascularity of the particular speci- men. Their mode of growth is by no means uniform. Sometimes they remain indolent and stationary, then again they increase steadily in_ size, slowly at one time and rapidly at another. Occasionally, after giving rise to much anxiety, they gradually disappear, but not unfrequently they present all the external characters and symptoms of fibrous or sar- comatous tumours, and now and then those of true cancer. In structure, glandular tumours consist of gland elements— that is to n\ lk'i>'^ J '€^m^f^'W0i mm Fig 19T Fu 19s say, of a basement membrane, furnished with blood-vessels on one side, and nucleated cells or nuclei on the other. Their firmness, softness, and friability, depend upon the amount of fibrous tissue in them, and upon the number of cells. The follicles are frequently much distended, pre- senting blind sacs apparently without ducts, and are crowded with epi- thelial cells, more or less compressed together. If ducts do communi- cate with them, these are similarly distended, as seen in Fig. 198. The thyroid gland is especially liable to a new formation of tissue, first described by Rokitansky, in which embedded in a lax fibrous stroma are rounded vesicles, surrounded by a layer of delicate pavement epithe- Figs. 196, 197, and 198. Structure of a glandular tumour, surrounded by a fibrous cyst, removed from the female mamma. Fig. 196. Thin section transverse to the glandular lobules, after the addition of acetic acid, shewing the condensed epithelial lining membrane and enclosed epithelium cells. Pig. 197. a, Mass of epithelium separated from the cut lobule ; b, cellular contents ; c, the same, after the addition of acetic acid. Fig. 198. Longitudinal section of one of the ducts leading from the lobules, after the addition of acetic acid. 250 diain. 172 PRINCIPLES OF ilEDICIXE. lium, and containing colloid substance, which escapes when one of these is raptured, Fig. 199, «, B* "Whether the remarkable structure denominated by M. Robin, " Tunieur Hete- radenique,"f in any way re- sembles this, it is difficult for me to say, never liaving liad an opportunity of examining a specimen. Lymphatic glands are very liable to enlarge through lo- cal irritation, arising from a neighbouring ulcer or injury ; O^-^ ~==^ I and the mesenteric glands are (2) ( N^ ' . ' ' especially so, in consequence ' ^ ^'^ of the various ulcers which form in the intestines. In typhoid fever they are fre- quently found swollen as large as hens' eggs, present- ing a reddish or purple hue externally, soft and spongy to the feel, on section exhi- biting a granular texture and greyish hue, and on pressure yielding a dirty white juice. This juice T\s. 199. Fig. 200. Fig. 201. Fig. 202. abounds in the cell elements of the gland, which exhibit an increased * Zur Anatomie des Kropfes, "Wien, 1849. f Lebert's Anatomie Pathologique Generale et Speciale, Liv. 10, 11. Fig. 199. New formed tissue in a follicle of the thyroid gland. A, Areolar fibrous tissue surrounding the epithelial-like lining of the areolas. Many of these have been removed to show the glandular formations within. These vary in shape, some, &, d, being constricted, others round or oval — a, c. B, Colloid masses of various shapes from the interior of a. g, Epithelium, with commencing fatty degeneration, seen also at d, e, and /. h, Blood-vessels containing colourless corpuscles of the gland. — (Wedl.) Fig. 200. Cells in fluid, squeezed from a mesenteric gland, in a case of typhoid fever. Fig. 201. The same in another case. Fig. 202. The same cells, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 173 power of development. The cells enlarge, their nuclei divide into two, these increase by division into four, or a multiple of two, and often form a cluster in the centre of the cell, as seen in the accompanying figures (Figs. 200, 201). the causes w^hich excite glandular growths are not always apparent. They may be constitutional and local, and in the latter case the irrita- tion exciting them may be direct, as from a blow ; indirect, as from a neio-hbouring sore ; or retlex, as when uterine disease aftects the mam- raaf Sometimes when the apparent cause is removed, the glandular growth disappears, but at others it continues to grow independently of any such cause. The laws, which regulate the occasional persistence or disappearance of these growths, have not yet been determined, but one essential and hitherto unrecognised condition, with regard to their inde- pendent growth, admits of being explained in the following manner : At first the irritation, however communicated to the gland, whether direct or reflex, operates by stimulating it to increased cell-growth, and by augmenting the flow of blood. Hence ensue turgescence and en- largement, with the formation of cells, often in such numbers that they cannot readily escape. This is especially the case in the female mamma of young women not pregnant, in whom, while this morbid action is progressing, the proper function of the organ is in abeyance. Hence the follicles enlarge more or less rapidly, and according to the amount of irritation and'increased nutrition which results, is the consequent amount of growth. It frequently happens, however, that if the increased amount of cell elements can find a ready exit, they retain their normal type for a certain time, and on the cessation of the cause, they cease to be formed or accumulated, and the growth disappears. But when they assume a power of independent development, this is not so readily accomplished. In this case they continue, and, by the permanent stimulation to growth, form persistent tumours. Again, the enlargement of glands in the neighbourhood of cancerous and scrofulous ulcers or growths is not necessarily caused by the pre- sence of cancer, or tubercle in them. I have frequently examined en- larged axillary glands, which have been removed with cancerous breasts, and found nothing but simple hypertrophy of those glands. In the case of an extensive epithelioma of the thigh, for which amputation was performed by the late Mr. R. Mackenzie, the inguinal glands on the aftected side were greatly enlarged. After the death of the individual, 1 found no epithelioma in those glands, but again only simple hyper- trophy. But if this condition be allowed to remain for any length of time, "epithelioma as well as cancer does form in them, or simple and tubercular exudations are thrown out, which assume the character of pus or tubercle. It follows that enlarged glands are not a necessary proof of the extension of certain growths secondarily, and that, as we shall subsequently see, their commencement, instead of discouraging, ought perhaps in certain circumstances to lead the surgeon to an early excision of the tumour. Epithelial Growths. — Epithelioma. The epidermic and epithelial cells are continually thrown oft' from the 174 PRINCIPLES OF MEDICINE. skin and mucous membranes, and new ones are as constant!}^ formed. Numerous circumstances may arise, which induce their production in greater numbers, or their accumulation in particular parts. In this case they may soften and give a morbid character to fluids, as that of the urine, or they may become indurated, causing thickenings or swellings on the mucous surfaces, callosities, or tumours of the skin. Structures composed of epidermic growths, as hair or horn, may become excessive, or arise in parts which are unusual. Lebert was the first to point out that many of the tumours hitherto called cystic, fibrous, and even can-, cerous, belong to this class of growths. In all cases, they consist of an increased number of epidermic or epithelial cells, more or less com- pressed together, frequently united by filaments of fibrous tissue, and supplied by blood-vessels. The term epithcUoma, first introduced by Hannover, may be appropriately applied to the entire group. The following are the principal forms assumed by this kind of growth : — 1. Corns and CaUosiiies consist of a local hypertrophy of the epider- mis, and are composed of numerous epidermic scales condensed into an indurated mass. The corn is a distinct rounded or acuminated tumour, varying in size from a barley-corn to that of a pea, more commonly surrounded by indurated epidermis. On examining a vertical section under high magnifying powers, it appears irregularly fibrous, but on making a horizontal section these are shown to be the edges of epider- mic scales, each of which has its distinct nucleus. Occasionally these cells soften and separate from each other, constituting the soft corn. Callosities of the skin exactly resemble corns in structure, but are dif- fused over a greater surface. Both corns and callosities are occasioned by interrupted pressure upon any part of the skin. To a certain extent they protect the delicate nervous filaments below. At other times, from their bulk or hardness, they cause increased pain whenever the pressure is modified or increased. Corns are common on the feet from undue pressure of the shoe ; callosi- ties occur on the knees of housemaids, on the hands of handicrafts- men, sempstresses, etc., or in any other portion of the surface exposed to pressure. The cure consists in removing the cause. We have fre- quently observed, that during an attack of fever and the subsequent con- .valescence, the corns and callosities on the feet of patients have dis- appeared, having " grown out," as it is called. Changing the shoe or bootmaker, or obtaining another last, has been known to remove them. 2. The scaly skin diseases must be classified among epidermic growths. Accumulations of epidermic scales, upon a reddened and indurated sur- face, constitute their characteristic features. In p>S'^'>'^'^^^^ they are gathered together in considerable masses. In pityriasis the scales are smaller, are more easily separated from the surface, and frequently asso- ciated with minute cryptogamic vegetations. The flattened and im- bricated form of ichthyosis is also composed of similar accumulations of epidermic scales, but without the reddened surface. (Fig. 85.) 3. War tsand Condylomata are also, for the most part, composed of epidermic cells condensed together. The wart consists of projections of a papillary form, varying in size, and occurs under circumstances where pressure does not take place. These growths appear to be constitutional, EPITHELIAL GROWTHS. 175 or associated with peculiar states of tlie body. Thus condylomata and Fi^. 203. Fig. 204. warts are frequently found round the margins of the anus, vulva, and penis, in syphilitic individuals. Warts, assuming the form of cauliflower ex- crescence, often arrive at a large size in such situations, weighing even several pounds. They frequently form on the hands of young persons, and are sometimes found in other parts of the body, coming and going without any obvious cause. Condijlomata, when closely examined, seem to be made up of a con- geries of papillae {^papilloma), sometimes flattened at the top, so that they cannot be separated ; at others, presenting fissures or sulci which lead down to a common stalk. Sometimes the papillfe are small and rounded ; at others, elongated and en- larged at their extremities. The tumours thus formed may be only the size of a pin's head, or may be so large as to weigh several pounds. In the latter case the central portions seem to consist of a fi- brous structure, probably an hypertrophy of the dermis, which is supplied with blood-vessels (Fig. 206). Their surface sometimes is smooth, resembling thick- ened epidermis ; at others it is lobulated, composed of rounded groups of papillfe, resembling externally a cauliflower. These tumours, when small, are almost wholly composed of epithelial scales, which assume a square or elongated form, their nuclei being for the most part very distinct. In the larger growths the sur- face is similarly composed, but internal- ly we find more or less areolar tissue, supplied with blood-vessels. Fig. 203. Warts on the penis. One-fourth the natural size. — {Adon.) Fig. 204. Summit of a papilla from a wart. Fig. 205. Perpendicular section of a papilla from an acuminate condyloma, after the addition of acetic acid, a, Vascular loop — internal to which is fibrous tissue form- ing the axis of the papilla — outside are nuclei, h, b, Basement membrane, c, c, Epidermic cells.— ( Wedl.) 250 diam. 176 PRINCIPLES OF MEDICIXE. snipping oif a small isolated papilla from such a tumour, and examining it entire, it presents a conical or round projection, covered with epider- mic scales, as in Fig. 204. When a vertical section of it is made, we ob- serve a vascular loop, surrounded by basement membrane, external to which are layers of epithelial cells varying in thickness (Fig. 205). The Ver- ruca Achrocordon is a peculiar epi- dermic tumour, furnished with a cen- tral canal, through which blood-vessels ramity abundantly to all parts of the "'°''""' tumour. The central parts of such tumours are composed of fibrous structure (Fig. 206) ; externally they consist of epidermic scales, arranged concentrically round the central vascular part, which, if cut into, gives rise to great haemorrhage. ( Vor/el.) All these tumours may soften and ulcerate on the surface, and, under such circumstances, give rise to purulent and ichorous discharges. 4. Another form of epithelioma is one which frequently commences as an ulcer, although sometimes it is preceded by slight induration of or a small wart on the part affected. It is common in the under lip, in the tongne, and in the cervix uteri. In the lip there may often be observed a furrow or groove in the indurated spot or wart, in which the ulceration com- mences. This slowly extends, with indurated, thickened, and raised margins, is cir- cular and cup-shaped, its sur- face sometimes covered with a white cheesy matter, at others with a thick crust or scab (Fig. 207). It slowly extends, until it involves a greater or less portion of the lip and neighbouring parts, pouring forth a foul ichorous discharge. In the tongue, the disease follows a similar Fig. 2:7. course ; the base of the sore, however, is generally more fungoid or papillated on the surface, and ex- ceedingly dense, owing to the close impaction and compression together of laminae of epithelium. These on section jiresent a mass having a white sur- Fig. 206. Transverse section of the base of a condyloma. The dark shading in the centre and radiating hnes, represent dense fibrous vascular tissue. — ( Wedl.) Fig. 207. Ulcerated epithelioma of the lip. — {Liston.) EPITHELIAL GROWTHS. 177 face, with a terniency to split up and separate, are dense to tlie feel, and do not yield on pressure a milky juice (Fig. 208). On the cervix uteri similar ul- cers are very common, with hard irregular edges, yield- ing a copious ichorous dis- charge, and causing more or less thickening of the neigh- bouring textures. The so- called cauliflower excres- ^'='- ^OS- cence is a form of epithelioma; so also are the cancer of the scrotum of the chimney sweeper, certain forms of rodent ulcer, and of noli me tangere. An epithelioma of the hand is well figured by Mr. Paget,* and so also is a remarkable one in the interior of the stomach by Professor A. Retzius.f In all these cases, the ulcers, when examined microscopically, present ^1 f f^i J^^^-C: y r ■. r ]f:, \: S\ Ti%. 209. / on the surface masses of epithelial cells in all stages of their develop- ment. Some spherical and nucleated are about the xoVot^^ ^^^ ''^^^ "^^^^ in diameter, others are much larger; both often resembling cancer-cells when isolated or viewed alone, but associated with flattened scales, varvino- in shape and size, sometimes occurring in groups adherent at their edges, at others mingled together in a confused mass. Many of the cells and scales often reach an enormous size (Fig. 210), and as they become old, split up into fibres. These elements are commonly mingled with numerous molecules and granules, naked nuclei, fusiform, granular, and pus cells. Below the surface the epithelial cells may be seen more * Surgical Pathology, vol. ii. p. 417. f Museum Auatoniicum Holmiense. Sect. Path. Tab. 7. 1855. Fig. 208. Seetiou of an ulcerated epithelioma of the tongue. Natural size. Fig. 209. Epithehal cells compressed together, immediately below the surface of the ulcer, Fig. 208. Fig 210. Epithelial cells, one of them very large, in white curdy matter squeezed from the duct, seeu Fig. 208. Fig. 211. The same, seen in mass. 250 diain. 12 178 PEINCIPLES OF MEDICINE. or less compressed and condensed together, and ^vlien the ej^ithelioma is Fig. 212. Fig. 213. chronic, and the structure dense, these present concentric laminae sur- rounding a hollow space or loculus, evidently owing to the compression Fig. 214. Fig. 215. Fig. 216. together of numerous epithelial scales. This peculiar appearance, some- times called " cell nests," is characteristic of this form of epithelioma Fig. 212. Concentric laminse of condensed epithelial scales, from the lower portion of the white matter seen Fig. 208, with epithelial cells, and fragments of muscular fasciculi. Fig. 213. Muscular tissue immediately below the white mass Fig. 208. Fig. 214. Epidermic scales, in mass and isolated, from the surface of an epithelioma of the scrotum, in a chimney-sweep. Fig. 215. Group of deep-seated cells, in the same case. Fig. 216. The same, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 179 (Fig. 212). On breaking lliem up, they exhibit a variety of forms, in which their epithelial character is visible on the one hand, and the fragments of concentric circles are seen on the other. The lymphatic glands in the neighbourhood of such ulcers liave a great tendency to be secondarily atfected, in which case they enlarge, soften, and easily break down under the finger. Not unfrequently they contain a yellow cheesy-looking substance, which, under such circum- stances, represents fatty degeneration, analogous to the reticukim of cancerous formations. On crushing a portion of the altered glandular substance between glasses, it presents the appearances represented Fig. 217. If the concentric masses are broken down, the individual epithelial ;r Fi? 217 cells are here also seen to be of various fantastic shapes, in which fragmentary portions of circles are detectable (Fig. 217). In the yellowish portions the nuclei are composed of fatty granules, and the cells themselves are molecular, and mingled with numerous oily particles (Fig. 218, also Fig. 92). A modification of this form of epithelioma occurs on raucous surfaces, especially in the urinary bladder, and has been variously called villous cancer, dendritic veoetation ..«-<;::5^..,^ o m^ (Zottenkrebs of Rokitansky). It forms a fungous projection, having a fibrous basis which is elongated, into branched stems, supporting villi, more or less aggregated together, and covered with a layer of epithelial cells. It is soft, and readily breaks down under the finger, the pulpy matter exhi- biting under the microscope numerous irregularly-shaped cells, partly Fig. 217. Fragments of the concentric masses figured, Fig. 212, from a lymphatic gland. Fig. 218. Epithelial cells, in yellow cheesy matter, of the same gland. Fig. 219. Cells in pultaceous white matter, from a fungoid epithelioma of the urinary bladder. Fig. 220. The same, after the addition of acetic acid. 250 diam. 180 PEINCIPLES OF MEDICINE. fibrous, aixl partly epithelial, in various stao-es of development (Fig. 219). 5. Hairy formations. — Great varieties exist in different individuals regarding the amount of hair on their body. Some men have been known to be as hairy as certain of the lower animals. Patches or groups of hair, seated on a somewhat indurated base, may frequently be seen scattered over the surface in parts usually smooth ; these constitute a form of so-called mole on the skin. Hair has been found on the surface of the mucous membrane, and even in the lungs ; and is common in encysted tumours, especially of the ovary and testis. In several such cases I have found the root of the hair implanted in a follicle, at other times loose, with the roots of a bulbous form exactly resembling those on other parts of the body. The point of the hair is generally somewhat truncated, presenting at its extremity two or more fibres, produced by the longitudinal splitting up of the hair. In length they vary from one quar- ter of an inch to several inches. 6. Horny i^roductions. — Under this head may be classed the pi-ominent growths in some forms of ichthyosis ; tumours re- sembling warts, but so in- durated as to resemble horn, and true horny ex- crescences growing from the surface. In some forms of ich- thyosis^ the growths stand out as distinct spines, broad on the surface, nar- row at their insertions, like columns of many sides accurately fitting to their neighbours. Horny tu- mours occasionally occur, varying in size from a bean, or extending over a space the size of half- a-crown. Many cases are on record of tiue horn having gTowu from the surface, especially from the head, originating in some sebaceous follicle. Fig. 221. From an old preparation in the Edinburgh University Museum. The medal attached to it bears the following quaint inscription—" Tliis horn was cut by Arthur Semple, ehirurgeon, out of the head of Elizabeth Low, being three inches above the right ear, before these witnesses, Andrew Temple, Thomas Burne, George Smith, John Smytone, and James Tweedie, the 14th of May 1671.— It was growing seven years ; her age 50 years. Natural size. T\s. 221. VASCULAR GROWTHS. 181 Tliev have grown several inches long, as seen in Fig. 221. On making a section of these productions, they are found to be identical with the structure of true horn in the lower animals, or with that of the nails on the hands and toes. They consist of condensed epidermic scales, which, on the addition of acetic acid, assume all the characters of such structures. Vase ular Groivths. — Angionoma. Vascular growths arc formed by an increase in the dimensions or number of the arterial, capillary, or venous vessels. Several growths already described, as well as such as are of a cancerous nature, are very vascular ; indeed, so much so, that in some cases the slightest touch causes alarming ha?morrhage, as in the case of so-called uterine polypi, and fungus hajinatodes. No doubt there is considerable increase of vas- cular growth in such tumours, but their basis is formed of other mate- rial, — they are not wholly vascular. This term is more properly applied to those diseases which have hitherto been ^.^ — ^ denominated aneurism, erectile tumours, and varix. 1. Aneurism is an arterial swelling, which may vary in size from the slightest possible dilatation of the calibre of the vessel, either wholly or partially, to the formation of enor- mous tumours, larger than the human head. Fig. 222. In sucli cases, we find the growth to consist externally of the dihxted and hypertrophied structures of the vessel itself, or of the tissues in its immediate neighbourhood, and of lay- ers of blood, more or less coagulated within it. The varieties of Aneurism are numerous, but the principal are — 1. Aneurism hy dila- tation, in which the whole circumference of the vessel is dilated. 2. Fig. 222. True saccular aneurism of the aorta, nearly filled with coagulated clot. — One-third the real size. — {After Hodgson, slightly modified.) Fig. 223. Remarkable spontaneous varicose aneurism, formed by communication between the vena cava and the aorta at its bifurcation. A, Aorta; B, Vena cava ; C, Aneurism ; D, Situation of a round aperture somewhat larger than a sixpence, through which the communication between vein and artery was kept up. — (Syme.) 182 PRINCIPLES OF MEDICINE. Saccular^ also called true Ane^irism, in which one portion or side of the vessel is dilated into a sac. 3. J^alse Aneurism, in which the coats of a vessel have been ruptured. It has been called ^;r/w^<^^'e when all the coats are divided, as by a wound, and consecutive, when it is consequent on ulceration or rupture of the internal and middle coats. 4. Mixed Aneurism, in which, after dilatation, general or partial, of all the coats of a vessel, the internal and middle ones burst, and a false aneurism is superadded. 5. Dissecting Aneurism, in which there is laceration of the internal and middle coats, so that the blood becomes infiltrated between the coats of the vessel, separates them for a greater or less dis- tance, and bursts externally at some distance from the internal lesion. 6. Hernial Aneurism, in which the external and middle coats are lace- rated, and the internal protrudes through tliem, forming a hernial aneu- rismal sac. 7. Aneurism hij anastomosis, in which an artery, by an Fig. 224. unnatural communication with a vein, causes a pulsating tumour in the latter. The tendency of these growths is to burst externally or internally into spaces Avhere least resistance is offered, but occasionally the clot of blood in the interior coagulates to such an ex- tent as to close up the cavity, prevent influx of fluid, and cause spontaneous cure — a result which is observable in the figure of a very rare specimen of aneurism of the left coronary artery described by Dr. Peacock.* The special Fig. 225. pathology of these growths, however, is far too extensive a subject to be entered upon in this place. * Monthly Journal of Medical Science, March, 1849. Fig. 224. Aneurism of the coronary artery, completely filled with coagulated clot. Natural size. — {Peacock.) Fig. 225. Section of erectile tumour. — {Miller, after?) VASCULAR GROWTHS. 183 2. Erectile growths are generally soft ; for the most part situated in tbe subcutaneous tissue, tlae skin covering them being of unusual deli- cacy. When compressed, they may be gradually emptied of blood, which returns like water into a sponge on removing the pressure. For the most part they are congenital. When the arteries are numerous in them, they have a brownish or reddish colour, and pulsate during life. When the veins abound, they are of a blue or purple colour. Their texture consists of numerous capillaries, more or less distended, mixed with arteries and veins, the interstices of which are filled up by areolar tissue. A section presents a spongy texture, composed of fibrous bands closely resembling the appearance of the corpus cavernosum penis, with areoke or spaces into which the blood enters (Fig. 225). The section of a fresh tumour is not unlike that of a sponge soaked in blood. In structure it is composed of vessels of all sizes, abounding in capillaries, which are more or less sacculated or aneurismal, and anastomose freely with each other. In one case of erectile growth in the liver, I found Fi?. 226. the intervascular structure to consist of caudate and branched cells,' and Fi2. 227. in another in the brain, I found it loaded with earthy salts. Fig. 226. Varicose cutaneous vessels of tlie anus in the subcutaneous cellular tissue. Fig. 227. Dilated papillae of the skin, cut horizontally, the liglit-coloured papillary structure containing dilated vessels — ( Wtdl.) 60 diani. 184 PEINCIPLES OF MEDICIXE. Varix is a permanently enlarged and tortuous vessel. Swellings from this canse are for the most pai't venous, and may exist in various parts of the body, but are frequent in the saphena veins of the inferior extre- mities, the spermatic veins (varicocele), and htemorrhoidal veins {haemor- rhoids). In all these cases the veins gradually enlarge, and then be- come distended, tortuous, and coiled up. Several of these, accumulated Fig. 22S. together, may produce knotty swellings in the legs, cause the testicle to assume an unusual size, or produce tumours which, during defsecation, are protruded beyond the margin of the anus. Such growths may ulcer- ate, and cause death by haemorrhage, or they may be spontaneously obliterated by the formation of clots within them. An artery rarely becomes varicose. The enlargement of vascular growths, for the most part arises through dilatation of the vessels ; no new materials are produced in them, with the occasional exception of such as arise in the clot of blood within them, viz. fibrous or albuminous laminae, or calcareous masses. Through the presence of these, the vessel becomes obliterated, and gradually assumes the density and appearance of ligament. Fig. 229. m Fig. 280. Fig. 231. Fi?. 232. Fig. 2-33. New vessels constitute one of the most common pathological forma- Fig. 228. Varicose vessels in the caput trigonum vesicae. — (Wedl.) Fig. 229. Inner layer of umbilical artery of cal<^ eight inches long. — [Drummond.) Fig. 230. Succeeding layer in the same vessel, composed of spindle-shaped cor- puscles. — {Drummond.) Figs. 231 and 232. Layers more external in the same vessel, in different stages of development into fibres. — {Drummond.) Fig. 233. Common carotid artery of an embryo calf two inches in length, showing diSerent directions of the fibre cells. — {Drummond.) 200 diam. VASCULAR GROWTHS. 185 tions. In the embryo the capillaries originate in independent cells, Avhicli throw out arms or prolongations that unite with one another (Figs. 234 and 235). The larger vessels originate in globular cells which become fusiform, and arrange themselves, some longitudinally and others trans- versely, to constitute the different coats of the vascular wall (Figs. 229 to 233). In the adult the ob- servations which have been made in connection with this subject, have led to three theo- ries. 1st, That new vessels are of independent origin, and that they, as well as the blood they contain, spring up in a blastema according to the general laws of cell formation. 2d, That the globules of the blood, escaping from the vessels, channel a way through the surrounding exuda- tion, and thus form new vessels. 3d, That the walls of the old Fig. 234 vessels themselves at particular places present bulgings and irregularities, which become pushed out more and more by the vis a tergo, and so form new channels. An inquiry into this subject is surrounded with difficulties, but all the results of modern research tend to the conclusion, that in exudations new vessels for the most part have an mdependent Fis. 236. Fis. 28T. orio-in, being formed as in the embryo ; although old vessels may occa- sionally send out off-shoots or prolongations. Thus in lymph we some- times observe cells, in all stages of development of the spindle-shaped and branched forms, which, "according to the observations of Drum- mond,* and more recently of Billroth,! by their fusion, or by their * Monthly Journal of Medical Science, November, 1854. f Billroth Ueber die Entwicklung der Blutgefasse, Berlin, 1856. Ficr 234 Stellate cells in the tail of the tadpole, developing into capillary vessels. Fi^. 235. Capillary vessels in different stages of formation from stellate cells, m the eye of the foetal ca\i—{Drummond.) Fio- 236. Branched cells in lymph exuded on the peritoneum. Fio- 237. Vessels in an early stage of formation, from a colloid tumour ot tue , 1 °' 250 awm. back. 186 PEINCIPLES OF MEDICINE. arrangement side by side, form capillaries of various magnitudes. These capillaries afterwards unite themselves with the pre-existing vessels. Cartilaginous Growths. — Enchondroma. Cartilaginous growths were first described by Miiller, under the name of Encliondroma (Osteochondrophites of Cruveil- hier). In the soft parts, they are surrounded by an envelope of cellular tissue, and in the bones by a bony capsule. In the first case they occur, although very rarely, in the glands, as in the parotid or mamma. In the second case they are most common in the bones of the extremities. The tumours may be round and smooth, or rough and nodulated from several of them being accu- mulated together. Though hard to the feel, they often present a peculiar elasticity. They crunch when cut with the knife, usually present a smooth, glistening surface, and are not unfrequently more or less soft, pulpy, gelatinous, and even diflluent in some parts of their substance. They are rarely met with. In structure, enchondroma presents all the characters of caitilage — f 1/ \ ^ / ^ r c^\ U — V I ^ \\f ^ ffi 11.7 \1^' .\/W Fig. 240. Fig. 241. that is, nucleated cells varying in size, isolated or in groups, situated in a hyaline substance. A network of filamentous tissue runs through the substance of the tumour, forming areolae, in which blood-vessels ramifv. Within the areolae so formed, the cartilage is found. These two ele- ments vary as regards amount in diff'erent tumours. Sometimes the cartilage is in excess, resembling that in young animals, or that in the Fig. 2.33. Fig. 2.38. Enchondroma of the hand and fingers. The tumour, of which a section has been made, is enclosed in a bony capsule. One-fifth natural size. — {Milter.) Fig 239. Structure of a firm nodule in an enchondroma of the humerus. The right of the figure represents, above, mineral deposit in and around the cells, and below, some isolated cartilage corpuscles. Fig. 240. The same, after the addition of acetic acid, rendering the whole, and especially the nucleus, more transparent. Fig. 241. The cartilage cells and fibrous ti.ssue separated and broken up, with numerous molecules in a nodule of the same tumour which was soft and in some places diffluent. 250 diam. CARTILAGINOUS GROWTHS. 187 foetus. At others the fibrous element abounds, the whole being- similar Fis. 24-2. Fig. iU. Fig. 243. Fig. 246. in structure to fibro-cartilage. Between these two extremes there is every gradation. Occasionally it presents all the characters of articular 5 c a Fig. 246. cartilage. I have seen all these kinds in one tumour. The cells present an extraordinary variety in their size and form, being sometimes large and embryonic (Fig. 239), at others small (Fig. 242). They may con- Fig. 242. Small cartilage with round granule cells, in the pulp scraped from the section of an enchondroma, which in colour, density, and apijearance, closely resem- bled a potato, or so-called Solanoma. Fig. 24.3. The same cartilage cells, after the addition of acetic acid. Fig. 244. Thin section of a firm portion of the same tumour. Fig. 245. Fine filaments which interlaced the cells, these having been washed out. Fig. 246. Great variety of cell forms containing one or more nuclei, observed in an enchondroma of the femur ; at «, nucleated cells are enclosed in areolar tissue ; at b. the cells nucleated and non-nucleated possess branched processes ; and at c, are remarkable bodies of different sizes, with fine radiating lines. — ( Weill.) 250 diam. 188 PEINCIPLES OF MEDICINE. tain from one to twenty nuclei (Fio-. 246). In shape they may be round, oval, irregular, or branched. They may also be associated with nume- rous granule cells, as in Fig. 242, from a specimen of enchondroma, removed from the integuments of the neck by Mr. Miller, which on sec- tion presented the smooth and moist surface of a cut potato. — (Sola- noma.) (Figs. 242 to 245.) Not unfrequently a bony nucleus may be observed in a nodule of enchondroma, and sometimes all stages of transformation into perfect bone, may be observed in them. Some of the exostoses, to be spoken of inunediately, are owing originally to an excess of cartilaginous growth. Enchondroraatous tumours are continually mistaken for cancerous growths, a fact pointed out by Miiller. They are usually denominated osteosarcoma. Not unfrequently they soften, and under such circum- stances, present all the external characters of what is called soft cancer. 7. Fig- 24T. Fig. 248. Fig. 249. This softened portion, even when examined microscopically, may lead to error, as the cartilage cells which then float loose, mixed with granules and the debris of the tumour, very much resemble those in cancerous growths. They may be distinguished, however, by the action of acetic acid, which aff"ects the whole corpuscle alike, instead of producing, as in the case of cancer, a marked difference between the external cell-wall and the nucleus (Figs. 240, 249). Another form of cartilaginous growth is observed in the so-called pulpy degenerations and ulcerations seen in articular cartilage. Goodsir was the first to point out that such ulcerations were in part owing to an increased growth of the cells ; and Redfern, whilst he has confirmed this statement, has described and figured all the various changes observ- able in those cells, and in the inter-hyaline substance in the difterent diseases of cartilage in man, and many of the lower animals. In conse- quence of his researches it is now ascertained that the cartilage cells enlarge, and, as Goodsir pointed out, there are gradually formed within Fig. 247. Thin section of an enchondroma, with a bony capsule, growing from the ischium and pubis. Fig. 248. Separated cartilage cells from a softened portion of the same tumour. Fig. 249. The same, rendered more opaque, after the addition of acetic acid. 250 di. CARTILAGINOUS GROWTHS. 189 them a mass of secondary ones. These burst into the surrounding hya- •\>r. "t ^. ^J ^1*^^*)^ v\^'9^^;4^^^! •'1 , \ "JV -^ 0, ^7^^-^ ■ (■' Fiji. 250. line substance, give it unusual softness, and cause it to swell. At the ■*^ i$M Fi- 252. same time the hyaline substance fibrillates, and splits up, a change best observed on the villous and rough abraded surface so commonly seen in diseased joints. Mechanical injury inflicted on these structures produces Fig. 250. Diseased liuman articular cartilage, from a scrofulous joint, showing tlie enlargement of the coriDuscles, the increase of nuclei within them, and tlieir escape into the intercorpuscular softened substance. — {Kedfern.) Fig. 251. Similar alteration in costal cartilage of the dog, caused by the passage of a seton thirty-four days before death. — {Redftrn.) Figs. 252 and 253. Different appearances of enlarged cells in diseased human articular cartilage. — {Eedfern. ) 190 PRINCIPLES OF MEDICINE. the same results, showing that both it and disease operate by stimulating cell nutrition and growth (Figs. 250 to 257, and 275). Fis. 254. =akoi_: Fisr. 255. Fig. 25". Osseous Groivths. — Osteoma. "We have seen that in many cartilaginous growths deposit of bone may take place to a greater or less extent. In such cases the new cartilaginous Fig. 254. Tertical section of cartilage from the surface of the patella, showing the fibrous splitting up of the hyaline substance. — {Bedfern.) Fig. 255. Another vertical section through the same diseased articular cartilage; a, free surface. — [Redftrn.) Figs. 256 and 257. Two fibrous projections, from the flocculent suiface of a dis- eased human semilunar cartilage. — {Bedfern.) 250 diam. OSSEOUS GROWTHS. 191 0^ Fis. 258. \ \ Fist. 259. Y\»•«. accumulated within cvsts, the result of trans- •i:-C?4W o»«^ivo \of^ formation of their contents; in the centre of colloid masses; in chronic exudations, and extra- vasations of blood, presenting a niilky, yellow, or fawn-coloured hue ; or in the blood, urine, °" ^^*' and other fluids, giving them a chylous character. Indeed, the presence of fatty molecules may be said to be almost constant in morbid products; and, when collected together in masses, they constitute organic lesions of the greatest gravity. Fatty Degeneration of Cells. — It was shown by Reinhardt, that all kinds of cell formation, under certain circumstances, undergo the fatty degeneration. The manner in which this is accomplished is in all cases the same. A few fatty molecules first form between the nucleus and cell-wall. These increase in number, and some of them apparently are fused together to produce larger ones. This process goes on until at length the whole contents of the cell consist of fatty molecules and S;o?S-ii»« Fig. 299. granules. The nucleus is now no longer visible, and in many cases Fig. 298. Fatty molecules in groups, from the opalescent or white opaque centres of large colloid masses in the ovary. Fig. 299. Granular corpuscles and masses from cerebral softening, a, Nucleated cell with a few granules ; b, granules within the cell, partly obscuring the nucleus ; c, granules over the nucleus ; d, granules within the cell, no nucleus visible ; e, cell nearly filled with granules ; f. cell completely tilled with granules ; g, cell contracted in its middle ; h, granular mass, the cell-wall having dissolved ; i and k, granular masses peeled ofl' from the vessels. 218 PRINCIPLES OF MEDICINE, wastes awa}^ as if from pressure. Occasionally, this fatty deposition of molecules takes place within the nucleus in the "first instance. (Fig. 92.) In either case the cell-wall, distended by the accumulation of fatty par- ticles, at length gives way, and the included oil granules either separate, or for a time adhere together in granular masses. Sometimes these bodies are easily ruptured by external violence ; at others they are more resistant, and the oily matter is forced through the cell- wall, and collects outside, whilst the cell itself is more or less collapsed. In this way, col- lections of fatty granules and granular cells take place in the ducts of all glands which are lined by epithelium ; in the air vesicles of the luno- and in the bronchi ; in the cells of the liver, causing fatty degeneration of that organ ; in the shut sacs of vascular glands, as the sple'en, and in all cell formations in exudation, especially those of pus and cancer. In stall-fed animals, a moderate accumulation of fatty granules in the interior of the hepatic cells is a normal condition ; and the amount of fat in various tissues, which separates health from disease, is, under a variety of circumstances, impossible to determine v/ith exactitude. Fatty Degeneration of Muscle. — There can be no doubt that the fibro- albuminous substance constituting flesh is capable of undergoing a trans- formation into fat. Of the exact chemical nature of that transformation .ffc' "^ _ , i-P:ia^li )i?U?:H'^ P^/^f.*l a^ ..%«^ti^VJi'^': I w- mmMm ^^ mmM4Mm Ifl ^^^^^ ' Fig. 801. Fig. 302. ' Fig. 303. we have yet to be informed ; but it may not only be observed in the dead body, but may be produced artificially, by exposing muscle to a running stream of water, whereby it is changed into adipocere. In Fig. 300. Granular corpuscles acted upon by pressure, a, Some of t]ie oily gra- nules made to coalesce; b, oil forced through the cell-wall; c, the same with collapse of the cell-wall; d, rupture of the cell-wall; e, dislocation of the nucleus. 250 dia7n. Fig. 301. Early stage of fatty degeneration of voluntary muscle, a, The muscle breaking across; b, the fibrilhe, easily separated. In both specimens the tissue is soft, although the transverse strife are still visible. — ( Wedl.) Fig. 302. Advanced stage of fatty degeneration in the muscular fosciculi of the heart. The transverse striaj have disappeared, and the fasciculi are wholly composed of oil granules and globules more or less aggregated together. — ( Wedl.) Fig. 303. Another example of advanced fatty degeneration of voluntary muscle, the fasciculi presenting various degrees of the alteration. 250 diam. FATTY DEGENERATION. 219 voluntaiy muscle, "vve observe tliat tlie degeneration commences witli diminished distinctness of the transverse strite, especially at the circum- ference of the fasciculus. As this extends inwards, minute molecules of fat occupy the position of the stria?, and at length obliterate them ; gradually these coalesce, globules of various sizes are formed within the sarcolemma, and the normal structure of voluntary muscle disappears. During the early changes the fasciculus becomes soft, exhibits a tendency to crack crossways, and ultimately is so pulpy as to be capable of being- squeezed easily into an amorphous mass, from which large oil drops exude. To the naked eye, the muscular substance becomes paler, and more fawn- coloured, and at length yellow, and its normal density is greatly dimi- nished. These changes are easily observed in the heart, in which organ they have been made the subject of special research by Ormerod, Paget, Quain, and others. The histological and clinical researches of Dr. R. Quain* on this subject are of the greatest importance. All the voluntary muscles, however, are susceptible of undergoing a similar lesion, and it not unfrequently occurs in those of the lower extremity after long continued paralysis, disease of the hip joint, or other lesions which necessitate immobility of the parts. In this case, and occasionally in the heart itself, in addition to the transformation of the muscular fasciculi above described, adipose tissue accumulates between them, and by compressing their substance adds to the rapidity and com- T^"r^r f'''''''^'^-^-'f'^f^T^^^^ ^pj^^TWj I Fig. 304. Fig. 305. pleteness of the transformation. In such cases the muscles are of a pale yellow colour, yielding on section large quantities of oil, while they pre- serve their usual form and fibrous look. I have seen all the muscles of * Med. Chir. Trans, vol. xsiii. Fig. 304. Fatty degeneration of the 23Soas magnus muscle of a lad, who died with morbus coxarius. a, Muscular fasciculi in which no traces of transverse strife are perceivable. The longitudinal stria? are still not quite obliterated, although mingled with numerous fattj- granules, b, Muscular fasciculi, whollj' composed of minute molecules and granules, with no traces of either transverse or longitudinal strisB. c, Fat cells of various sizes, running between and encroaching upon the flisciculi. Fig. 305. Other fasciculi from another portion of the same muscle, after the addi- tion of aether. The adipose cells have been made round and somewhat flaccid ; the nucleus consists of a congeries of brownish granules. 250 diam. 220 PEINCIPLES OF MEDICINE. the lower extremities so affected. Occasionally, while some muscles exhibit this transformation in its most advanced stage, others close beside them present their normal red colour, so that the limb on dissection resembles the alternate red and fatty streaks of bacon. In this case the degenerated muscle has the whole of its fasciculi transformed into adi- pose cells, with nuclei, as seen in Fig. 305. In involuntary muscles fatty degeneration may also be observed, althougli it is by no means so common as in voluntary ones. In this case oily molecules are deposited in the elongated fusiform cells compos- ing the texture, and by their pressure on the nucleus cause its disap- pearance. "Whether the distended pregnant uterus shrinks to its nor- mal proportions after delivery wholly in consequence of such a degeneration (Heschl) is a point not yet determined. But there can be no doubt that many of the greatly enlarged fusiform cells of the organ (Fig. 141), do become more or less crowded with fatty granules (Fig. 306). Fatty Degeneration of Blood-vessels. — The lai'ger blood-vessels, espe- Fig. 306. Fig. 80r. Fig. 808. .^feo*^* Fis cially the arteries, are very commonly the seat of a fatty degeneration, generally called atheroma. It presents the appearance of a'whitish or yellowish cheesy, but sometimes indurated and brittle substance, de- posited between the coats of the vessel, and often protruding on its inner surface. This deposit consists of numerous fatty granules, mingled Fig. 306. Enlarged fusiform cells of the pregnant uterus, after delivery, filled with fatty granules. 250 diam. Fig. 307. Atheroma of a blood-vessel. Natural size. Fig. 308. Fatty granules, oil drops and granule cells, with crystals of cholesterine from broken down atheroma of an artery. Fig. 309. a and h. Two groups of fatty molecules from atheroma of artery, 250 diam. FATTY DEGENERATION. 221 with crvstals of cliolesterine (Gulliver), to which, when hard and brittle, are added calcare- . ._— pn,,,--— ^^^ .-__^ salts pll'r- ■ !^^V ons amorphous (Figs. 307 to 310). The smaller ves- sels and capillaries are frequently seen to be covered with patches of fattygran- nles, which vary in number from two or ,,_^^^„„,„___ _ three, to large mas- \ \ ^.Yusio.d^ Y ses of them, which '^ ^ c ^ a e infiltrate the neighbouring tissue. The various appearances of these were carefully described and figured by me in 1842,* and attributed to exudations thrown out from the vessel. In 1849 Mr. Pagptf also described the same facts, and attributed them to fatty degeneration of the vessels themselves. Now, without denying the occasional fatty transformation of the walls of minute vessels, and the accumulation Fis. 311. Fig. 312. of fattv molecules within the nuclei, it may readily be seen that for the most part the fatty granules are outside the vessels. Indeed, the * Edin. Med. and Surg \ Medical Gazette. Journal, vols. Iviii. and lix. Fio- 310. Transverse section through the coats of the popliteal artery of an aged woman, who had gangrene of the feet, a, Inner coat ; 6, longitudinal fibre ; c, cir- cular fibres : d, fimbriated and elastic coats loaded witli fatty granules ; e, external areolar tissue.— (TFerfZ.) ^ 200 diani Fig. 311. Cerebral vessels of an aged individual who died of apoplexy, a, Ulti- mate^'capillaries ; h, larger vessel ; c, small artery, with fatty granules scattered over its surface. — ( Wedl.) , . , j Fio- 312 Vessels fi-om softening of the corpus striatum, coated with granules and granSiar masses.— ( Wedl.) 250 dmm. 222 PRINCIPLES OF MEDICINE. extreme tenuity of the capillary wall does not permit of their forma- tion in its substance, as it is much thinner than the granules themselves. Besides, it may frequently be observed that the large amount of fatty granules outside the vessels is enormously disproportioned to the bulk of the latter, and altogether inexplicable by supposing them to be formed in and given off by the vascular walls themselves, which for that purpose must assume a secretive function. I have also seen and figured cell- formations in every stage in the granular fatty matter, constituting soft- ening of the brain. (See Fig. "l 13.) Of these Mr. Paget wrote in 1853,* — " Produced as they are in parts of the brain and cord in which no cell structures naturally exist (for they may be as abundant in the white substance as in the gray), we have yet, I believe, to trace the source and method of their formation." This admission appears to me altogether hostile to the idea of their originating in a degeneration of the vessels, whilst their formation in an exudation, as I have previously described (p. 131), is consonant with every known fact. The true soft- ening of the brain from deficiency of nutrition frequently exhibits struc- tural changes altogether different, as I shall subsequently demonstrate. (See Diseases of the Nervous System — Softening.) Fatty Der/eneration of the Placenta. — The lesion which has received this name from Dr. Barnes and others, was figured by me in 1844,f and likened to that which occurs in certain softenings of the brain. I still hold the same opinion with regard to it, and consider the fatty molecules and granule cells not to be formed by a transformation of placental tissue itself, but of the exudation or extravasation of blood which is poured out from its vessels. The yellowish or fawn-coloured deposits may be infiltrated throughout the tissue of the placenta over a greater or less space, or they may occur in isolated spots forming nodules. They * Surgical Pathology, vol. i. p. 146. f Treatise oa Inflammation. Plate — Fig. 10. Fig. 313. Villi from the placenta of a six months' foetus, a and b, The vessels coated with molecular fatty matter ; c, exudation from the vessel, nearly occupying the whole substance of the villus ; d, chronic exudation outside the vessel, converted into brown pigment. — ( Wedl.) FATTY DEGENERATION". 223 are generally somewhat indurated, and give rise to the idea that they are coagulated fibrin. I have frequently examined them and traced all the changes intermediate between a coagulated exudation or extravasa- tion of blood, and the ultimate conversion of the foreign matter into a mass of molecules filling up the intervascular spaces. Similar observa- tions have been more recently ma presence of this latter tint around ecchymotic spots, Vx and in other situations. Virchow first described in ^. „„. • 1 Fig 326. extravasations of blood prismatic crystals, with rhomboidal bases, often approaching a needle shape, of a yellowish or deep ruby colour, which he denominated hematoidine. They are most frequently found in the sanguineous extravasations of the brain, in the corpora lutea of the ovaries, and in chronic haemorrhages of the liver, ot hydatid cysts, and of other textures, but rarely in pulmonary or cancer- ous extravasations. In size, they vary from the 3 oVo^li to the ^^otli of an inch in their long diameter (Fig. 326). They are transparent, and Fig. 326. Crystals of hematoidine. a, Large oblique rhombic prisms; at +, oblique six-sided prism; b, smaller forms. — (Wedl.) 250 dmrn. 228 PRINCIPLES OF MEDICINE. strongly refractive, insoluble in alcohol, aether, dilute-mineral acids and alkaUes. Concentrated mineral acids caiise them to assume the shades of green, blue, rose-tint, and finally a dirty yellow. Yelloiv Pigment. — The real colour of the blood corpuscles is yellow, and so is the liquor sanguinis in which they are dissolved, and conse- quently all recent exudations of lymph, as well as most kinds of pus and tubercle. Blood, after being extravasated, is broken down and absorbed ; and as the colouring matter becomes less intense, it generally assumes a yellowish tint, as around ecchymotic spots, and old extravasations. Hence, also, the colour of the corpora lutea, and the yellow softenings of the brain, as well as the de^p orange tint occasionally observed as the result of hsemorrhages. The adipose texture, as well as the morbid accumulations of fatty matter, assumes a yellow tint, as when muscle undergoes the fatty degeneration, and the reticulum previously described forms in cancer. There is, however, another source of this colour in the bile, as it con- tains a deep yellow pigment, which, when absorbed into the blood, tinges all the textures, and passes otf in large quantities by the skin and kidneys. The urine, when impregnated with it in considerable quantity, has the colour of porter to the naked eye. When bile, diluted with water, is treated with nitric acid, a marked series of changes in colour ensue. A little acid renders it green, a larger quantity blue, pui'ple, violet, and lastly, a dull red or brown yellow. These changes are sup- posed to be owing to the existence of three colouring matters in the bile, one brown, the cholepyrrhin^ another yellow, the bilifuh'in, both disco- vered by Berzelius, a third the hiUphcein of Simon. AYhether these pig- ments are derived from, or convert- ed into hematine, has not yet been ascertained, though Virchow suspects that they are the same, from the similar changes produced in crystals of hematoidine by the action of acids. Brown Pigments. — During the de- composition of extravasated blood, it has often been observed that the tints it sometimes presents are of a reddish, and sometimes of a bistre brown. Bile, also, when in mass, and inspissated, often assumes this colour. Different ganglia scattered through the nervous system owe their colour to the formation of brown pigment molecules, which are deposited in the nerve cells. The skin, in some races, is naturally brown or swarthy ; the areolae round the nipples as- Flg. 327. Wartlike brown ncevus innternm of the female mamma, a, Epidermic cells, with their nuclei concealed by a dark bro'mi pigment ; i, the nuclei surrounded with a simOar pigment ; c, cells without pigment ; d, reddish-brown pigment, in the substance of an hjpertrophied papilla ; e, nuclei in fibrous texture ; /, vascular loop. — ( Wedl.) ^ V Fi?. 327. ^^^^«P) PIGMENTARY DEGENERATION". 229 surae this tint during pregnancy; exposure to the sun induces this colouration of the skin, and causes freckles, and often large brown patches to appear on it in the fairest women ; many warts and naevi are also of this colour. In all these cases the colour arises from the deposi- tion of a brown molecular pigment, in the deeper cells of the epidermis, and sometimes, as in warty "naevi, from accumulation of dark pigment in minute sacs (Fig. 327). Not unfrequently brown pigment may be observed collected within car- tilage cells, when that texture is diseased in the neighbourhood of necrosed bone, or in death of cartilage itself (Fig. 328). Occasionally, also, it isfound covering placental villi, or situated between the vessel and limitary mem- brane of the tuft, evidently the result of changes occurring in extravasated blood (Fig. 329). Dr. Addison has described a form of anamiia, in which the skin assumes a peculiar colouration, in connection with a diseased condition of the .« i Fi?. 82S. Fig. 329. supra-renal capsules. It presents " a dingy or smoky appearance, or various tintsor shadesof deep amber or chestnut colour; and in oneinstance the skin was so universally and so deeply darkened, that, but for the features, the patient might have been mistaken for a mulatto."* Eleven cases have been published by Dr. Addison, and several others subse- quently by Mr. Hutchison,f where, co-incident with more or less of this bronzing of the skin, the suprarenal capsules were indurated, cancerous, or otherwise diseased. The presumed connection between the functions of these glands, and the secretion of pigment in the integuments, has excited the attention of physiologists and pathologists. The experiments of the former and observations of the latter have recently shown that * On the constitutional and local effects of disease of the supra-renal capsules. 1855. f Medical Times and Gazette. Fig. 328. Atrophied bronchial cartUage, with deposition of brown pigment, a. Cells containing brown granular pigments; h^ cells containing large fat globules; c, secondary cells with fatty granules. The intercellular substance is loaded with and obscured by brown pigment granules. — ( Wedl.) Fig. 329. Placental villi, containing brown pigment from an aborted foetus, 18 inches long. a. Villus, at its termination loaded with brown pigment ; h, one only partially so filled at its summit, but with molecular pigment scattered through its substance.— (Wed?.) 2h^ diam. 230 PRINCIPLES OF MEDICHSTE. there is no real relation between disease of these glands and the amount of pigment in the skin. Dr. Harley,* more especially, has demonstrated that their excision in white and piebald rats, causes no alteration in the health or external appearance of the animals. Numerous cases also are now on record of bronzed skin without alteration in the supra-renal cap- sules, and of extensive lesion of these glands without bronzed skin. Green Pigment. — The cause of green pigment has not yet been deter- mined. AYe have seen that nitric acid produces a grass-green colour when added to bile, and it is possible that the addition of some acid matter to hematine in certain states of combination may produce a similar result. Abscesses of the brain not unfrequently contain pus of a decided green colour, and vomited matters occasionally present the same hue. The fceces in young children are sometimes of a spinach green, which is supposed to result from an altered condition of bile, or from the presence of blood. The contents of cysts frequently contain fluid of different shades of green. In mortification and putrefaction after death, the inte- guments frequently assume a greenish hue. Lastly, morbid growths, especiallv in the bones of the cranium, have been described and figured of a decidedly green colour [Chloroma) by Balfour,t King,;}; and Lebei-t.§ Black P'uimeni. — Black pigment is by far the most common degenera- tion met with, and is found in various situations. Thus ecchymotic ^^. extravasations generally assume a dark purple or -..,.• -.-"'^^^'i'r.. black colour. Vomitings of blood in yellow fever •.^^^;'^^*?*v^' and gastric cancer are frequently dark brown or «%;^ '^- ''•^.¥;;'' ~i black; so also are the foeces after blood has been ^r^':'~ _ ''^ii mixed with them [Mekena), or after taking fer- ''\y. ruginous medicines ; certain softenings of the V -r :■■ stomach itself, of the intestinal glands, and of the entire mucous membrane in cases of dysentery ; i •- - '• the contents of ovarian cysts and other encysted tumours ; intestinal and ovarian cicatrices ; the sordes on the teeth and o-ums in cases of fever ; and mortified or dead parts. "When morbid growths are black they have received the name of Melanoma, and the black colouration of the collier's lung and bronchial glands has been called Palse Melanosis or Black Phthisis. Nothing is more common than to see chronic tubercle surrounded by black pigmentary deposit. Scattered tubercles on the peritoneum are often surrounded by a black rino^, which, when magnified, presents the appearance represented (Fig. 330.) Black patches have occasionally been produced on the skin, appa- rentlv from the secretion of pigmentary matter on the surface, which is capable of being washed off. A case of this kind is recorded by Mr. * Brit, and For. Med. Chir. Review, vol. xxL 1858. \ Edin. Med. and Surg. Journal, vol xliil p. 319. t Monthly Journal of Medical Science. Aug. 1853. g Anatoniie Pathologique, Planche xlv. Fig. 330. Ring of black pigment masses (a) and molecules (6) round a tubercle of the peritoneum. The black tint disappeared after some days' immersion in alcohol. 250 diam. PIGMENTARY DEGENERATION. 231 Teevan,* in the person of a young girl, aged 15, tlie upper part of whose face was covered with a black discolouration. The colouring matter was analysed by Dr. Rees, who found in it carbon, associated under the microscope with short liairs, epithelial scales, and granules and globules of fat. Portions of necrosed bones are often of a black colour, a change which according to AVedl commences at the external portion of the systems of bone corpuscles, disposed round the Haversian canals. The blackening is probably owing to a chemical change of the osseous tex- ture, similar to what occurs in caries of teeth from the action of acid Fis. 332. Fig. 334. Fig. 335. saliva. It is not dependent on an exudation, which in sections of a bone so afi'ccted is nowhere visible (Fig. 331). Black pigment may exist in the form of minute granules (Fig. 332), or of irregular masses scattered throughout a texture (Fig. 333). Some- times the former are found within cells which may be round, Hattened, many-sided, or have irregular prolongations (Fig. 334, 336). This occurs in the choroid membrane of the eye ; in the skin of men and animals during health ; in the melanotic growths so common in grey horses (Fig. 335), in the epithelial cells of the collier's lung, and in certain forms of cancer (Figs. 336, 337). In all these cases the nucleus is some- times clear and colourless, and at other times obscureil by the black pig- ment. Black pigment may also occur in the crystalline form, associated, with hematoidine, in old sanguineous extravasations. It has then been called Melanin. * London Medico-Chir. Transactions, vol. xxviii. Fig. 331. Transverse section of a necrosed Tibia, a, Medullary canals divided transversely ; h, pigment, formed at the junctions of the concentric bone systems ; c, radiating bone canaliculi. — ( Wedl.) 90 diam. Fig. 332. Black pigment molecules from the lung. Fig. 333. Black pigment irregular masses semi crystalline, from an intestinal aggre- gate gland. Fig 33-i. Polygonal cells loaded with pigment, from the surfece of the pericardium. Fig. 335. Cells loaded with pigment, having clear nuclei, from a melanotic tumour of the horse. 250 diam. 9R9, PEIXCIPLES OF MEDICINE. It may be easily shown that the black pigment granules, cells, and crystals, foimd in morbid products, although thev may closely resemble each other to the naked eye, and even under the microscope, are different in their chemical compositions. Thus one kind of black pigment loses colour on the addition of nitro-muriatic acid or chlorine water, whilst another resists not only these agents, but even the action of the blow- pipe. It follows that the latter consists of carbon, while the former is a peculiar secretion formed within cells, or a transformation of the colouring matter of the blood. Blue, jjurple, and other Pigmeiits. — Blue pigment has been described as occasionally occurring in urine. This was first ascertained by Prout to be due to blue indigo, and it appears probable from the researches of Schunk and others, that all the blue and purple colourations which have been seen in urine, are due to the decomposition of Indican (a normal constituent of this excretion) and the formation of blue and red indigo. The addition of strong sulphuric acid to an equal quantity of urine, at once produces these colourations. — (Carter.) General Pathology and Treatment of Pigmentary Degeneration. The formation and modifications of pig-ment, as observed in plants and animals, is a subject which has been little studied, and opens up a wide field of inquiry for the chemical histologist. In endeavouring to ascertain the causes which give rise to change of colour in the textures, we must attend to the following circumstances : — 1st. Colouring matter bejirs a certain relation to the non-nitrogenous and oily constituents both of plants and animals. Thus, vegetable oils and resins are seen to form in plants where starch or chlorophyle is col- lected, the latter substances disappearing in the cells, as the quantity of oil increases in them. In animals we almost always find pigment asso- Figr. 336. Cells in a melanotic cancer of the cheek, the black pigment in which disappeared on the addition of hydrocliloric acid. Fig. 337. Cells in the black sputum of the coUier, the pigment of which is per- sistent under the action of every known chemical agent. 250 diam. PIGMENTARY DEGEXEEATIOX. 233 dated with fat. The brilliant colours of the invertebrata are so many coloured fats, and the pink fat of the salmon, and green fat of the turtle, indicate the same relation in animals higher in the scale. The epidermic appendages, which are generally coloured, are always covered with fat, secreted bv a special apparatus — the sebaceous glands. The blood corpuscles are intimately associated with the chyle, which is an oily emulsion, and the bile is rich in fat. In diseased conditions of the liver, the hepatic cells often contain oil to the exclusion of the yellow pigment. 2d. It would appear that light, heat, and exposure to atmospheric air, are connected with the production of pigment. The young leaves of plants are much lighter in colour than those which are older, and the hair of young animals is not so dark as that of the adult. In autumn the leaves fade, and become brown, reddish, or yellow, and in man we observe that the pigment of the hair ceases to be formed in advanced age, which at length becomes Avhite. Young fruit is green, and as it ripens, the part exposed to the sun is most coloured. Exposure of the skin of man, as is well known, renders it darker, and the fairest skin- ned individuals (whose integuments are well loaded with fat) are those who are most subject to freckles. Then it must be remembered, that while light evolves colour in living, it destroys pigment in dead textures. Now the decomposition of the atmosphere is carried on in vege- tables bv the leaves, under the stimulus of light, and in animals by the luno-s and skin. In plants the leaves fix the carbon and give off the oxvo;en ; in animals the lungs receive oxygen, while carbon is separated in the form of carbonic acid by the same organs, and oxygen in combi- nation with water, in the form of exhalation, is given off both by the lungs and skin. That the skin is connected with respiration is proved by the fact, that if its fanctions are interrupted, pulmonary diseases and even asphyxia are the common results. Carbon is also separated in the form of oily matter largely by the skin and by the liver, an organ also connected with respiration. Hence why Europeans in .tropical climates, bv breathing a rare atmosphere, eating much, and taking little exercise, are liable to hepatic diseases. Thus the lungs, skin, and liver, are inti- mately associated, in the function of excreting carbon, and it is curious that these are the three oi-gans in which pigment is formed. 3d. There seems to be a certain connection between the materials introduced into the structure of the plant or animal by means of the soil and of food. Some plants are rich in acids, others in alkalies, or various salts originally derived froai the soil, and we have seen that these re-ao'ents operate on colouring matter. Although this subject has been very slightly investigated, we can still perceive how, by the evolution of chemical products, acting on different pigments, the various shades of colour may be occasioned, which we observe in most plants and. some animals at certain seasons. Thus green chlorophyle may be changed in one place into a yellow resin, and in another, by the forma- tion of ulmic or other acids, be transformed reddish or brown. In animals the influence of nutrition is traced with more difficulty, but even here we may discern that at certain seasons (such as that of breed- ing) new products are evolved, which, by operating on the blood or the 234 PRINCIPLES OF MEDICINE. vital properties of cells, may eliminate more or less colour. Accord- ing to Heusinger, carbonaceous food used in excess tends to tlie pro- duction of pigment, and hence he explains how the Greenlanders, not- withstanding the cold, are dark coloured, from their constant consump- tion of fat. For the pathology of carbonaceous deposit in the lungs of the collier, I must refer to the special diseases of the respiratory system. (See Carbonaceous Lungs.) The treatment of pigmentary degenerations is most uncertain, but if the preceding observations are in any way well founded, it must be clear that the management of this lesion must be directed to removing the physiological conditions on which it depends. Mineral Degeneration. By this term is understood the infiltration or deposition of mineral matter into a texture, in such a way that it is no longer capable of per- forming its functions. We have already seen that sometimes this takes place in such a regular manner as to form bone, which replaces the pre- existing texture, as in muscle, membrane, or certain exudations and tumours. But at others it enters into the constitution of a texture dis- solved in fluid, and is thus deposited in or throughout its substance, changing its physical and destroying its vital characters. In this way we separate mineral degenerations from concretions, which are acci- dental collections in hollow viscera, although undoubtedly they insensibly pass into one another. There is scarcely perhaps any tissue, whether elementary or compound, that may not undergo the minei'al degenera- tion. But it is frequently observed in the coats of blood-vessels more or Fig. 338. Structure of mineral degeneration of tlie walls of an aneurism, a, The internal membrane witli groups of fatty granules; b, horizontal section of the creta- ceous middle coats, presenting irregular spaces, of various dimensions, filled with carbonate of lime; c, globular masses of mineral matter, in the lighter portions of the section 6. — {Wedl.) 2h0 diam. MINERAL DEGENERATION, 235 less associated with atheroma; in exudations; in certain morbid growths — rarely in nervous texture. Mineral Degeneration of Blood- Vessels. — Nothing is more common than to find the large arteries brittle from the deposit of mineral matter in their coats, often associated with fatty degeneration or atheroma ; sometimes the one lesion and sometimes the otLer having the predomi- nance. Plates and patches of mineral matter may in this way often be observed, which on stripping off the inter- nal membrane (Fig. 338, o)may be seen em- bedded in the middle coat, b. These never present the structure of bone, but either an amorphous conglome- ration of mineral mat- ter, or an amalgama- tion of round globules, similar to those which Czermakhas described as sometimes occur- ring in dentine (Fig. 338, c). Occasionally Fig. 839. though more rarely, the smaller vessels undergo a similar degeneration. In tliis case mineral matter is deposited in their coats, which when Avidely scattered also presents a globular form, closely resembling drops of oil, for which they are apt to be mistaken, unless mineral acids are added, when they dissolve with effervescence. Fig. 339 represents tliis de- generation in the small vessels of the brain as de- scribed by Dr. Bristowe and Mr. Rainey.* Mineral Degeneration of Nervous Texture. — Deposition of mineral matter in the tubes or ganglionic cells of nervous substance is a rare occur- rence in man, although more common in sheep and other of the inferior animals Fig. 340. Foerster, however, has recorded the * London Pathological Transactions, vol. iv. p. 118. Fig. 339. Incrustation of the small vessels of the brain, with carbonate and phos- phate of lime, in the form of globules, some masses of which are separated, whUst others are aggregated together outside the vascular wall. — [Bristowe and Rainey.) Fig. 340. Mineral degeneration of the nerve-cells and tubes of the spinal cord. — {Foerster.) 250 diam. 236 PRINCIPLES OF MEDICINE. case of a boy ^ho had paralysis of the lower extremities, and in whose spinal cord after death, the nerve-cells and tubes were found encrusted with mineral deposits, as seen in Fig. 340. In this case, also, the creta- ceous closely resembled fetty matter ; but on the addition of hydrochloric acid, the granules were dissolved with eflFervescence.* In other Textures mineral matter may be deposited occasionally in their interstices, but if, as in muscular tissue, it does not assume the form of a bony growth to which we have previously alluded (p. 194), it is usually the result of an exudation. The fibrous membranes of the brain not nnfrequently in this way contain calcareous laminated depositions. In certain parts of the pia mater, and the choroid plexus especially, we often find mineral bodies of a round or oval form resembling starch cor- puscles. (See Amyloid Concretions.) Mineral Degeneration of the JE. nidations. — All the forms of exudation after their soft parts are absorbed, may occasionally leave behind them a greater or less quantity of mineral matter. Thus, on serous membranes, in areolar textures, in the sinuses leading from chronic abscesses and so on, masses of earthy matter are met with, formed of amorphous mineral Fig. 841. Fig. 342. Fig. 84;3.J substances, composed of phosphate and carbonate of lime. These are evidently the result of a simple exudation, the animal matter of which has been absorbed, whilst the mineral constituents in excess are ao-gre- gated together, and form laminae on membranes, or nodules in parenchy- matous organs. I have seen the gall-bladder in this way converted into a calcareous shell, and the pericardium into an unyielding mineral box, inclosing the heart. The cardiac valves are also especially liable to these mineral incrustations. A cancerous exudation in the same manner under- goes the calcareous transformation. The mesenteric glands mav not unfrequently be observed to be partly cancerous and partly cretaceous. On one occasion I examined a large cancerous growth of the omentum and peritoneum, which was so loaded with phosphatic salts, that slices of it when dried lost little of their bulk. The juice squeezed from this tumour, besides masses of mineral matter, was seen to contain cancer- cells in various stages of disintegration, naked nuclei, fusiform cells, and a multitude of molecules, some fatty and some mineral (Fig. 341). On * Mikroskopischen Pathologischen Anatomie, TaC xv. Fig. 341. Mineral masses ia a degenerated cancerous tumour of the omentum. Fig. 342. The same, in a degenerated cancerous mass in the Hver. Fig. 343. Cancer-cells infiltrated with cretaceous molecules, in a mesenteric gland. COXCRETIOXS. 237 another occasion I found the cancer-cells embedded in and infiltrated throughout with minute cretaceous molecules (Fig. 343). In cancer, as in atheroma of arteries, the mineral is often associated with the fatty degeneration. A Tubercular Exudation passes more readily into creta- ceous and calcareous transformation than either the simple or cancerous forms. Indeed, it may be said that the natural mode of arresting the advance of tubercle is by converting it into mineral matter. I possess specimens of miliary as well as of infiltrated tubercle, arrested in all Fig. 345. stages of their progress, by cretaceous transformation, in which case, on microscopic examination, it is seen to consist of mineral masses associated with a few tubercle corpuscles, debris of the tissue in which it occurs, and occasionally a few crystals of cholesterine (Fig. 344). Mineral Degeneration of Morbid Groicths. — Mineral deposition may occur in all kinds of morbid growths, but is most common in fibroma and cystoma. In enchondroma the tendency is to form bone. The white "fibrous tumours of the uterus, we have previously seen, may undergo the osseous transformation (Fig. 2V0) ; but this is an occurrence of extreme rarity. Far more commonly the centres of such growths are composed of amorphous mineral depositions (Fig. 345), which frequently increase, and invade their whole substance, causing arrest of their pro- gress. I have often found embedded in the uterine walls, mineral masses, varying in size from a hen's egg to that of a cocoa-nut, formed in this manner. Fine preparations, showing the same fact, may be seen in the Edinburgh University Museum, COXCRETIONS. Bv concretions are understood non-organized and non-vascular pro- ductions, formed bv the mechanical aggregation of various kinds of matter, generally in the ducts or cavities of the hollow viscera. It has already been pointed out, that although they pass gradually into the class of deo-enerations, several of which closely resemble concretions, still they are distinguished from them by their never having been organized, or Fig. 344. Mineral masses in a cretaceous tubercle of the lung. Fig. 34.5. Section of an amorphous mineral mass forming a calcareous nucleus of a uterine fibrous tumour. — ( WedL) 250 diam. 238 PRINCIPLES OF MEDICESTE. Fig. 346. formed out of an organic structure. They possess a remarkable dispo- sition, however, to collect round a central nucleus, which may be organic or non-organic, and often present as the result of pure accident. Hence they generally exhibit a tendency to assume the globular or oval shape. Albuminous Concretions. — It has al- ready been explained that albumen may be precipitated fi-ora its solutions in the form of membrane (p. 211). This is sometimes so effected as to produce con- cretions, of which I have long possessed a remarkable specimen, found loose in the cavity of the abdomen. Mr. Shaw has described a similar specimen, about one-half the size of mine, con- taining a nucleus of fat — also formed in the peritoneal cavity.* It was excised from a hernial sac, and consisted of aggregated layers of albuminous substance, as seen in iigs. 346, 349, 350. The con- centric layers of aneurismal co- agula, and some so-called fibrin- ous depositions on the valves of the heart, which subsequently be- come white and indurated, are of a similar character. The sec- tion of the nucleus in my speci- men (Fig. 347) is represented magnified fifty diameters. Fig. 348, showing the adipose cells of the structure, loaded round the circumference with mineral mat- ter. In all other respects it re- sembled Mr. Shaw's specimen. Fatti/ Concretions. — These constitute gall stones, which for the most part are formed of laminae of cholesterine, associated with inspissated bile. They are found in the gall ducts or bladder, and vary in colour, size, form, and number. They may be perfectly white, and then they consist almost wholly of pure cholesterine. Sometimes they are brown, and at others jet black, approaching carbon in chemical composition. There may be only one large gall stone, nearly filling the gall bladder. ^Yhen there is only one, it is oval in form, but when there" are several stones present, they take a many-sided form, in consequence of pressure * Loudon Pathological Trans, vol. vi. p. 205. Fig. 34S. Fig. 346. Longitudinal section of the albummous concretion referred to, and its encysted nucleus of fat. — {Shaw.)— Natural size. Fig. 347. Section of the nucleus of an albuminous concretion. — Natural size. Fig. 348. Section of the nucleus of an albuminous concretion, showing the circum- ference loaded with mineral matter, and the cell structure of the interior. 50 diam. CONCRETIONS. 239 on each other. In one case, as many as 2000 minute biliai^y concretions were counted in the gall bladder. The black gall stones are often rough, round, and spiculated. On section they generally pi'esent a nu- cleus which is composed of inspissated bile, and mucus, surrounded by concentric rings. Occasionally, the centre of the stone is liollow, and the substance "lining the cavity crystalline. The tough white masses occasionally found in cystic tmnoms {cholesteatoma) are also fatty concre- tions. Sometimes also fatty masses have been passed by stool, more especially when the pancreas has been diseased. Pifimentary Concret'mis. — These are most common in the lungs and bronchial glands of colliers, from which I have often dug out masses varying in size from a millet seed to that of a pea, with shiny smooth frac- tured surfaces, composed of pure carbon. Occasionally 1 have seen a bronchial gland converted into a cyst, filled with a thick black fluid, like inspissated paint, principally composed of carbonaceons matter, which would doubtless in time also have formed an indurated concretion. Fia. 849. Fis. 350. Mineral Concretions. — This is by far the most common foi-m of con- cretion found in the body, and usually results from the deposition of various salts from their solutions, often round a nucleus of foreign mat- ter, so as to form solid masses varying in size, form, and general arrange- ment of parts. Not unfrequently the nucleus may be a portion of coa- gulated blood or inspissated mucus, so that mineral concretions are sometimes found in the veins [phleholiles) and in all mucous passages, such as the salivary, bronchial, pancreatic, hepatic, renal, etc. Frag- ments of degenerated mineral texture may also be pushed out from the walls of such passages and constitute a nucleus, which collects mineral matter around it. In almost all such cases, the mineral is composed of phosphate, with varying })roportions of carbonate of lime, and the foi-m of the concretion will be influenced by the size and shape of the cavity in which it is found. An excellent example of this may be seen by exa- mining the grains of sand in the pineal gland, which will be found to Fig. 349. Portion of one of tiie concentric lamellaj, of the same concretion. Fig. 350. Transverse section of the edges of the concentric lamellaa — (Shaw.)- 250 cUam. 240 PRINCIPLES OF MEDICINE. consist of botryoidal masses vaiyino; in size, but constituting mineral moulds of the glandular shut sacs in which they were produced. Fig. 351. Urinary Concretions. — Mineral concretions, however, are by far m common in the urinary apparatus, and may be formed in the tubules or pelvis of the kidney, in the ureter, or in the urinary bladder. In the tubules of the kidnev they usually assume the character of amorphous deposits, filling up and distending the tube, and presenting radiating white lines in the secreting cones. They may be composed of phosphate of lime or urate of ammonia (Fig. .'S52). Occasionally masses of a putty- like substance are formed in the substance of the kidney by the accumulation of such deposits, which in time would have consoli- dated into calculi. More rarely the entire kidney is so infiltrated with mineral mat- ter, that its functions are destroyed. I possess a specimen of this kind, where the organ might be supposed to be petrified, and others exist in the Ed burgh University Museum. ost rite. 352. Fig. 351. Various forms of biliary concretions. / White biliary concretions, com- posed cliiefly of cholesterine. c, Irregular biliary concretions of inspissated bile. 5, Black biliary concretions, chiefly carbonaceous, d, Yellow biliary concretions, with spicula formed in the ducts of the liver, e, Section of a dark-brown biliary calculus, so indurated as to be capable of receiving a polish, showing the concentric arrange- ment of its substance, f, Section of a large white biliary concretion, showing the radiated as well as concentric arrangement. — Natural size. Fig. 352. Vertical section of the kidney, a, Some of the tubules filled with urate of ammonia, and presenting irregular black streaks, with lateral branches and twigs, 60 di. b, The molecules of urate of ammonia aggregated together in masses. — (Wedl.) 250 diam. CONCEETIONS. 241 When calculi form in tlic pelvis of the kidney, they assnme the form of the cavitv, which varies, however, in ditFereut cases, being contracted in some and dilated in others. The accompa- nying figure of a renal ^^"\ calculus exhibits regu- ^^ lar protuberances, jut- ting out between the urinarv cones from a mass formed in the pelvic cavity (Fig- Fig.Sog. Fig. 354. 358). Renal calculi generally give rise to constant irritation and surrounding suppuration, constituting what Raver has called calculous pyelitis. Their chemical constitution is usually uric acid, or phosphate of lime, alone or united in various proportions. Fi?. 355. Fi£r. 356. The most frequent seat of urinary calculi is in the bladder, whence, from the circumstance of their giving occasion for one of the most im- portant operations in surgery, they have been made the subject of care- ful study. Here they vary in size, general appearance, and chemical constitution. In size" they range from that of a millet-seed or grains (known under the name of gravel), which may pass along the urethra, to that of a body weighing several ounces, and occupying nearly the ■whole bladder. In form they may be round, oval, flattened, irregular, or nodulated, and in chemical constitution may consist of phosphate of lime, triple phosphate of ammonia and magnesia, uric acid, oxalate of lime, or xanthic oxide. Not unfrequently in one calculus may be ob- served deposits of varying chemical compositions, round a central Fio-. 353. External view of a remarkable renal calculu.?, with projections on all sides of it but one, impacted in the pelvis of the kidney. — Real size. Fio-. 354. Section of the same calculus, with nucleus of uric acid and oxalate of lime. Fig. 355. Calculus with lithic acid nucleus, surrounded by oxalate of hme, and covered externally with laminas of lithic acid. — (Syme.) Fig. 356. Triangular formed calculus of lithic acid deposited round a phosphatic nucleus at one corner. — {Sy/ne.) 16 242 PEINCIPLES OF MEDICINE. nucleus, iudicating the salts predominant in the urine during the period of its formation (Figs. 355 to 361). Fi^'. 862. Tig. 360. Fig. 861. One of the most remarkable circumstances connected with vesical calculi is, that the nucleus may be composed, not only of various kinds of salts or of fragments of other calculi, but even of foreign substances which have been introduced from without. Thus various rounded bodies thrust down the urethra may form the cen- tres of these concretions. Fig. 362 represents a piece of slate pencil as the nucleus of a phosphatic concre- tion. Mr. Syme removed it by the ope- ration of lithotomy, and the man confessed he had introduced the foreign body himself, which had slipped from his fingers, and entered the bladder Fig. 357. Oval calculus of lithic acid, having a litliic acid nucleus, surrounded by oxalate of lime. — {Lision.) Fig. 358. Oval calculus of uric add. — (Lision.) Fig. 359. The triple phosi^hate surrounding a mulberry concretion of oxalate of lime. — (Lision.) Fig. 360. Nodulated mulberry calculus composed of oxalate of lime. — (R. Mac- kenzie.) Fig. 361. Phosphatic calculus formed round a fragment of uric acid calculus, pre- viously broken up by lithotrity. — (Syme.) — Real size. Fig. 362. Phosphatic calculus formed I'ounda piece of slate-pencil, which had been introduced into the bladder through the urethra. — (Syme.) — Real size. COXCRETIOXS. 2^3 two years previouslv. One of the most extraordinary cases of this kind Fig. 3C3. is that recorded by the Lite Dr. E. Mackenzie, in which a man in a state of intoxication was, dm-ing a quarrel, knocked down by his comrades, who cruelly thrust several horse beans into his urethra. Six months subsequently he was operated upon for stone, and five cal- culi removed, each of which on being cut open was found to contain a bean, surrounded by a shell of triple phosphate* (Fig. 363). Dr. Dunsmure has also related a case of li- thotomy, where the nucleus of the stone originated in the man's falling with ^^olence across the gunnel of a boat in such a way as to lacerate the perineum, and force a portion of his woollen trousers into the bladder. I examined the nucleus of the calculus after removal, and found the fibrous substance it was composed of to consist of wool.* * Montlily Journal of Medical Science, January 1853. Fig. 363. Sections and external appearance of the calculi in i£r. Mackenzie's case, formed round horse beans, introduced into the bladder in the manner described. — (/?. Mackenzie.) — Real size. Fig. 364. Prostatic calculi exhibiting the concentric laminse, and nuclei of these bodie's.— ( Wedl.) 250 diam. Tis. 364. 244 PRIXCIPLES OF MEDICEN'E. Prostatic Concretions. — The adult prostate gland almost invariably will be found to contain a number of calculi, which increase in number with the age of the individual, and are often very numerous when the gland is enlarged. They are of a yellowish colour, vary iu size from g-oVtl^ to the yjo^t of an inch in diameter, and are characterised by their con- centric laminae, surrounding a single or double nucleus, which also varies greatly m size. Dilute mineral acids cause the calcareous matter to be dissolved, leaving, however, the structural appearance unaffected, and rendering them occasionally soft and compressible. In this respect they resemble the amyloid bodies which occur in the arachnoid, and like them thev may possibly be colloid masses, throughout which mineral matter is imbibed in a fluid state, so as graduallv to convert them into calculi. ri?. 365. Hairy Concretions. — Balls composed of hair are not unfrequently Fig. 365. Mass of hair found in the human stomach, as described above. Infe- riorly it was encrusted with a layer of altered food, a fragment of which has been removed towards the left, showing the hair beneath. — {Ritchie.) — Three-fourths the reaJ, size. CONCRETIONS. 245 found in the stomacli and alimentary canal of the inferior animals, es- pecially such as are in the habit of licking their hairy coats. Rare cases have been recorded where similar masses have been found in the stomach of the human subject. One of these has been published by Dr. Ritchie of Glasgow.* It was that of a factory girl, aged 21, vfho had contracted the habit of pulling hair from her head, while em- ployed at work, and swallowing it. She had ileus, followed by symptoms of rupture of the intestine. On dissection, the ma^s here figured, form- ing a mould of the stomach, composed of moist female hair, was disco- vered, and two smaller ones were found in the intestines (Fig. 365). Similar cases with hairy concretions are recorded by Pollockf and May.;]; Vegetable Fibrous Concretions. — These are only found in the alimentary canal, and in man are most common in the \ intestines. The largest collection of ;\ them extant is in the Edinburgh TJni- t^^a**'^ -;V Fiff. 366 Fig 367. versify Museum, which was made by the second Monro. An admirable dissertation reo-arding them was published by his son, Monro tertius.§ ^\"ollaston first demon- strated that they were principally compos- ed of the fibrous matter of the oat seed, a fact confirmed by the careful researches and published figures of Dr. Douglas * Monthly Journal of Medical Science, July 1849. f Pathological Transactions of London, 1851-2. j Association Journal. No. 156, 1856. § Morbid Anatomy of the Human GuUet, Stomach, and Intestines, Edinburgh, 1811. Fig. 366. Section of a remarkably-shaped intestinal concretion, a, Nucleus of extravasated blood; b, b, b, concentric laminse. It weighed 14^ ounces, measured 7 inches in length, and was evacuated by the rectum.— {Hiiss and Mosander.)—Half fJlP T€.Q.\ StZ€ Fig. 367. Section of an intestinal concretion, with a plum stone for its nucleus, in the Mom-o collection of the Edinburgh University ILuseum.—Beal size. 246 PRINCIPLES OF MEDICINE. Maclagan.* These concretions vary in size from a pea to tliat of an orano-e. They are round or oval in shape if isolated, but are frequently compressed or flattened at the sides, and occasionally of very irregular sliapes, according to the amount of pressure or impaction to which they have been subjected. In colour they are of a yellowish brown, but are much lighter if intiltrated with earthy salts to any unusual extent. They easily crumble down under firm pressure, and present a short fibrous texture, like the felt of a hat. On section with a sharp instrument, they present on the cut surface a series of concentric lines, which are often of a lighter colour and harder consistence than the general substance of the concretion. In the centre may fi-equently be observed a nucleus composed of some foreign body, such as a plum or cherry stone, a piece of bone, etc. Chemically, they consist principally of fibrous vegetable matter and phosphate of lime, mingled w ith small proportions of water, soluble vegetable matter, fat, foeces, and a little silica derived from the structure of the oat — (Maclagan). On examining a small fragment of these concretions under a power of 200 diameters linear, they are seen to be made up of an ago-regation and mingling together of vegetable fibres, principally derived from the carrj- opsis of the oat, mingled in recent specimens with numei'ous irregular crystals and amorphous precipitate of the phosphate of lime. The fibres vaiy greatly in length and diameter, but in form are pointed at one extremity, truncated at the other, with a central canal, which gradually diminishes to- wards the pointed extremity. The accompanying figure repre- sents a fragment taken from the concretion represented Fig. 368, from the Monro collection, in which, besides the vegetable fibres alluded to, masses of mo- lecular mineral matter may be ■^''■^^"'" observed soluble in dilute nitric acid, of which the white concentric lines were principally composed (Fig. 373.) As regards the manner in which these concretions are formed, it is to be observed, that the fibres of the caryopsis of the oat possess, in a remarkable degree, the property of felting, which, as pointed out by Dr. Carmichael of Buckie,f is prevented by oil, and favoured by the use of dry substances, as fuller's earth. Both these substances are used largely in wool manufactories, the one for carding and the other iov felt- ing. I am indebted to that gentleman for some specimens of concre- tions, formed of oat dust (that is, the hairy covering of the oat), simply by the rotatory or oscillatory motion of the wirecloth sieve of a mill. From thence may always be collected soft concretions of various sizes, * Monthly Journal of Medical Science, Sept. 6, 1841. f Ibid. June 1848. Fig. 368. Hairs from the caryopsis of the oat, felted together, and mingled with granular masses of the phosphate and carbonate of lime. 250 diam. C0XCRETI0X3. 247 formed round pieces of thread, or other foreign bodies. The same thing appears to result in the animal body, from the peristaltic action of the intestines, when the fibrous dust is imperfectly separated from the meal, as was formerly the case in the outmeal used largely as food for man in Scotland. Since the employment of winnowing machines, and greater consumption of meat and oleaginous substances, the formation of these concretions has become very rare. In horses, however, they are still common, and it is remarkable that in remote districts, w^here meal is still imperfectly prepared, cases still occasionally occur, such as the one recorded by Dr. Turner of Keith,* of a man who, in 1841, passed fourteen, and in 1845-6, other eighteen of these concretions. Amyloid and Amylaceous Concretions. — Yalentin,f Lebert.J Gluge,§ and others, have figured rounded mineral bodies with concentric circles, frequently present in the brain's substance, and more or less soluble in mineral acids. In April 1847,|| I presented a portion of a tumour to the Pathological Society of London, which was attached to the tento- rium, and crowded with similar bodies. They were evidently mineral concretions, formed, however, on an organic base, varying in size from the — ^-oth to the .toV o-th of an inch in diameter. Their fracture was exacUy like that ot' starch corpuscles, but they were not rendered blue * Monthly Journal of Medical Science, Sept. 1841 and January 184S. f Handworterbuch der Pli3-siologie, Taf. 1, Fig. 2. t Physiologie Pathologique, PI. xi. Fig. 10. § Pa"thologi?che Anatomie, Liv. 16, Taf. 2. II Proceedings of Pathological Society of London, 1S46-7, p. 17. Fio-. 369. Amyloid bodies embedded in a seemingly amorphous matter. Fi°. 370. The" same, after dilution with water, now seen to be invested with a fibrous sheath, and surrounded by fusiform cells and naked nuclei. Fig. 371. The same, after the addition of acetic acid. FiS. 373. The same, after the addition of nitric acid, a, One of tliese bodies with a thick investing capsule ; l, c, and d, others showing the various ways in which they crack on pressure; e, cylindrical form produced by rolling them between glasses. 250 diam. 248 PEINCIPLES OF MEDICINE. on the addition of iodine. Nitric acid dissolved the mineral matter, and showed them to be composed of concentric fibres, surrounding a nucleus, with distinct nuclei (Fig. 372). They were embedded in a fibro-nucleated structure, which foi'med a sheath round eacli concretion. Since then, I have frequently seen similar bodies in the arachnoid mem- brane and substance of the brain, and they have been also observed by Dr. Quain, and many others. These ai'e amyloid bodies. Yirchow* was the first to point out that several of these bodies in the brain assumed a pale blue tint on the addition of iodine, and subse- quently became violet-colour on being treated with sulphuric acid. He considered them to be cellulose, a principle which he also had show^n to exist in other pathological formations. Mr. Buskf demonstrated that il»°^^rvO •••"^ ^f.'i --"^ •'So'."' -v. ■ - Fisr. 3T3. Fig. 874 these bodies were optically as well as chemically identical with starch, and that they were true corpoj-a amylacea. They have been found in various tissues and fluids by subsequent observers, and have been made the special subject of research by Dr. Carter,^ who has demonstrated their existence in almost every tissue and fluid of the human body, and in every kind of morbid product. They are of two varieties, the one (described by Mr. Busk) resembling wheat starch, the other and rarer kind corresponding in every particular with that derived from the potato. It follows, that there exist concretions, some of which resemble while others really are starch corpuscles. The former are amyloid, and the latter amylaceous concretions. Both these bodies, without the action of re-agents, are not only liable to be confounded with each other, but with colloid and fat masses. It is questionable, indeed, whether the amyloid concretions are colloid bodies, which have subsequentlv become impreg- nated with mineral matter, or whether they are starch corpuscles that have undergone a mineral degeneration. But the relation of these two kinds of concretions to one another, to fat and colloid masses, are points * Archives, Band vL s. 125. 1854. f Quarterlj^ Journal of Microscop. Science, vol. ii. p. 106. 1854. X Edinburgh Medical Journal, August 1855, and Graduation Thesis, 1856. Fig. 373. Small corpora amylacea, in the auditory nerve of a deaf individual, with several granule cells. — {Foerster.) Fig. 374. Variouslj'-shaped and sized corpora amylacea, from the human pancreas, a, Nucleated; i), c, rf, variously-shaped : e, seen edgeways. — {Carter.) 250 dia7n. CONCRETIONS. 249 which have not yet been investigated. The presence of sugar, which has recently been shown to be always a constituent of normal blood, in that part of the circulation which lies between the hepatic and pulmo- nary veins, may also be connected with the formation of one or more of these non-nitrogenous substances. All speculation on this subject, however, is at piesent highly hypothetical, and it is only from the progress of organic chemistry that we can hope to derive a satisfactory explanation of these transformations which go on in the blood tissues, so that we may determine the laws regulating the production of the amylaceous and amyloid concretions. SECTION III. ox THE RECEXT CHAXGES IX THERAPEUTICS, OCCA- SIOXED BY AX ADVAXCED KXOWLEDGE OF DIAGXO- 8IS AND PATHOLOGY. ly the previous two sections I liave endeavoured to a'ive a condensed account of the present state of diagnosis, and of the pathology of organic diseases. A practical knowledge of the one, aTid a better appi-eciation of the other, have been very widely diffused witliin the last sixteen years. In consequence a change almost amounting to a complete revolution in our treatment of disease, has taken place within that short period. It is true that this change is not yet reflected in our systematic works, although clinically it is everywhere recognized. "When we compare the actual practice of medicine with what it was, or with what it is repre- sented to be, even in modern books on the theory and practice of physic, the discrepancy must strike even the least observant. It seems to me that the time has now arrived for calling the attention of the profession, and more especially of its youthful members, to the causes which have produced so important a result, and for pointing out some of those principles on which an improved medical art for the future must necessa- rily be based. I ha\'e already alluded to the general treatment required in diseases of nutrition (p. 107), and have endeavoured to show that a knowledge of the various processes, of which that function is made up, is a necessary preliminary step to correct medical practice. Our agents for combatino- this class of disorders, are nutrients, hematics, eliminatives, astringents, etc. Diseases of innervation require for their proper management the same previous knowledge, and demand as remedies stimulants, sedatives, narcotics, etc. The mode of applying these can only be learnt by treat- ing maladies in detail, whilst for what is known of the general principles of their action I must refer to special works on this subject* Remedies have hitherto been employed too much in reference to symptoms, and with too little regard to the pathological states which produce those symptoms, or to the intimate relations winch exist between the nutritive * See especially Headlam on the Action of Medicines. FALLACIOUS CHARACTER OF PAST EXPERIENCE. 251 and nervous functions. Thus, for instance, impaired digestion may cause headache and sleeplessness. Now, we can relieve the latter symptoms by morphia ; but if this remedy increase the want of appetite, as it really does, what have we gained ? The urgent symptoms are temporarily pal- liated, but their cause, so far from being removed, is actually intensified. This distinction between a palliative and a curative treatment has been too much overlooked in medical practice. Drugs have been given to relieve symptoms, while the causes producing them have not been sufficiently attended to. Need it then excite surprise that as our knowledge of pathology lias advanced, and our means of diagnosis have improved, this discrepancy has become more apparent, and that we now direct atten- tion more to the causes and less to the eft'ects of disease ? The chano-es which have recently taken place in medical practice, as a result of this mode of viewing diseases, will be referred to in the spe- cial part of the work. Two great facts, however, seem to me, from their especial importance, to demand attention here. These are— Is?, The diminished employment of blood-letting and other antiphlogistic reme- dies in the treatment of acute exudations, or so-called inflammations ; and 2d, The power which it has been demonstrated may be exercised over certain diseases of innervation, through the influence of suggestion or strong impressions made upon the mind. Both these fects have re- cently excited great attention and discussion ; their influence on medical theory and prjrctice has already been great, and their explanation on scientific gronnds seems to be called for, with the view of establishing correct principles for our future guidance. THE DIMINISHED EMrLOYMENT OF BLOOD-LETTING AND OTHER ANTIPHLOGISTIC REMEDIES IN THE TREATMENT OF ACUTE INFLAMMATIONS. It must be admitted by all who contemplate the actual state of medi- cal practice in this country, that the use of blood-letting, and of other antiphlogistic remedies, lias within a recent period greatly declined. According to Dr. Alison,* such remedies, and more especially blood- letting, wCTe formerly highly successful in arresting the disease, but fail to do'so now, and are even injurious; and the inference he draws from these supposed facts is that inflammation itself is no longer the same, that its tvpe, and more especially the febrile symptoms accompanying it, have altered from an inflammatory to a typhoid character. In short, it seems to be Dr. Alison's opinion, that our advanced knowledge of diagno- sis and pathology has had httle influence in producing this great revo- lution in our treatment, but that the human constitution (in a manner which is not explained) is fundamentally altered, and that medical men were as rio-ht in bleeding twenty years ago as they are correct in now abstaiuino- from it. In opposition to these views, it will be ray endeavour to show^— l.s/, That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted Avith the nature * Edinbure,h Medical Journal, March, 1856. 252 PRINCIPLES OF MEDICINE,. of, and mode of, detecting internal inflammations. 2d, That inflammation is the same bow as it has ever been, and that tl\e analogy, songht to be established between it and the varying types of essential fevers^ is falla- cious. .3f7, That the principles on which blooddetting and antiphlogistic remedies have hitherto been practised are opposed to pathology. 4/A, That an inflammation once established cannot be cut short, and 'that the object of judicious medical practice is to conduct it to a favourable ter- mination, bth, That all positive knowledge of the experience of the past, as well as the more exact observation of the present day, alike establish the truth of the preceding propositions as guides for the future. Pkoposition 1. — TJtnt little reliance can he placed on the experience of those ivho, like Cullen and Gregory, loere unacquainted rvith the nature of, and the mode of detecting, internal injiammations. Inflammation for many years was generally recognised, especially in external parts, by the existence of pain, heat, redness, and swelling, and in internal parts by fever, accompanied by pain, and impeded function of the organ aff"ected. In short, groups of symptoms, in accordance with the nosological systems of the day, constituted inflammation. But the school of morbid anatomy, by showing that inflammation was a diseased condition of a part, entirely overthrew the errors and confusion inherent in all such nosological systems. Clinical observation, based on a more correct diagnosis and pathology, has since demonstrated that artificial nosological groups of symptoms bear no relation whatever to the inter- nal inflammations they were formerly supposed to indicate, and has led to a mass of information, connected with internal disease, which, up to this time, has never been correctly systematised. Again, more recent histological research, by exhibiting to us that inflammation is in truth a disease of nutrition, governed by the same laws that determine the growth and functions of cells, as thev exist in the embryo and in healthy tissues, has united physiology and pathology into one science, and has removed our present knowledge still further from the traditional errors of the past. Why, then, should we on our onward course be governed by the opinions of Cullen and Gregory, of Gaubius and Sydenham, of Aretseus and Hippocrates ? These distinguished men all advanced medicine in their day, as far as they were enabled to do so by the then state of science and the means within their reach ; but the princi2:)les wdiich guided them ought no more to be considered laws to be followed now by practical physicians, than should the exploded astronomical doc- trines of Copernicus and Tycho-Brahe be acted on by practical naviga- tors. It is not my intention, therefore, to enter into a lengthened refutation of the opinions of former writers, or even of many modern ones, in determining what pathologists now understand by the term inflammation. What I mean by it in the following remarks, is an exu- dation of the normal liquor sanguinis ; and Dr. Alison evidently means the same thing, when he acknowledges "that exudation of lymph is essential to almost all changes of structure produced by inflammation." Whatever, then, may have been formerly understood by this word in- flammation — in whatever wa)' it may be now applied — whether to the THE UNCHANGEABLE NATURE OF INFLAMMATION, 253 congestion of tlie blood-vessels, the exudation of liquor sanguinis, or to the change in the texture causing these phenomena — it is important to remember that in speaking of it both Dr. Alison and myself mean an alteration in a part characterised by the exudation of lymph through the walls of the minute vessels, resulting from changes moi'e or less well marked in the nervous, vascular, sanguineous, and parencliymatous ele- ments of that part. (See p. 12';, et seq., also Dr. Alison's observations in the Note to this subject, at p. 279.) As regards diagnosis, it must be acknowledged by all parties that, up to a recent period, internal inHaramations were sought to be recognised only by svmptoms. But medical men, who have of late years studied these iiiflaunuations by physical signs as well as by symptoms, must have coiue to the conclusion, that symptoius alone are altogether insuffi- cient to enable us to determine the existence of internal inflammations. This is a point which, if necessary, could be established by innumerable facts, which show, 1st, That all the symptoms of inflammation may be present, and yet iwHt-mortem examination demonstrate the absence of lesion ; and, 2dly, That inflammation has been the cause of numerous deaths, without one of the symptoms generally supposed to be its accompaniments having been present. But here, also, it is unnecessary for me to enter at any length into this question, because it is admitted by Dr. Alison that we can now detect inflammation of the lungs " in cases where there is so little of pain, or cough, or dyspnoea, or inflammatory fever, that we should not in former times have given them the name of pneumonia." But when he goes on to say that " the cases of pneumonia thus overlooked were attended with little or no immediate danger," I am constrained to dissent from this opinion, for it appears to me that many of these cases, especially such as are complicated and occur in old age (so-called latent pneumonia), are, at this moment, the most fatal, and that they always must have been so. On the other hand, the symptonas which formerly were supposed to indicate pneumonia, viz., pain, cough, dyspnoea, rusty sputa, and fever, we now know are met with in a variety of lesions, independent of pneumonia, especially in certain cases of bronchitis in young subjects, or engorgements and apoplexy of the lung, associated with fever or heart disease in older persons. Hence, formerly, bleeding was not practised in many cases where pneumonia was present, whilst it was largely resorted to in others where that disease never existed at all. Other writers besides Dr. Alison have endeavoured to show, and not unsuccessfully, that what was formerly understood by pneumonia or peri-pneumonia, is altogether diff"erent trom what we now mean by these terms. But they have not been so siiccessful in deducing from the experience possessed by former physicians in treating symptoms, what ought to be the rule of practice for those in modern times who recognise the anatomical lesions of organs. If, indeed, it could be shown that the group of symptoms formerly called inflammatory always indicated the same morbid lesion, former experience might still be useful to us. But wc contend that this is what clinical observation proves to be im- possible. Such are the contradictory statements and the confusion resulting from the unacquaintance of the past race of practitioners with a correct diagnosis and pathology, that no confidence whatever can be 254 PRINCIPLES OF MEDICINE. placed in their impressions, as to wliat cases were or were not benefited by bleeding. Hence, although I am far from repudiating experience in cases which in the present day are clearly recognizable as true inflammations, it is surely unreasonable to be guided by that experience in cases where it is acknowledged that the observations are imperfect and vague, and which, even among those who desire to take advantage of it, causes endless differences of opinion as to what was meant or intended. Medicine is not a scientific art which is dependent for its principles on the study of, and commentary on, the older writers. What they thought and what they said, are not, and ought not, in a question of this kind, to be our guide, as to what was or is. On the contrary, it is the book of nature, Avhich is open to all, that we ought to peruse and study, and why should we read it through the eyes of past sages, when the light of science was comparatively feeble and imperfect, instead of bringing all the advanced knowledge of the present time to elucidate her meaning? The lesson, which a careful study of the history of medicine has forced upon me, is the necessity of re-investigating, with all our improved modern appli- ances, the correctness or incorrectness of existing dogmas, in order to establish an improved practice for the future. Proposition 2. — That injlammation is the same now as it has ever been, and that the analogy sought to he established between it and the varying tyjies of fevers is fallacious. The essential nature of inflammation has been already alluded to, viz., a series of changes in the nervous, sanguineous, vascular, and parenchymatous functions of a part terminating in exudation of the liquor sanguinis, or what some call effusion of lymph. Now what proof is there that any of these necessary changes have of late years undergone modifications ? If a healthy man receive a blow, or any other injury on his person, are the resulting phenomena in these days in any way difterent from those which took place in the days of Cullen and Gregory ? Were the effects which followed wounds received at the battle of the x\lma different from those which resulted from similar injuries at the battle of Waterloo ? This has not yet been shown. Do we observe any essential difference in our civil hospitals in the effects of injuries, or in the process of healing, after wounds and operations? This also has not been shown. Again, if a healthy individual now-a- days be exposed to cold or wet, and be seized with an inflammation of the lungs or pleura, is not the lung hepalized in the one case, and do not layers of organizable lymph form in the other, in exactly the same way as formerly ? If so, is not hepatization removed, and does not the lymph conti-act adhesions in the same manner now, as in the days of Cullen and Gregory ? If these changes have been materially modified in recent times, I again urge that such modifications have not been shown ; and if they have not, in what can it be said that inflammation and i(s results have changed within the last twenty years? To this question, notwithstanding repeated careful perusal of Dr. Alison's paper, I am obliged to say I can find no answer. It is true he THE UNCHANGEABLE NATUKE OF INFLAMMATION. 255 points out that the sj/mptoms of pneumonia of Cullen differ from those of the pneumonia of GrisoUe. lie also contends that it is only from the symptoms that we can judge of the effects of remedies. But before we can draw a comparison between variations in such symptoms as indications of the value of treatment, or found upon them a doctrine like the change of type in any given disease, it must be shown that the symptoms observed formerly and those seen now belong to the same lesion. No such comparison, however, can be drawn, because what Cullen meant by pneumonia were the symptoms themselves, whereas now such symptoms are known to be in no way necessarily indicative of pneumonia, as I have previously explained. Under these circumstances nothing can be more unsatisfactory than to enter into an inquiry as to whether the inHanimatory fever and hard pulse of Cullen's pneumonia — which may or may not have been pneu- monia at all — does or does not differ from a true inflammation of the lung, as we now recognise it. Dr. Alison, by drawing a comparison be- tween the two, seems at least to think they are allied, and he ai'gues that the fever accompanying the one was inflammatory, whilst that accompanying the other is typhoid. Hence the reason why he thinks the first did, whilst the last does not bear bleeding. He has also long argued* that these differences are still observable in private or dispen- sary, and in hospital practice. But I have had abundant opportunity of satisfying myself that a true pneumonia is the same under everv cir- cumstance. During a seven years' tolerably constant attendance as physician to the Royal Dispensary of this city, I have seen pneumonia as typhoid as it can well be; and in the Infirmary, during the last nine years, I have seen it attack vigorous, healthy young men, and present all the characters of the inflammatory type. These last are exactly those cases which do best without bloodletting, whilst, at the same tiu:!e, they are those also which bear bleeding well. The explanation of these (to some) apparently contradictory facts will be given subsequently. Another idea very extensively prevails on this subject, and is urged by Dr. Alison, viz., that inasmuch as fevers undoubtedly present chano-es in type, inflammation may do so likewise. That essential fevers at difter- ent times are typhus, typhoid, or ephemeral, cannot be doubted, but this is evidently produced by variations in the intensity or the nature of the exciting cause. On what these differences depend is not yet deter- mined. I have watched extensive epidemics of fever in France and in the Rhenish provinces, where almost every case was typhoid, and con- nected with intestinal lesion, and observed others in Edinburgh, where nearly every case w^as typhus, and free from organic lesion. I also noticed that, when owing to failure in the potato crop, as in 1846, the food of the people was materially changed for the worse, the fever in Edinburgh assumed far more of the typhoid type; and I have no doubt that changes in diet, in locality, in climate, in atmospheric influences, and a variety of causes, may induce modifications in fever. But surely no analogy ought to be drawn between the undoubted changes produc- ing such varieties of fever, and those causing an inflammation, which in all countries, and under every variety of external circumstance, are * Outlines of Pathology and Practice of Medicine. First Edition, p. 221. 256 PRINCIPLES OF MEDICINE. always the same. Even the resuUs are said to be distinguishable only by a change in the force of the pulse. But what should this asserted change in the force of the pulse lead us to infer? Is it said that instead of being strong and hard in cases of pneumonia, as it used to be, it is now more soft and indicative of debility ? Is it then argued that the whole people of this country, since the davs of Cullen and Gregory, have become so debilitated and deterio- rated — that their constitutions have been so altered for the worse, that attacked by the same lesion and to the same extent, there is no longer the same reaction ? and that the strong man of the present day labour- ing under inllamniation presents the symptoms which twenty years ago distinguished the weak one? If so, where is the evidence of this? Are our soldiers and sailors, workmen or others, physically less capable of exertion than formerly ? Is it true, that the strength of mankind has so radically altered for the worse during the last twenty years, as to account for the supposed fact that inflammation formerly required excessive loss of blood to check its progress, whereas now it stops of itself? For my own part, I have earnestly sought for, but cannot dis- cover, a shadow of evidence for sucli a belief. Sloreover, I have a most lively remembrance of all the facts and circumstances connected with the bleedino- of many patients thirty yeais ago, when I first commenced the study of medicine, as well as of such as took place in the Royal Infirmary of Edinburgh, when I was a student in this University in 1833 ; and my impression is, that not the slightest difference exists between the character of the pulse now and what it was then. Since this question has been raised, I have had frequent occasion to point out in the wards of the Infirmary cases of pneumonia in vigorous persons, in whom the pulse as formerly has been full and strong. (See pneumonia cases of R. M'Farlane and John Macfarlane.) I have been informed by some Indian practitioners that in the East blooddettino- is now as little practised as it is among ourselves — so that if Dr. Alison's theory be correct, inflammation among the Asiatic nations and Hindoo tribes has undergone the same change of type as is alleged to have taken place in Great Britain. But I have also heard that in Italy large blood-lettings are still practised as they were for- merly ; and I know from actual observation that M. Bouillaud still pur- sues the coup sur coup treatment in acute inflammations in his wards of La Charite Hospital, Paris. On visiting him there in the August of 1856, I saw several patients (all young persons) whom he had treated in this way, and who were then convalescent. On asking him whether he had observed any change in the character of the pulse, or a more typhoid character of the fever in recent times, his reply was emphati- cally, " certainly not." A similar reply was made to the question by every practitioner I interrogated in Paris, who attributed the general diminution of blood-letting in France to the gradual emancipation of medical men's minds from the doctrines of Broussais. Is it not more reasonable then to think, that the change of practice in India results from an alteration in precept and example, and that the continuance of the practice in Italy and in the wards of M. Bouillaud, is owing to the absence of such change rather than to suppose that inflammation alters its type, just where the practice alters, but remains stationary in FORMER REASONS FOR BLEEDING ERRONEOUS. 257 those countries, and even in those wards of an hospital where it does not? Hence I am firmly of opinion, that inflammation in a part is the same now as it has ever been, and is only subject to the variations which occur in all diseases, such, for instance, as are dependent on differences of ariori reasons in favour of the policy of upholding our patients, even in the earliest stages of acute disease, by such food as may be best suited to their digestive organs, such as is most readily assimilated, and calls for the least effort, the smallest expenditure of vital force, for its primary digestion. Nutritive matter in a state of solution — broths, soups, farinaceous matters — answers this pui-pose best, and also alcohol, which is directly absorbed without any previous change, and tends to feed the calo- rifacient process, and to diminish the waste of tissues which would necessarily follow in order to maintain it. "Inflammation is a deranged nutrition. Like the normal nutrition, it involves supply and waste, and as the latter is considerable, the former will be proportionably so. The tendency in inflammation is to the more or less rapid formation of abnormal products, such as lymph and pus; and the supplies for these formations must be drawn from the blood, or from the tissues, in both cases with the eSect of more or less exhaustion of the vital force, with more or less extensive organic disintegration. The active chemical process which accompanies all these changes, engenders the great heat of the inflamed part. " The more this process of inflammation draws upon the blood the greater will be the exhaustion of vital force, and the more the whole frame will suffer ; the more it feeds on the tissues, the greater wiU be the difficulty of the reparative process. Is it not. then, important that adequate supplies should be conveyed to this proces.=, abnormal though it be? And is it not likely that the most appropriate supplies may be conveyed to it through the blood, so that the waste of tissue may be stopped, and the tendency to abnormal formations be checked, at least from that direction ? " And thi.s. in truth, seems to me to be but the plain and simple fact ; — you must feed inflammations as vou would other active vital processes. You must, that is, 1 288 PRIXCIPLES OF MEDICINE. feed them to prevent them from extending to, and preying on, healthy organic struc- tures, and committing great destruction. Bear in mind, too, that you cannot stop an inflammation so long as the exciting cause of irritation is inherent in the inflamed part ; you cannot cure an inflamed eye so long as the irritating particle of dust remains adherent to it. It is wise policy, then, to try and gain time, until by anti- dotal means, or by elimination, you can get rid of the local irritation, whatever that may be." Dr. ilarkham, in an able series of communications in the Lancet for November and December 1857, and in the Edinhurgh Medical Journal for 1857-8, pp. 886, 1058, not only upholds them, but advances new and, it seems to me, unanswerable arguments in their support. The following is a summary of the more important points insisted on by him: — The hj-pothesis that venesection was a right remedy in inflammations in former days is entirely founded on the supposition that the practice of physicians in those ' days was a proper practice ; but it is impossible for us now to arrive at any just conclusions on this point ; they have left us nothing but their assertions and convic- tions whereby to try the value of theu- practice. This we know, that their expe- rience quite differs from oiu-s in this particular of practice ; herein all ar6 agreed, and those who have faith in the infallible clear-sightedness of our forefathers, in order to reconcile the apparent discrepancy which thus arises between the practice of past and present days, call in the agency of a change-of-type theory. Thus, theory is called in to support hypothesis ; and as may be readily anticipated, the whole fabric melts away under the touch of modern medical argumentation. Clinical medicine (as now understood) is entirely a modern invention. Our fore- fathers bled in pneumonia, that is, for everything that occurred wrong and produced inflammatory symptoms within the thorax : they bled in tubercular disease, m pneu- monia, in heart diseases of all sorts, in rheumatism of the thoracic muscles, etc., etc , and from thence they concluded that venesection was good in pneumonia, and we are called upon to endorse and accept their sentiments. Now, it is a fact beyond all cavil, and worthy of note, that the whole profession (for individuals have diflered in all ages about bleeding) began to change their opinions about venesection, at the very time that they began to study medicme by the lights of modern investigation, viz. modern pathology and diagnosis. The reason is plain. Every well-kept record of diseases showed the injury done by large bleedings in inflammations ; and, doubt- less, the accumulated facts, duly reasoned on, at length brought physicians to hesitate in the practice, and at last to denounce it. The change of type theory rests wholly on a belief m the testimony of the expe- rience of skilled physicians in past days. These men were strong-minded men, full of sense, and their well-educated senses, we are told, were little likely to have their judgment misled; they bled, saw the excellent results of bleeding, and justly con- cluded that no remedy was so admirable m inflammation ; theref(/re the diseases for which they bled undoubtedly demanded bleeding. We bleed not as they, tlierefore disease has changed its tj-pe. True, they lauded venesection to the skies, but they have left us no records, whereby we may judge of the correctness of then: opinions. Others, however, who loved and admired bleeding equally as they did, and whose authority, none will deny, equals the best of theirs, have put on record the data whereon their love of the practice was based, and we can judge them. Had Andral, like Cullen and Gregory, left nothing recorded but his unbounded eulogy of venesec- tion in pneumonia, he also, like them, would have been quoted as an authoritative proof of the efficacy of it ; but he has given us the data, whereby we may test the value of his assertions, and we find them utterly condemnatory of his practice. Can THE BLOODLETTIXG COXTEOVEEST OF 1857-8. 289 any one doubt, that the practice of those other worthies would stand equally con- demned, could it he brought in a like manner to the bar of modern criticism ? If Andral was deceived, why not they? Andral teUs us, that the experience of ages has taught us to be more prodigal in the taking of blood in pneumonia than in any other disease ; that there is no period of the disease, no condition of the pulse, no apparent debUity of system, no age, which forbids its practice. Let us see how his conclusions are justified. He records 65 cases of pneumonia; of these 36, more than one-half, are fotal. Of the uncomplicated cases, there are 9, which reach only the stage of engorgement, and two of tliem — about 1 in 4 — die. Thirteen reach the second stage, and of these 5 die — 1 in 2^. Seven cases reach the thira stage, and they all die. Of complicated cases he gives 36 ; of these 22 die ! Another fatal argument against the change-of-tyjje tlieory is this telling fact, that wise men have, in all ages, and still do in this age with equal fervour, differ as to the value of remedies. From the days of Celsus down to our own. men have fought for and against bleeding, just as some do now. In France and England, mercury is a specific in syphilis ; in Scotland, mercury is a poison in syphilis. In the w^ards of the same hospital, physicians with European reputations, on the same day, treat fever, one by copious bleedings, the other by copious draughts of wine, both honestly convinced, fi-om the results of their treatment, of the propriety of their practice. That which alone gives undoubted value to a remedy is the consentaneous opinion of experienced men, which is universally accepted as true, and is not contradicted iy the opinion of equally experienced men. Then, again, if we look at the treatment by venesection of other acute diseases in past days, we must admit, from the very nature of them as taught us by modern pathology, that bleeding never could have been the remedy for them. Could it ever have been the right remedy for tubercular disease ? yet it doubtless was the remedy, for in those times phtliisis was " pneumonia." Could it ever have been needed in rheumatic fever ? and yet has there been any disease to overcome ^hich more blood has been shed ? From Sydenham down to Bouillaud, the practice has been sus- tained as steadily as an infallible dogma ; to this moment authoritative text-books impress its use upon the rising generation of phlebotomists. The idea was, that the maieries morhi could be " evacuated at the mouth of the vein," and of course the practice was logically followed. But modern pathology has taught us this : that there is a poisonous matter in the body producing those peculiar symptoms, and empirical treatment has demonstrated to us through manifest results, constantly ensuing, and not contradicted by opposing opinions, that we possess an agent, which will neutralise that poisoniug element. But rheumatism must surely have ever been the same disease ; consequently, the wisdom of the ancients notwithstanding, bleed- ing never could have been the remedy for acute rheumatism. The injury done by it in such disease, physicians of all late ages have not failed to mention. If our fore- fathers were wrong here, why not in other inflammations ? Dr. Markham, in a paper lately read before the Medico-Chirurgical Society of Lon- don, has endeavoured to show what is the manner in which venesection does act when it acts beneficially in inflammation. He therein argues that bleeding is use- less, as regards the inflammation : but that it is frequently of service by relieving certain of the secondary consequences which result from the inflammation, viz., con- gestion of the heart. (See pp. 295-6.) He beheves that it is never of service in any case, except when this congestion of the heart exists. He quotes cases of dis- eased conditions of the brain, of the abdomen, of the heart, and of the lungs, in all of which congestion of the heart secondarily arose, and in which venesection gave relie£ He argues for the inefScacy of bleeding over internal inflammations, from what we see of its inefificacy in external inflammations. Venesection has no visible 19 290 PRINCIPLES OF MEDICINE. influence over oiDhthalmia or rheumatism, or any other external inflammation, except when very large, and then only temporarily. "Why should it have any influence over internal inflammations ? Surgeons have long since given it up, because they saw its inutility ; but physicians could not see their way so clearly to a like conclu- sion, until modern pathology enlarged their powers of vision. He considers that practice clearly demonstrates the fact, that bleeding is not required except when congestion of the heart exists, and that the beneficial influence of bleeding is more marked in proportion as this condition of the heart exists in a more marked manner. Of course, however, there are congestions of the heart, and periods in the course of all congestions, in which the remedy can give no relief. When, indeed, is bleeding now-a-days resorted to except in those cases in which this congestion exists ? If the position maintained by him be correct, then he thinks it follows that the objects of, and indications for, bleeding become clear and definite. Dr. Markham also draws attention strongly to the distinction wliich is to be drawn between venesection and the direct abstraction of blood from an inflamed part. We have, he says, the positive ocular demonstration of the benefits of local bleeding in external inflammations. A few leeches applied to an inflamed rheumatic joint or around an eye rarely ever fail to reduce the chief characteristics of the inflammation — the pain, heat, redness, and swelling. Twenty ounces of blood taken from the arm produce no such eftect. Arguing from what we see in external inflammations, he concludes that local abstraction of blood must be also beneficial in all those internal inflammations in which there is a direct vascular communication between the inflamed part and the skin from whence the blood is drawn. Practice, he affirms, entirely corroborates this view. Leeches on the thorax are of use in pneumonia, because they relieve the pain of the inflamed parietal pleura; they manifestly draw no drop of blood from the lungs. They are of service in pericarditis applied over the cardiac region, because they also relieve the local pleuritic inflammation, which he believes to be the cause of the pain. Acute pain does not always accompany pericarditis, he says ; neither does local pleurisy, and we may legitimately account for the absence of the one by the absence of the other. Leeches are useless as regards liepatic affections, but they sometimes relieve the pain of the peritoneal inflammation, which is sometimes, excited by those affections, and of whose existence we find frequent proof in the dead-house, in the shape of old organised adhesions of liver to abdominal walls. In peritonitis he thinks tliem of service ; but in kidney aff'ections useless ; the relief so often apparently given by them being caused by those still more powerful remedies — the warmth and repose in bed, which their application necessarily occa- sions or indicates. In fine, he says the absence or presence of this vascular con- nexion gives us an explanation of the fact, that leeches often do no good in internal inflammations, and that they often are of no service. Of the mode of action of the leeches on local inflammations he has nothing to offer ; he accepts the fact as cer- tain. He does not deujr the benefits of local irritation ; he believes that it may act in a reflex manner through the vaso-motor nerves on the vessels of the inflamed part ; but the pathological history of this wonderful nervous agency has yet all to be written. It is possible that leeches may thus sometimes, by irritation, influence the vascular states of inflamed or healthy organs within the body, in cases where no vascular communication exists between the parts whence they di'aw blood and the organs within. Dr. George Balfour, in a paper published in the Edinlurgh Medical Journal for September 1858, shews that from the earliest times certain medical men have suc- cessfully treated inflammations without blood-letting. But his notion that this has resulted from blind empiricism, rather than from theory, I think disproved by his THE BLOODLETTING CONTROVERSY OF 1857-8. 291 own observations. The following quotation contains his views' on the subject : — " Brought up in the professional tenets of one so respected and loved as Dr. Alison, I can never forget the horror with which I at first regarded the practice of Skoda, the incredulity with which I listened to his explanations, or my astonishment when extended observation had convinced me of the correctness of his conclusions, the truth of which eleven years of private practice in this country have but tended to confirm. True pneumonia has been, in my experience, a comparatively rare disease, and I have had under my care only seventeen cases, all of which recovered. AU bore a strong resemblance to Cullen's type, and would, I believe, have borne blood- letting well ; that they would have therefore recovered better is impossible ; that they would have recovered quicker is unlikely, as, 'after full or repeated blood- letting, convalescence is generally slow' (Alison), forming a striking contrast to the rapid recovery of those who have never been bled. I may say, then ; that my own personal experience has not led me to suppose that the practice of not bleeding in pneumonia has been brought about by any change of type ; neither has my reading given me any reason to think that there has been any wave or waves of changing type, but rather to agree with Dr. Duncan that, as far as regards inflam- mation at least, such 'changes exist only in the imagination of physicians,' and that from the time of Pythagoras downwards to the present, the non-bleeding treatment of pneumonia has been in all ages at least as successful as its opposite ; has seldom, if ever, wanted an exponent, and has been practised by quite as many of the ' cla- riores rtiedicV Modern pathology has no doubt rectified many mistakes into which a refined physical diagnosis had led physicians, and by clearly explaining the modus operandi of the treatment, has rendered it more easily adopted by a certain class of minds : just as the spread of civilisation, its vices, its malaria, and overwork of both body and mind, has rendered a proportion, at least, of our population less tolerant of blood-letting in disease than our less refined forefathers, and so enabled another class of minds more easily to adopt the non-bleeding system. Yet the whole course of medical history tends to teach us, that though blood-letting has been practised in all ages, it has been necessary in none. Its opponents have clearly shown that it can correct no humours, evacuate no materies morbi, and has no influence over exudation ; while those of its advocates who have most ably investigated its use, have distinctly proved that it cannot cut short the disease (Chomel, Andral, Louis), prevent exudation, or jugulate any symptom (Grisolle). So little influence has it over those phenomena which may be supposed to precede inflammation, that it is precisely in the case of those who have lost much blood previous to the occurrence of inflammation that we have most to dread a fatal termination ; and in commenting on a fatal case of this character, one of the greatest clinical teachers of this or any other age commences by the strong assertion, that the first consideration suggested by it is, 'the tendency which excessive depletion produces to the formation of inflammation.' " (Graves.) Such is an account of the blood-letting controversy excited by my remarks, and which has been carried on during the years 1857-58. That the extraorduiary acti- vity which, during the last fifteen years, has been communicated to the natural sciences, should fail to produce any change in medical practice, was scarcely to be expected, any more than that such change could be efiected without great opposi- tion and much discussion. Yet, singular to say, the discussion in this case, instead of preceding, has followed the change, inasmuch as many of those who are now con- tending for the advantages of blood-letting and antiphlogistics in inflammation, are the very parties who acknowledge that they no longer employ them. But, though tardy, the discussion may still be useful, should it serve to direct men's minds to 292 PRINCIPLES OF MEDICINE. what I conceive to be the true principles which should guide our endeavours to advance medicine. These are — 1st, That an empirical treatment, derived from blind authority, and an expectant treatment, originating in an equally blind faith in uaturei are both wrong : 2dly, That a knowledge of physiology, pathology, and therapeutics, and not experience alone, is the real foundation for the practice of the medical art ; and, 3dly, That a true experience can only have for its proper aim the determmation of how far the laws evolved during the advance of these sciences can be efficiently made available for the cure of disease. THE INFLUENCE OF PREDOMINANT IDEAS ON THE HEALTHY AND DISORDERED FUNCTIONS OF THE BODY. Dr. Henry Monro,* speaking of monomania, says that " in these cases neither the controlling agency of the will nor the reason is suspended on most subjects, though it is so on certain points; these people can guide their thoughts well enough on most questions, can see the full relations that cause bears to effect, and that mental impressions bear to external things, but they cannot properly control those impressions which are most strongly fixed on the mind. This state has very fre- quently a stage of contest and conscious difficulty at fii'st, when the struo-gle between the morbid impressions and the faculties by which to control them is great ; indeed, we may say that all morbid and excessive impressions which exclude all other considerations bear the rudimentary form of this aftection, though insanity cannot be said strictly to be fully developed until the contest is decided by such a victory on the part of the morbid impressions that the moral liberty to exercise their reasoning faculties on these subjects is gone. Now, the first stage of the process here so accurately described, viz., that in which persons cannot control those impressions which are most strongly fixed on the mind, — may be produced artificially in about one out of twenty individuals of the entire population. Thus, if that number be chosen indiscriminately, and directed to gaze steadily at any object for about ten minutes, a peculiar condition of the cerebral functions will be produced in one or more of them (especially if they be young) ; and under this condition those aff"ected may be made to act in accordance with any train of ideas which may be suggested to them, their motion and sensation being influenced in a variety of ways.f It seems as if their mental faculties become fatigued, in consequence of which they lose the 25ower of controlling any idea that becomes predominant. The peculiar mental condition thus produced manifests itself while * Remarks on Insanity, etc. \ The mode of producing this condition may be varied, but it is in all cases essen- tially the same. Tims Mesmer caused individuals to sit in a kind of trough, and they were directed to look at a wire placed in their hand. The Fakirs of India throw them- selves into a trance by looking at the extremity of their own noses. Mr. Braid of Manchester holds an object a little above the ej-es, so as to fatigue them sooner. Dr. Darling causes them to look at a small coin placed in the palms of their hands, whilst others fix the attention of persons on themselves, on the tips of their fingers extended towards their eyes, and make motions or so-caUed passes which arrest the attention. INFLUENCE OF PREDOMIN^iNT IDEAS ON THE BODY. 293 the individual is gazing upon the object, in the first instance, by a misti- ness of vision, succeeded in some by a feeling of lassitude and desire to sleep, in others only by a stiffness of the eyelids, and in a third class by deep-drawn sighs, hurried respiration, heaving of the chest, or other si*' Fis. 382. Fig. 383. in the brain are generally surrounded by a layer of cerebral substance exhibiting all the characters of this form of softening (Fig. 383). Can- cerous exudation into the brain is very rare (Fig. 277). 2d, Hemorrhagic softening. — When blood is extravasated with force into the cerebral structure, it breaks up the nerve-tubes of the part and coagulates. The coagulum then forms a solid mass, whilst the serum, more or less tinged with colouring matter, is infiltrated to a greater or less distance and absorbed. Under such circumstances, the softened ner- vous tissue surrounding the clot pre- sents fragments of the nerve-tubes alone, which under the microscope frequently exhibit a peculiar ten- dency to form circular, oval, or irre- gularly-formed globules, with double outlines, as in Fig. 384. There are none of the granule cells so charac- teristic of an inflammatory softening, although they may appear later, as the result of exudation from the cere- bral vessels surrounding the clot. In such cases the greatest variation in the appearance of the nerve-tubes is observable, from a slight diminution in their natural firmness and consistence, which renders them easily separable, or causes varicosities or swellings in them to be readily pro- Fis. 3S4. Fig. 382. Structure of a tubercular exudation in the cerebellum, composed of gra- nules and tubercle corpuscles, with a few fragments of nerve-tubes. Fig. 383. Structure of the softened cerebellum, immediately external to the same tubercular mass, containing a larger number of fragments of the nerve-tubes, with numerous granular corpuscles. Fig. 384. Structure of the softened cerebral substance, surrounding a recent clot of blood, showing the appearance assumed by the nerve-tubes when broken up, and softened by imbibition with serum. — See Apoplexy, case of Pitbladdo. 250 diam. CEREBRAL AND SPINAL SOFTENINGS. 807 duced on pressure, up to a condition when tliey exhibit nothing but fragments and separate globules, as in fig. 384. The coloured cerebral softenings wliich are subsequently produced as a resultof hemorrhage arc owing to the transformations which go on in the coagiilum itself. They assume a bright orange, brick red, yellow, fawn, or dirty brown colour, and under the microscope are found to consist of hematine in various forms and tints. Thus the whole may be granular, or mingled with crystals of hematoidine or melanine ; and the granules, granular masses, and celloid degenerations, may present numerous shades of orange, red, brown, black, etc. etc. (See Pigmentary Degeneration, p. 227, "fi! seq.) 3'/, True fatty softcninr/. — This lesion, that is, a primary fatty dege- neration independent of exudation or hemorrhage, is one of the exist- ence of which I was for a long time very doubtful. Careful investigation, how^ever, has satisfied me, that it does occasionally, though rarely, present itself, apparently as a consequence of obstruction of arteries. In this case the vessels are not coated necessa- rily with granular exudation, but the nerve- cells undergo the fatty degeneration pi'ima- rily and are enlarged. The walls of many of them also are dissolved, leaving triangu- lar or crescentic-shaped granular masses be- tween the nerve-tubes. This alteration is accompanied with diminution of the cere- bral density, and the nerve-tubes are also easi- ly separated and bi-oken up, though not so readily as in the last form of softening noticed. 4fh, Serous or dropsical softening. — This kind of softening is due to imbibition of the serum, which is effused into the ventricles in cases of hydrocephalus and other diseases. Hence it is only found in the neigh- bourhood of such effusions, and most commonly in the central portions of the brain, as in the white matter of the septum lucidum, fornix, etc. It is the white softening of morbid anatomists, and consists structurally of nothing but the oedematous normal elements of the parts, without any of the changes peculiar to the exudative, hemorrhagic, or true fatty softenings. The observations of Dr. Robert Paterson of Leith tend to show that the brain substance is very porous, and that if a slice of it is placed in water, it readily imbibed a considerable quantity, becoming at the same time more soft. Whether such softening ever occurs in the living body is very doubtful ; it is most probably a post-mortem change. Sometimes serum is found to a considerable extent in the ventricles, without softening of the surrounding parts. The fluid apparently in such cases has not passed through the lining membrane of the ventri- cles. At other times this has occurred, and the softening so occasioned Fig. 385. Fig. 385. Structure of the softened pons varolii, in a ease wliere tlae basilar artery was obstructed, shewing true fatty degeneration of the nerve-cells, among somewhat softened and broken up nerve-tubes. — See Cerebral Hemorrhage, case of Alexander Walker. 250 diam. 308 DISEASES OF THE NEPwVOUS SYSTEM. is found to be greatest near tbe central parts, and to diminish according to the distance from them. The causes which pioduce, and at others impede, post-mortem imbibition are unknown. 6th, Mechanical softening. — I have frequently seen softenings occa- sioned in the brain, and more frequently still in the spinal cord, through crushing the nervous texture, after death, in various ways. Thus the saw or chisel mav occasion mechanical softenings in the superficial parts of the brain, when the calvarium is being removed by inexperienced or unskil- ful operators. In France, where the hammer is used for this purpose, it is a frequent cause of supei-ficial softenings. The spinal cord is especially liable to be injured, bv slipping of the chisel or lever used in elevating the pos- terior spinous processes of the vertebrse. Portions of soft nervous tissue, such as the corpus striatum, have frequently had their texture reduced to a pulpy consistence by mere handling, or by constant application of the fin Fig. 38T. dently with the violent symptoms, is consistent with every known fact Fig. 387. A blood-vessel from the central substance of the brain, coated with a molecular exudation, and with nuclei forming in it. Fig. 388. Another blood-vessel, with masses of recently coagulated exudation attached to it. " 250 diam. 344 DISEASES OF THE NERVOUS SYSTEM. another boy, H. B., two and a half years old, whom I saw in private practice, who was previously in good health, the same fact was observable. On the 6th of July 1 848, he could not eat his breakfast ; at 1 p. m. he vomited ; at 4 P.M. febrile symptoms appeared ; dui-ing the niglit there was great restlessness with occasional screaming; on the morning of the Vth there were general convulsions, but principally on left side, and he died at half- past six. The examination was peifoimed by Mr. Goodsir. "With the exception of 3iss of slightly turbid serum in the ventricles, nothing was found in the brain but a yellow discoloration the size of a sixpence on the surface of the right corpus striatum. On microscopic examination, this was seen to consist of the same molecular matter surrounding the blood- vessels, as is represented Fig. 387. These and many other observations, therefore, appear to me a sufficient proof that there is a form of acute cerebritis, consisting of the exudation of liquor sanguinis and the coagulation of the fibrin around the vessels, which may prove fatal very rapidh', especially in children, but that when such changes occur in the adult or in aged persons, it has a tendency to become chronic, and leads to Avhat may be called exudative softening. See p. 305. Chronic cerebritis so occasioned can only be distinguished with certainty by a microscopic examination. It may present various shades of colour — white, grey, yellow, or fawn-coloured. I have seen white softening's which to the naked eye exactly resemble such as are caused by imbibition after death, but which show under the microscope numerous granule cells in all stages of formation, proving that an exudation and a new growth must have been established before death. In the same way a diffluent grey softening of the white cerebral substance, which has been i-egarded by some as atrophic, I have shown by its structure to have originated in an exudation (Fig. 389). The yellow and fawn-coloured softenings gene- rally owe their colour to an admixture of blood to a greater or less extent, but are otherwise essentially the same. Hence, as previously '^" ^"^ stated, I regard the microscopic examination of such lesions to be absolutely necessarj' to ascertain their nature, and the existence of granule cells in the white substance of the brain as a positive proof of exudation. We have previously seen that it is a matter of great difficulty to dis- tinguish in the living subject acute cerebritis from meningitis. Neither is it always easy to separate chronic cerebritis from many cases of soft- ening resulting li-om hemorrhage, or from fatty degeneration resulting from arterial obstruction. The cause of this is obvious, inasmuch as all these lesions, consisting of more or less destruction of the nervous tissue, may be expected to affect the brain in the same manner. In their mode of onset, however, they exhibit a difference. Thus, as a general rule, hemor- rhage is indicated by suddenness of attack, whilst uncomplicated chronic Fig. 389. Structure of a chronic grey softening of the cerebral hemisphere, resem- bling chalky milk, entirely composed of exudation, transformed into granules and cells. 250 diam. CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 345 cerebritis o-raduallr affects the mental and motor functions in various ways and deo-rees according to the portion of the brain affected. But it must not be 'overlooked, th'at an intiammatory, a hemon-hagic, and a primary fattv softening mav occur together in one individual, as the conditions which occasion one are also "favourable to the production of the others. Hence I must refer the reader to the considerations on this point under the head of Cerebral Hemorrhage. Great discussion has taken ptace as to whether a chronic inflamma- tory softening ever undergoes a cure. Durand-Fardel thinks that the curability of cerebral softening is a fact of which we can no more entertain disbelief in the present day, than we can of the curability of pulmonary tubercle. Most certainly"the observations of Rostan, Cruveilhier, Sims,^ Dechambre, and Durand-Fardel have fully established the possibility of this occurrence. Besides, why should not a coagulated exudation of blood-plasma into the brain, in consequence of the changes whereby it is broken down and disintegrated, be ultimately absorbed in that organ as well as in any other? It appears to me, however, that the anatomical appearances, by means of which pathologists have endeavoured to demon- strate the curability of a softening, are not to be depended on. Durand- Fardel points to the softening resembling chalky milk as a proof of the passage of the lesion into a state of cure, and Dr. Sims described fawn- coloured cavities as evincing the same fact. Xow I have seen cases where the o-rev milky softening was associated with hemiplegia of long standing, but which presented, on microscopic examination, the appearance repre- sented Fio-. 389, which although undoubtedly evincing great disorga- nization, cannot be said to show signs of healing. The fawn-coloured cavities of Dr. Sims I have not onfy seen to be tilled with granule cells in all stao;es of formation, but associated with intense recent contraction on the opposite side of the body. Neither of these lesions, therefore, appears to me to present anatomical proofs ot a cured softening. Dr. Todd also believes in the cicatrization of chronic softenings, and even considers that the rigidity which occasionally comes on late in paralysed muscles, is attributable to the irritation which the contraction produces on the neighbouring healthy cerebral substance. Whether the yellowish or fawn-coloured indurated spots, which are very rarely observed in the brain-substance, are proofs of cured softening, it is very difficult to say, for I have seen such indurations crowded with granule cells. (See Case XVII.) Hence the morbid anatomy of cured cerebral softenings is a subject still demanding careful investigation. The ireneral diagnosis and treatment of chronic cerebritis will be considered under the head of Cerebral Hemorrhage, with which it is often associated. CEREBRAL DISEASE FROM OBSTRUCTIOX OF ARTERIES. Case XV.* — Paralysis rapidly becoming general — Old Ajjoj^ledic Cyst in right Corpus Striatum — Softening of Pons Varolii — Clot obstructing Basilar Artery — Pneumonia of Left Lung. History. — Alexander "talker, a;t. 50 — a pensioner — admitted December 3, 1855. * Reported by ilr. John Glen, Clinical Clerk. 346 DISEASES OF THE NERVOUS SYSTEM. According to the account of the patient's brother, he has been long subject to vertigo, both when at home and as a soldier in India. For this complaint he has been bled fifteen times, and always with temporary relief. He has been of temperate habits, and has lately been working in a printer's office, where he was accustomed to carry heavy weights oii his head. Yesterday, having undergone unusual bodily fatigue and great mental anxiety in consequence of his sister's death, he was suddenly seized, about 4 P.M., with a feeling of pricking and numbness in his left arm, which commenced at the fingers. Siiortly after, there occurred thickness of speech, which rapidly increa.sed. During the night he became speechles.s, but could make signs, and appeared conscious. In the morning he was conveyed to the Infirmary. Symptoms ox Admission. — On admission, there is no sensibility in the left arm — on being flexed it appears peculiarly rigid, though not retracted. On stimulating the left leg, there is evidence of only slight sensibility, and feeble reflex movements. Right arm moves readily on the application of stimuli, but the right leg, though somewhat retracted, is partially paralysed. Left pupQ somewhat more contracted than the right one. Face pale, without distortion of the features. Cannot speak or protrude the tongue, but is evidently conscious, listening and watching movements with an anxious expression of countenance. Cardiac sounds inaudible ; pulse 88, of good strength; inspirations deep, expirations accompanied with snoring rales. Skin warm and dry. Bowels constipated ; bladder distended. To have a turpentine enema. The urine to he drawn off by a catheter. Iced-ioater to be constantly applied to tlie scalp (tlie man's head was bald), and the following bolus to be carefully placed on the posterior third of the dorsum of the tongue^ so as to ensure deglutition. R. Olei Crotonis gait, j ; Puiv. Jalap. Co. 3i ; Confect. Sennce, q. s. ft. bolus. Progress of the Case. — December Uh. — 30 oz. of healthy urine were drawn off yesterday by the catheter. This morning both foeces and urine were passed invo- luntarily in bed. Both arras and legs are now completely paralysed, and do not move on the application of strong stimuli. Respiration is more laboured ; pulse 120. week ; still conscious. To nourish the patient as much as possible by the mouth, and if necessary, i)er anum, with strong beef tea. December oth. — Respirations still more laboured, and the chest does not expand. The loud snoring with expiration masks the pulmonary sounds, and his position on the back cannot be changed to admit of examination of tlie lungs. In other respects is in the same state, but weaker; pulse 120, weak. Is motionless, speechless, with the lips slightly separated. On attempt- ing to introduce nourishment by the mouth, the jaws are firmly closed, and matters which are taken cannot be swallowed, although he makes efforts to do so. The water has been drawn off regularly by catheter, and nutritive enemata. witli brandy, administered. He is still evidently conscious. December Qth. — Since yesterday has been gradually sinking ; tlie cheeks are distinctly paralysed, and distended at each expiration. This morning the left pupil became much more contracted than the right ; the corneae became dim, and the respirations 40 in the minute ; the pulse fluttering; coma supervened ; and he died at 2 p.m. on the 7th. Sectio Cadaveris. — Twenty-three hours after death. Head. — Surfaces of the arachnoid moist; slight serous effusion between the sulci of the cerebral convolutions. On .slicing tlie hemispheres, their substance exhi- bits a greater number of bloody points than usual. They are symmetrical ; the right lateral ventricle somewhat smaller than the left. The two contained 3 iij of transparent serum. The right optic thalamus was decidedly larger than the left one, and at its base, near the corpus striatum, presented on section a well marked cribri- form appearance. In the posterior fourth of the left substance of the corpus striatum was a diffluent mass the size of a pea, which flowed out on section, having a small CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 347 cavity with the walls of a fawn colour. Both choroid plexuses contained simple cysts, the greater number on the left side. On cutting through the pons varolii, its centre vi'as found softened, and of a pulpy consistence, the upper half more than the lower, and the right more than the left side. The whole softened portion was gradually washed away by a thin stream of water, showing a distinct irregular margin, inclosing a cavity about the size of a hazel nut. The basilar artery, throughout its whole course, was opaque, its coats loaded with calcareous and atheromatous matter, and obstructed by a colourless clot, which at one point was transformed into mineral matter. Spinal Cord. — The spinal cord was carefully examined, and found to be healthy. Chest. — The inferior lobe of left lung hepatized, of a dirty grey colour, and in the upper lobe two masses of pneumonic condensation about the size of walnuts. Mar- gins of both lungs emphysematous. Heart healthy. All the other organs were healthy. Microscopic Examination. — The contents of the old apoplectic cyst in right cor- pus striatum had disappeared, but the indurated walls consisted of a dense aggrega- tion of brownish opaque molecules, which gradually diminished externallj', and were gradually lost among the tubular and granular substance of the striated body. The softened portion of the pons varolii was entirely composed of the disintegrated tubular and vesicular structure of this portion of the encephalou. There -nere no granule cells or granule masses, such as are found in softening from an exudation. But the nerve-cells contained an unusual number of minute brownish granules, and floated about isolated in the softened substance, as seen in Fig. 364. The clot in the basilar artery contained irregular masses of phosphate of lime, which at one point were so closely aggregated together as in themselves completely to block up the ves- sel. The hepatization of the left lung presented all tlie stages of the congestive, exudative, and suppurative stages of pneumonia. These were remarkably well seen in the two masses in the upper lobe, in which the centres were soft and purulent, the air vesicles filled with pus, and the surrounding mass indurated, exhibiting dif- ferent stages of the transformation of an amorphous exudation into cells. (See Fig. 357, p. 242, which was drawn from a demonstration made from one of these masses.) Commmtan/ — After vertigo and other head symptoms for many years, for wliich he was in the habit of being bled, this man, in conse- quence of unusual bodily exertion and mental anxiety, was suddenly seized with paralysis in the left arm without loss of consciousness. This was followed by paralysis of speech, and of the other limbs, inability to pass urine or retain the foeces, and spasmodic closure of the jaws. These symptoms indicated a lesion of the central parts of the brain, which, from the suddenness of their occurrence, 1 supposed would be a hemor- rhage either in or pressing upon the pons varolii. But on examination there was found an old apoplectic cyst in the left corpus striatum, which did not appear to have caused any of his recent symptoms, and is not accounted for in his history. The general paralysis was evidently owing to the softening of the pons varolii, and this in its turn was certainly not dependent on an exudation from the bloodvessels, a fact which I ascertained by careful and prolonged microscopical examination, I could not therefore resist the conclusion, that the disorganization of the nervous substance was attributable to the obstruction in the basilar artery, and a peculiar fattv degeneration commencing in the nerve cells. Of this lesion we shall be able to form a better idea after examining the facts of the followinof case : — 848 DISEASES OF THE NERVOUS SYSTEM. Case XVI.* — Apophxij — Hemiplegia of Left Side — Convulsive Attacks — Cardiac and Renal Disease — Old Clot in the right Cerebral Hemisphere, loith surrounding softening. History. —Elizabeth Ross, set. 26, married — admitted May 23, 1853. States that about -i^ years ago she suffered from acute rlieumatism, on recovering from which she frequently experienced palpitations, and during the last 18 months there has l^een occasional epistaxis, preceded by giddiness, dimness of vision, and muscje volitantes. Last January, when quietl_y sitting in a chair, she suddenly fell to the ground insensible, in which condition she remained 48 hours. On recovering her consciousness, she could not speak ; the left half of the body and face was deprived of motion and sensibility. Five weeks afterwards she began to regain her speech and the command of the left arm and leg, but observed at the same time an oedema- tous state of the feet and legs, and that this gradually spread over the whole body. Three weeks ago she again became suddenly insensible, and continued so 1| hours, during which time she was much convulsed. Slie had three similar fits during the succeeding ten days, which were preceded by a choking sensation in the throat, pal- pitation and uneasiness in the precordial region. Symptoms on Admissiox. — On admission there is still partial paralysis of the left side of the body, which is much colder than the right side. On attempting to walk she cannot raise her left foot completelj^ from the ground, but drags it behind her. She cannot bend her left wrist or arm, or raise them so readily as she can those of the right side. Her mouth is slightly drawn to the right side, and the tongue when protruded appears to be somewhat to the left of the mesial line. The sensibility over the whole left side is somewhat impaired. She complains of uneasi- ness in the precordial region. Action of heart strong, but rhythm regular. Apex beats between the 5th and 6tli ribs, about half an inch to the outer side of the nipple. Transverse cardiac dulness 3|- inches. A blowing murmur is heard with the first sound at the apex, and a double blowing murmur at the base, of which that with the second sound is the loudest and longest, and is distinctl}^ audible in both infra- clavicular spaces. Immediately above the right sterno-clavicular articulation con- siderable pulsation is visible to the eye, but no tumour can be defined upon mani- pulation. Over this part a harsh single blowing murmur is audible, and fremitus is very perceptible to the finger. No venous pulsation. Radial pulse 87 per minute, strong and hard, communicating a jerking sensation to the finger. The voice is weak, and articulation diflBcult and indistinct. Respirations irregular and spasmodic. 20 per minute. No dyspnoea. Cough short; expectoration scanty. Chest resonant everywhere on percussion, and the only abnormal sound audible is a fine moist rattle with inspiration over the two lower thirds of left lung posteriorly. Tongue is red and drj- : appetite very bed, and dysphagia to such a degree that she can only take liquid food. Slight epigastric tenderness. Bowels costive. Micturition diffi- cult, painful, and frequent. Urine of pale colour, neutral reaction, sp. gr. 1010, with deposit of triple phosphate on coohng ; quantity passed small, and deposits when heated a considerable coagulum. There is general oedema of the whole surfiice of the body, but especially of the inferior extremities. R Pil. Scillce et Digitalis, vj : Sumat unam his in die. ^ Pil. Opii, gr. i. hora somni sumend. Habeat Elect. Laxans 3 i j ; et repetatur post horas sex si opus sit. Progress of the Case. — May 25ih. — Sleeps better. Bowels relieved. (Edema of upper part of body diminished. Urine still in small quantity, highly coagulable, and containing waxy and fatty casts. Heart's action not so strong. June 6th. — Since last report has been gradually improving. She can use the extremities of * Reported by Mr. Joseph Johnson, Clinical Clerk. CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 349 left side more freely, and the sensibility is more acute. Can rise and return to bed ■without assistance. Speech more distinct. Impulse and murmur over sternum greatly diminished. Heart's impulse more feeble and blowing sounds not so loud. Pulse 90, still jerking. Complains of pain, but without tenderness in right lumbar region. (Edema of lower limbs stiU considerable, though diminished. Digestive fuuctions normal. Renal symptoms the same. Has been taking half a grain of the proto-iodide of inercury every night, tvith mild diuretics and occasional laxatives. June lih. — Yesterday afternoon, at 4 p.m., she became giddy, and soon fell into an unconscious state, accompanied with convulsions equally strong in the limbs of both sides; screams and moaning. The pupils were dilated and the eyeballs turned outwards and upwards. She had no foaming at the mouth, but frequently shut her jaws with great violence, so that her tongue could -with great difficulty be kept from being injured. The attack lasted ten minutes. During the evening, she had lour other attacks of about the same duration. After each fit she remains for some time in a drowsy condition, and cannot answer questions perfectly. After the first attack six leeches were applied to the temples, and a turpentine enema given. In the evening a blister was applied to the head. To-day is much better. June 9th. — Had another slight attack yesterday morning, and a third last night. Paralysis not Increased; other symptoms the same. Jmie I9th. — Since last report has been com- plaining of wandering pains, more especially in right hypochondrium. The gums on the l-ith became slightly tender, when the proto-ipdide of mercury was omitted Since the 10th there has been diarrhoea, the bowels havmg been opened 6 or 7 times daily, notwithstanding the employment of various astringents with opium by the mouth and rectum. About 4 p.m., without any precursory symptoms, she sud- denly became unconscious and convulsed. She strained and struggled violently for about fifteen minutes ; the convulsions at first being equally severe on both sides, although latterly they were entirely confined to the left side. Her mouth was drawn towards the right, and the lower jaw was incessantly carried from one side to the other, with a semi-rotatory motion, as in grinding food. The eyelids remained permanently open, and the eyeballs were carried in an upward and outward direction, in which position they remained during the continuance of the fit. The breathing became slow, sometimes interrupted and irregular, attended with stertor during inspiration, and a putfing out of the cheeks during expiration. There was also foaming at the mouth. These phenomena soon subsided, and the patient was left in a coma- tose condition. Two hours thereafter these phenomena recurred twice, without the patient in the intervals regaining the slightest degree of consciousness. The foeces and urine were pa.ssed involuntarily. During the last attack the inhalation of chloroform was tried, but the breathing becoming more stertorous and hurried, and the pul.se intermitting and almost imperceptible, it was instantly stopped. Ahradatur Cajnllitiuyn; Applicetur Capiti Emp. Caniharid {4: x 6). June 20th. — Became con- scious last night about 8 o'clock, when she could answer questions correctly, but slowly, and in an inarticulate manner. She complains, when interrogated, of great exhaustion and severe frontal headache. Diarrhoea continues and is involuntary. Pulse 90. weak, almost imperceptible. Stupor at intervals. Habeat Vini § ij. June 2lst. — Xo return of convulsions. Stools not passed involuntarily as formerly. No pain in head, and says she is free from suflering. Countenance dull and stupid ; pupUs natural; expression of eye sluggish. Respiration slow and snoring. Over both sides of chest anteriorly, loud moist rales are audible. Pulse 90, very weak. Other symptoms unaltered. Haheai Vini 5 iv indies. Nutritive food and drinks. Towards evening the mucous rattle in chest became very loud, and the breathing snoring, and occasionally interrupted ; no pain anywhere. Could with difiBculty be roused to answer questions. Died at 1.30 a.m. 350 DISEASES OF THE NERVOUS SYSTEM. Sectio Cadaveris. — Thirty-Jive hours after death. Body pale, not emaciated ; lower extremities very oedematous. Head. — The arachnoid membrane presents its natural degree of moisture. On section of the right hemisphere of the brain, a softened portion is situated above and to the outer side of the corpus striatum. It measured I^ by 1 inch, and extends externally close to the cerebral convolutions. In its centre there is a hard round nodule, about the size of a small hazel nut, of a dark-red colour, with a zone of bright yeUow, extenduig about a quarter of an inch into the softened cerebral sub- stance. This is of friable consistence, and of a yellowish hue in the centre, becom- ing of an ash-grey tint, and of almost diflBuent consistence towards the circumfer- ence. Externally the diseased substance gradually passes into the healthy cerebral structure. Arteries healthy. Chest. — Pericardium distended, containing 3J- oz. of pale straw-coloured fluid. Left ventricle firm, its cavity dUated. The mitral orifice admits the entrance of two fingers ; but the anterior segment of its valve has on its external surface a few scattered fibrinous granules, wliile its posterior-inferior angle is thickened and covered with small masses of fibrui, which extend along the shortened chordae ten- dinea;, giving them a fringed appearance. The aortic valves are much thickened, hard and inelastic, especially at their free borders, upon "ivhich also a few aggrega- tions of fibrinous granulations are seen simQar to those upon the mitral valve. They contain in their interior a small amount of atheroma, which extends into the aorta for about three quarters of an inch. Tiiey admit the passage of water tlirough them rapidly, on its being poured upon them fi-om above. The pleurae on both sides are partially adherent by long bands of chronic lymph. The right pleural cavity con- tains about six. and the left about three ounces of serum. The lungs are slightly collapsed, flaccid, and imperfectly crepitant. In several places are indurated masses, varving in size from a pea to a hazel nut, composed of infiltrated blood. Other por- tions of the lungs pour out, from their cut squeezed surfaces, a small quantity of turbid serum, with pus from the smaller bronchi. Abdomen*. — Cavity of the peritoneum contains a considerable quantity of serum. Liver of natural size, but the colour dark from venous congestion. Spleen of firm consistence, 7 inches long by 4 broad. Both kidneys slightly larger than usual, of firm consistence, puckered surface, and stellate irregular vascularity. On section, they present the usual characters of the waxy degeneration. Other abdominal organs healthy. Xo leucocythemia. Microscopic Exajiixatiox. — The central portion of the diseased cerebral struc- ture is principally composed of fibre cells, distinctly nucleated, infiltrated, however, w^th sanguineous colouring matter, in various stages of degeneration, and mingled with purple and ruby crystals of hematoidine. The more external yellow and grey softenings present granules and granular masses in great abundance, mingled with reddish and yellow portions of disintegrated blood ; the latter with a few crystals of hematoidine, are most abundant towards the centre. Externally the softening is principally composed of disintegrated nerve-tubes, presenting various forms with double lines. Commentari/. — In this young woman vascular disease of the heart had supervened upon acute rheumatism, and vegetations had formed upon the sui-faces of the mitral and aortic valves. These vegetations, as we shall subsequently see, are deposits of the fibrin in the blood which niav become detached, and be carried by the circulation into more dis- tant and smaller vessels. Four months previous to admission, when CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 351 quietly sitting in her chair, she became suddenly apoplectic; and on recoverino- her consciousness laboured under hemiplen-ia of the left side and paraivsis of speech. Five weeks subsequently syniptouis of renal disease manifested themselves ; then there supervened another attack of apoplexy, followed by a long train of nervous phenomena, which exhausted her streiioth and caused death. I took charge of the case in the middle of June, bv which time she was so reduced that wine and nutrients failed to rallv her. On post-mortem examination the arteries of the brain were healthv, but evidence of an old hemorrhage existed, and the ques- tion tliat arises is, whether or not this had been caused by obstruction of the middle cerebral artery, from one of the clots derived from the heart? Though this cannot be affirmed, it appears to be very probable. The lesion" so produced by its irritating action in the surrounding brain tissue, conjoined with occasional congestions, is quite sufficient to explain all the nervous phenomena which followed. Case XYIL* — Tico sudden attacks of Apoplexy — Hemiplegia — Cardiac Disease — Persistent Albuminuria — Enlarged and diseased Spleen — Cerebral Softening — Anasarca — Atheroma of Arteries — Obstruction of the left middle Cerebral Artery. History.— James Balfour, set. 38, a smith — admitted April 13, 1857. The patient has been a man of temperate habits, accustomed to good diet, and in the enjoyment of excellent health for the greater part of his life. For nearly a twelvemonth before admission, his wife had noticed that he was not looking so weU as formerly, but he liimself had no feeling of Qlness, and continued to follow his usual occupation until three months ago. At that time, one day, while engaged at his work, he was sud- denly seized with headache and vertigo, the pain being so severe as to compel him to return home and go to bed. He became insensible, and remained comatose for three days. On recovering from this state, he found he had lost the power of his right side, and that his features were drawn to the left. His speech was not affected. From this state he gradually recovered, and in four weeks was able to return to work. Three weeks subsequently, while in the act of shoeing a horse, he again .sud- denly lost to a considerable extent the power of his right side, and his speech now became affected. Since the second attack he has never been able to resume his work; for, although he has recovered the power of his right side almost entirely, he has gradually become weaker. For the last five or six weeks his legs have swollen towards night, and during the same period there has been slight diarrhoea, which has increased considerably d\u-ing the last ten days, but which causes no pain. Two weeks ago he was attacked with severe vomiting, the matters ejected being appa- rently bilious, and since then he has suffered from pain in the splenic region, espe- cialh' when he stands or moves about. Symptoms ox Admission. — On admission, the patient talks in a loud monotonous tone, indistinctly, and with stammering; he cannot whisper, though he can speak in lower tones than usual. When speaking, the voice often becomes whining; he cries and sheds tears without any obvious cause. The sensibility of both sides of face, of the trunk, and limbs, seems unimpaired, tongue slightly protruded to the riglit side, while the mouth is drawn to the left ; when the patient eats, the food lodges in the right cheek ; he tastes and feels as well on the right side of the tongue as on the * Reported by Mr. T. J. Walker, Clinical Clerk. 352 DISEASES OF THE NERVOUS SYSTEM. left. The grasp of the right hand is as firm as that of the left, and the patient walks without a hmp, but there seems a want of certainty in planting the right foot, and he staggers slightly on turning quickly round. His intelligence and memory are unim- paired. He cannot write now as well as formerly, being unable to form the letters ; but he can read WTiting and printing. On percussion, the transverse dulness of the heart is found to be 3i inches, and for an inch external to this the note is flat. On auscultation at the apex, a blowing murmur is heard with the first sound, and the second is somewhat lengthened. At the base there is a blowing murmur with both fii-st and second sounds. This double murmur is propagated along the great vessels, and is heard most distmctly along the sternum and in the epigastrium. The pulse is 76 per minute, soft and weak. Tongue has a dark coat in the centre, and is furred round the edges ; appetite small ; food neither causes pain nor inconvenience, and is not vomited. There is considerable tenderness on pressure all over the left side. Has painless diarrhoea, with frequent watery stools of a dark-brown colour, and foecal odour. Hepatic dulness is not easily determined, but appears about -i^ inches verti- cally. In the splenic region there is a large area of dulness extending into the abdo- men, where a tumour is felt. The dulness commences at the seventh rib, an inch and a half below the level of the nipple, and extends vertically for 8 inches. On pressure over the enlarged spleen the patient complains of pain. When he lies on right side, the upper margin of the dulness is found to be lower than when he lies on the back : the anterior limit does not change. Urine slightly albuminous ; contains a sediment, consisting of mucus, squamous epithelial scales and numerous tube casts, chiefiy granular, but a few waxy, containing one or two epithelial scales. There is slight pitting on pressure over the feet and ankles. Respiratory system normal. Ordered an a-stringeni iwwder to he taken at bed-time. Progress of the Case. — The treatment for the diarrhoea by astringent powders was continued until the 20th April with no good result, but the pain in the splenic region was considerably relieved by the exliibition of a terebiuthinate followed by an opiate epithem. Astringents succeeded in arresthig the diarrhoea on the 24th, and it did not recur throughout the progress of the case. The amount of urine passed during the week diminished from 62 to 23 ounces, and again increased to 43 ounces daily. From the 24:th April until May 6(h, the physical signs and symptoms continued much the same, but diu-ing this period the urine diminished, the anasarca increased, the aspect became more heavy, the weakness more marked, the articulation more embarrassed, and the ideas seemed to be formed slowly although correctly. No leucocythemia. On May 1th there was marked tenderness on pressure in both hypochondria. At the apex of the heart a long blowing murmur srachronous with both soimds still audible, and at the base a double blowing murmur. Great dyspnoea and prostration. Coma. He died the following morning. Sectio Cadaveris. — Seventy-Jive hours after death. Head. — Surface of brain was natural; but the ventricles contained 2| ounces of clear serum, and their lining membrane was tough, thickened, and almost of a leathery feeL On the surface of the right corpus striatum there occurred two patches (the larger being 2 lines by 1, and the smaller being half that size) of an opaque yellow colour — slightly depressed — quite superficial — not softer, but rather tougher than usual On the surface of the left corpus striatum, a similar patch, not larger than a hemp seed, occurred. On the inner surface of the lower part of the descending comu of the left ventricle, there was observed a mass, the size of a small pea. consisting of gritty matter, embedded in a membranous cyst, and surrounded by a soft substance of a dark, reddish-brown colour. The choroid plexuses and other portions of the brain healthv. The middle cerebral arterv on the right side, in the fissure of CEREBRAL DISEASE FROM OBSTRUCTIOX OF ARTERIES. 353 Sj'lvius, close to its division into two branches, looked opaque and felt firm, being obstructed over the last two lines of its course by a yellowish mass, which also extended one line along the larger of the two branches. The other arteries of the brain and both carotids were healthy, presenting the merest trace of atheroma at the division of the common carotids. THOR.A.X. — Heart weighed 19 ounces. On the anterior flap of the mitral valve numerous small vegetations occurred in the left ventricle. The aorta at its origin was almost completely obstructed by a mass of vegetations, some the size of a pin's head, others about the size of a small pea, and one nearly as large as a filbert. They .were clustered on the ventricular surface of the right and left semi-lunar valves, and on the margin of lacerations in then" vicinity which occurred in the endocardium. There was no posterior semi-lunar valve, its substance having apparently been broken away, leaving only a ragged, soft, atheromatous edge close to the aorta. The endo- cardium was thickened and opaque over the ventricle. The mitral valves were much thickened at their edges, with noJular swellings projecting towards tlie auricles. The pleurie contained each two pints of clear, rather dark-coloured serum ; the lungs were collapsed posteriorh-, and a little emphj-sematous anteriorh', but everj-where crepitant. Abdomes. — The peritoneum contained more than a quart of dark-coloured clear serum. In the intestines there was no trace of ulceration, but the mucous membrane of the colon and of the lower part of the ileum was congested. The liver weighed 4 lb. 7 oz., presented congestion of the hepatic veins, but in structure was normal. The spleen measured 7^ inches, weighed 2 lb. 2 oz., and on section presented one- thu"d of its area normal in colour, consistence, and minute structure ; but the other two-thirds were of a fawn yellow colour, of firm consistence, without trace of vascularity. The kidneys weighed 14 oz., were of smooth surface, but on section presented portions of a dark red, and others of a yellowish-grey colour. The dark red colour was due to the extravasation of a thin layer of blood. Microscopic Examixatiox. — The serum in the ventricles contained a few epithelial cells. The superficial indurated patches on the surface of the corpora striata were chiefly composed of numerous granules and molecules, containing many granule cells, closely aggregated together and apparently in a state of disintegration. The gritty matter in the centre of the old apoplectic clot dissolved with eflervescence in sulphuric acid (carbonate of lime). The brown matter surrounding it consisted of numerous oily granules, mingled with masses of yellow and brown pigment. The vegetations covering the aortic valves consisted entirely of granular matter, evident!}- undergoing the fatty degeneration. The yellow portion of the spleen consisted of a translucent substance, in which the normal elements of the organ appeared shrunk and decayed. The kidneys presented the usual aj^pearance of partial fatty degeneration of those organs. Commenfari/. — On the entrance of this man into the house, it was recognised that he laboured under obstructive disease of both valves ; and it is observable that the history says nothing of his having ever been atfected with rheumatism. He had previously experienced two attacks of apoplexy, followed by hemiplegia on the left side, and when he came into the house there were superadded symptoms of cerebral softening, of Bright's disease, and of enlargement of the spleen. I subsequently determined that there was no leucocythemia. On jjost- mortem examination, organic alterations of the heart, brain, spleen, and kidneys, were discovered. The slight indurations in the corpora striata were curious. They were composed structurally of numerous granules 23 Soi DISEASES OF THE NERVOUS SY5TE:M. and o;ranule cells, and it may be asked wlictlier they were the results of previous heraorrhas^ic extravasations, or of exudations. I think the latter, as they appear to have been very chronic in their nature, and not to have been connected with any recent symptoms. The apoplectic attacks and hemiplegia on the right side seem to have depended on the limited hemorrhage, on the inner surface of the descending cornu of the left ventricle. ^ It is true, we have historically an account of two apoplectic attacks with hemiplegia, and only the trace of one hemorrhage. It is observable, however, that the centre of this old clot presented a different structure from its circumference, and that, consequently, the blood of which it was composed may have been thrown out at different times. This, however, is a matter of opinion, and did not admit of demon- stration. It should also be noticed that the clot found in the artery of the Svh-ian fissure on the right side did not appear to have occasioned anv svmptoms, or to have produced other structural alteration. These chronic cerebral lesions seemed ultimately so to have affected the circula- tion within the craniiun, as to have caused effusion, the two ventricles beinsr o-reatlv distended with serum, to which the coma preceding death was probably attributable. The three cases now given appear to me to afford evidence of disease of the brain, being occasioned by obstruction of the arteries, an idea that was distiuctlv put"" forth by Carswell and Bright, but the confirmation of which, based on combined pathological and clinical observations, was reserved for more recent observers, and especially for Yirchow, Kirkes, Tiifnell, and others. This obstruction may arise in two ways, — Iv^, From disease of an arterv, causing coagulation of the blood, and obstruction immediately within the portion olf vessel aftected. 2d, In consequence of coagula from the heart becoming loosened, then carried in the course of the'circulation, and subsequently arrested in some distant and sraaller arterv. An example of cerebral disease produced in the first way is ob- served in Case XV., and illustrations of the second mode are given in Cases XVI. and XVII. Galliver was the first to demonstrate that the so-called ossification of arteries, commonly observed in old persons, was in fact a fatty dege- neration of the vessels, consisting of numerous oil granules and crystals of cholesterine, accumulated between their coats, and frequently asso- ciated with deposits of earthy salts. This disease of the arteries, however, is a true arteritis (Donders and Jansen), originating in an exu- dation between their coats, from the vessels which supply them, which exudation subsequently undergoes the fatty degeneration. This l^^ion induces slight constriction of the vascular calibre, thickening of the arterial wall, and occasional roughness of the internal surface — circum- stances which favour coagulation of the blood at the part, and cause more or less obstruction. In chronic cases the vessel becomes brittle, and hence, on any unaccustomed exertion, it gives way, and occasions hemorrhage. These obstructions and ruptures of the vessels from chronic arteritis, are the most common causes of chronic cerebritis and hemor- rhagic apoplexy. The case of Walker, however, (Case XV.) demon- strates another'mode in which softening may be occasioned. Here ob- structiou of the basilar artery had occurred, occasioned by a local arteritis, CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 355 and subsequent mineral degeneration of the clot. The result was a pecu- liar kind of softening, which, as the sole lesion of the cerebral substance, I observed in this man for the first time. In the pons varolii the tubes and nerve cells were loosened and easily broken down, without any exu- dation from the vessels, granules, or granule cells, such as are observed in chronic cerebritis. The nerve cells, however, were enlarged, and con- tained an unusual number of small fatty molecules, forming masses of various sizes, so as to constitute a partial mould of their interior. Many of these masses were naked, and swam about in the liuid, but were easily recognised by their shape to have originally been formed in the interior of cells (Fig. 364). I have fi-equently seen this alteration associated with exudative and hemorrhagic softenings ; but as constituting the sole lesion, and occasioning an extensive softening, producing such undoubted symptoms in the living body, this is the only case, so far as I am aware, in which it has been clearly described. It appears to me to consist of a primary fatty degeneration of the nerve cells, and to depend upon altered nutrition of the part; a condition hypothetically put forth as a cause of softening by Delaberge and Monneret, but now for the first time demon- strated. That foreign solid bodies floating in the blood would obstruct the smaller vessels and occasion exudations, was first shown by the experi- ments of Magendie, Cruveilhier, Gaspard, and others, who injected starch, quicksilver, and various substances into the blood, with the etfect of pro- ducing fatal inflammations. Cases by Virchow, Kirkes, Tufnell, and others, have further shown the probability that the coagula and so-called vege- tations formed in the interior of the heart, may in like manner be oc- casionally loosened, carried by the blood to a distant part, such as the brain, lungs, or extremities, and become impacted in a distant artery. If so, they may, by causing obstruction, induce hemorrhage, exudation, and perhaps the kind of lesion from diminished nutrition of which I have just spoken. Many cases are now on record, and Cases XVI. and XVII. are good examples of them, where, in conjunction with valvular vege- tations in the heart, clots have been found in the arteries leading to im- portant organs, causing in the same individual cerebritis, pneumonia, nephritis, splenitis, etc. etc. But although it is certain that solid plugs may block up arteries and occasion serious results, it is by no means clear that all the instances of disease which have been cited as proof of this in the living body really depend on arterial obstruction, or because cerebral hemorrhage and softening or pneumonia are, as is well known, common sequelae of diseased heart, that therefore plugs of coagulated fibrin, derived from the last-named organ, should originate these secon- dary lesions. I need scarcely point out that increased or diminished impulse of the heart itself, arising from hypertrophy or fatty degene- ration of its fasciculi, are equally powerful causes of cerebral disease, and that this in its turn very commonly occasions pneumonia by its para- lysing influence on the vagi nerves. Besides, although clots are often found in arteries, associated with cardiac vegetations, I am not aware of any facts which demonstrate that the clot originating in one place is the identical clot which has been found in another. Much stress has been laid upon the form of the clot, the broken-oft-lookiug appearance of its ends, its structure, etc. etc. It has been supposed that whilst spou- 356 DISEASES OF THE XERVOUS SYSTEM. taneous coagulations, or such as are induced by arteritis, are gradually converted into fibrous tissue, those coming from one place and impacted in a vessel at a distance break down and undergo a disintegrating pro- cess. Attempts even have been made to show that the broken ends of impacted coagula correspond with and fit the surfaces of other coagula in the heart, or on the cardiac valves from which they have been sup- posed to originate. All I shall say with regard to such arguments is, that numerous investigations into the structure of coagula under a varietv of circumstances have convinced me that we possess no certain means of distinguishing one clot from another, and that all such state- ments should be received with great caution. Otherwise, every case of apoplexy and softening will have to be ascribed to wandering coagula. At the same time the probability of this occurrence is so great, and its explanation of certain facts so simple, that it has every claim to be entertained in practical medicine. Thus cases have occurred where the pulse of an artery has suddenly stopped, followed by more or less numb- ness and coldness of the parts to which it led. Tying arteries has pro- duced similar effects. Fragments separated from the aortic valves would readily pass into the carotids or vertebrals, especially the former, and become impacted in the cerebral arteries. Hence local congestions, causing headache arad other symptoms, followed by exudations and he- morrhan-es, producing convulsions or paralysis. In the same manner, coawulaformed in the right side of the heart may pass into the branches of the pulmonary artery, causing pneumonia more or less extensive. Spontaneous coagulations also may occur. Thus, in the spring of 1856, Professor Miller asked me to examine a clot which formed a mould of the pulmonaiy artery, and was unusually firm and fibrous. It had apparently occurred during life, in an elderly gentleman, who was sud- denlv seized, when in a warm bath, with symptoms of oppression in the chest and dyspnoea, and shortly after died. On examination no other lesion could be discovered but the clot referred to. Similar cases of sud- den death owing to a like cause have been recorded by Paget, Virchow, and others. The true lesion in all these cases is obstruction of the vessels, however produced, whether by coagulation of the blood from unknown causes, by arteritis or aneurisms causing clots to form within the vessel, or by such clots travelling from one place to another, which, however, I am' disposed to think has very rarely been demonstrated, ^'irchow has sought to elevate this simple matter into pathological doc- trines, under the names of Thrombosis and EmhoUsmus. CEREBRAL HEMORRHAGE. Case 'KXlll.*— Apoplexy, followed by Hemiplegia of Left Side — Recovery. HiSTOET. — Andrew Bryce, fet. 72, tailor — admitted Jan. 29, 1851. He states that on the 9th October last, while walking up Dundas Street, he suddenly felt very dizzy, and was obliged to sit down. He lost his senses completely for several min- utes, and when he again became conscious he found he could not waUc. He was assisted home, and on the afternoon of the same day admitted into Xo. 10 of the * Reported by Mr. Cunningham, Clinical Clerk. CEREBRAL HEMORRHAGE. 357 Royal Infirmary. He was freelj' purged, aud has been confined to bed ever since. Since his admission he has been gradually gaining power in the paralysed side. Symptoms on Admission. — At present he complains of occasional frontal headache, increased during cold weather. His intelligence is unaffected. The special senses also normal. He cannot raise himself into a sitting posture. He can move the left hantl, but is unable to direct it steadily to a distant object; neither can he place it on the top of his head. WhUe m bed the left leg moves as perfectly as the right, but he cannot stand upon it. The sensibility of the left leg appears to be at present normal, but that of the left arm is slightly impaired. There is also a little rigidity of the left arm. The tongue is protruded in the median line. On laughing, the mouth is drawn slightlj- towards the right side. Sensibility of the face unimpaired. The pulse 88; is of natural strength. The urine is not so copious as formerly, and is made in a smaller stream and more frequently. He has sometimes passed gravel, and observed his urine of a high colour — sp. gr. 1023 — non-albuminous — a copious dejDOsit of phosphates. Progress of the Case. — This man remained a few days in the ward, during which no change occurred in the symptoms, and on Feb. 7th he returned to Xo. 10, from which he was dismissed with the power of the left side nearly restored, ilaj' 13, 1851. Case XIX.* — Apoplexy, followed by Hemiplegia of the Eight Side — Recovery. History. — Anthony Caron, hairdresser, a Frenchman — admitted Feb. 6, 1851, in a state of coma, in which condition he was found lying on the Grantou road, and was immediately brought to the Infirmary. Symptoms on Admission. — When first examined, he appeared to be about fifty years of age, and of robust habit of body. He was perfectl\' unconscious of sur- rounding objects, and as if in a deep sleep — the surface pale, the countenance calm, and respirations natural. The mouth was slightly drawn to the left side. The right arm, allowed to fall down after being raised, sank rapidly like an inert mass — the left, similarly treated, fell slowly. Pricking the right leg and foot caused no shrinking of the limbs ; but the left limbs when pricked were rapidly withdrawn. Pulse 60, rather full, but, considering his habit of body, probably of natural strength. On returning to him an hour after the first examination, consciousness had to a con- siderable extent returned. He opened the mouth when asked to do so, and the tongue was ascertained to be covered with a white fur. He also raised the left arm and leg readily, but could not move the limbs on the right side. The pulse remained the same. In consequence of this change in his condition, the full bleeding which was previously determined on from his arm, was changed into the removal of § xij of blood, by means of cupping, from the nape of the neck. He was ordered a pill con- taining 01. Crotonis min i, and ext. colocynth, gr. v, to be taken every four hours until the bowels were freely moved. Cold was to be applied to the head, and the most perfect quietude enjoined. Progress of the Case. — The following daj' he was much better — consciousness had returned, and from this time he gradually improved, and was dismissed May 17, the arm having somewhat recovered its motion, but with the leg still lame aud paralysed. Cotnmentary. — The term apoplexy has been used in two senses. By the older writers and clinical observers, it was used to denote a sudden loss of consciousness and volition, independent of the various * Reported by Mr. Cunningham, Clinical Clerk. 358 DISEASES OF THE NERVOUS STSTET,!. morbid lesions wliich may occasion these symptoms. By the followers of the French school of pathoKogy, the same word has been applied to an extravasation of blood into an organ ; and hence the terms apoplexy of the Inng, apoplexy of the spinal cord, apoplexy of the kidney, etc. Ecchymosis of the skin, the residt of a contusion — such as is present in what is commonly called a " black eye " — is in this sense an apoplexy. I believe it better to adhere to the meaning of our ancestors, the more so as it is not always possible to determine when a cerebral hemorrhage is present. Hence the two cases which have been given, characterised by sudden loss ot consciousness and volition, coming on spontaneously, are called apoplexy. But should such cases prove fatal, and Ave are ena- bled to speak positively as to the cause of the apoplexy from post- mortem examination, then we may denominate them with more propriety cerebral hemorrhage, softening, etc. etc., according to circumstances. In the two cases before us there is great similitude — both were seized suddenly with apoplexy while walking. In the first case, however, the apoplectic state was of a few minutes' duration ; in the second, it con- tinued several hours. The one case occurred between three and four months before it came under our observation ; in the other, he was seen in the apoplectic condition, or immediately after he emerged h-om it. In both there was perfect hemiplegia ; but in the one case there has been complete recovery of sensation and partial recovery of motion, as regards the afi'ected side. In the other, both sensibility and motion are still completely lost. On examining Case XIX., the practical question to decide on was whether he should be bled ? But the patient shortly after exhibited signs of coming out of the apoplectic condition, and it was clear, therefore, that the pressure on the brain was spontaneously diminishing, the pulse was steady and of natural strength. How could a bleeding have benefited him I The chief point here, therefore, was not to interfere with the operations of nature, but assist her as much as possible in the operation she had next to perform — that is, causing absorption of the clot. Tliis I presume to be best accomplished by quietude, by the avoidance of all circumstances which could excite the heart's action, regularity of the excretions, and moderate diet. These are, therefore, the measures Avhich were adopted, and his recovery, though slow, was satisfactory. Case XX.* — Palsy — Ileriiipliijia of Left Side — Recovery. History. — Jessie Fleming, set. 45, single, milliner — admitted Xov. 27, 1856. Since last May the mind of patient has been in an unsettled state ; previously she eujoj'ed good health. During last summer her digestion was much impaired, and she suffered from severe cramps in the left leg, especiallj- during the night. On Friday last, Nov. 21st, while engaged at her work, she suddenly fell down, and though retain- ing her senses, felt unable to rise without assistance ; shortly after she quite lost the use of the left side. When put to bed, she experienced great pain in the head, for which she was cupped over the back of the neck, to the amount of 13 ounces; and next day a large blister was applied to the same part; two pills were taken every three hours till her bowels were freely moved. On the 23d of November, * Reported by Mr. M 'Arthur, Clinical Clerk. CEEEBRAL HEMOREHAGE. 359 some leeches were applied to the temples, and on the 24th she was removed to the infirmary. Symptoms ox Admission. — Great pain is felt over the top of the head, which is constant, and prevents the patient from stooping. Speech thick and imperfect. The muscles of the left superior extremity are completely paralysed, and do not admit of extension; the muscles of the head and face are not afifected, nor is sensi- bUity impaired. Cannot move the left leg, but on applying an irritant to the sole of the "foot tlie limb is at once retracted. Pulse 120, of good strength; other symptoms normal. The head to he shaved, and ice to be applied to the scalp. To have a purgative bolus. Progress op the Case. — On the following day the pain in the head was much reheved. and from this time she slowly regained the use of her arm and leg. Her recovery, however, was retarded by a carbuncle which formed over the right inter- scapular region, and subsequently by an exantheraatous eruption, accompanied by considerable fever. She was dismissed April 8th, when she could walk witli the aid of slight assistance, and move the arm of the affected side without difficulty. Commentanj. — In this case sudden lieniiplegia occurred without loss of consciousness, when the individual was wide awake and performing ber household duties, a fact which was established by frequent inter- rogation and bv the accounts of others. It may be presumed that a vessel had suddenly given away, causing hemorrhage into the right cere- bral hemisphere. Tlie clot must have been larger than in the last case, not only because the paralysis was more extensive, but from the longer time necessary for recovery. Case XXI.* — Sudden Paralysis of Face and Left Arm — Pneumonia — Bright' s Disease — Recovery. History. — Christina Hutchinson, tel. 40, married, a sempstress — admitted Xo- vember 7, 1854. She states that on the 5th inst., at half-past 1 o'clock A.M., on waking from sleep, she found that she was unable to lift the left arm, and that she had lost the power of speech. She also experienced intense general headache, as well as great pain in the right side of the face, which was greatly swollen. She does not know whether she was insensible previously. On the preceding evening she had gone to bed healthy and strong, though with a sense of fulness in head. - Though habitually enjoying good health, she has occasionally had palpitations, with dizziness of the head, dimness of sight and tinnitus aurium, especially brought on by stoopin?. Seventeen months ago she had an attack of acute rheumatism. Symptoms ox Admissiox. — Her speech is somewhat embarrassed, and her intelU- gence dull, though she is quite conscious of surrounding objects. Hearing perfect. Sees dimly. Left pupil does not contract so readily on exposure to light as the right. The face is dragged to the right side. Cannot lift up the left arm, though she can move it slightly by a strong effort of volition ; neither can she grasp an object firmly with the left hand. Sensibility of the limb much dimmished, but not lost. The left leo' and side unaffected. Tongue when protruded seen to be loaded and apparently turned to the left, although this is really owing to dragging of the mouth to the right side. Deglutition, especially of liquids, difficult. Bowels constipated. Sliglit pain in the loms. Urine slightly coagulable, sp. gr. 1014. Pulse 86, small and weak. * Reported by Mr. 0. Beaugeard, Clinical Clerk. 860 DISEASES OF THE NERVOUS SYSTEM. Heart normal. Other symptoms healtbj. A hlister to be apiAied to the nape of the neck. To have 01. Ricini § ss. Quietude and rest enjoined. Progress of the Case. — November 14. — Since admission has gradually recovered her intelligence and power of speech, the features of the face are less distorted, and the sensibility in the left arm has been augmented. There has been constipation, whicli required pills of colocynth and croton oil to overcome. To-day complains of a sharp pain in the left lateral region of the mamma, increased on deep inspiration. The dulness on percussion but slight; sibilatiou audible on auscultation. Xovember 28th. — Since last report, has had an attack of pneumonia, involving two-thirds of the left lung, and characterised by all the signs and sj^mptoms of that disease. (See Pneu" monia.) To- day she has completely recovered, the pulmonary disease has passed through its usual course, leaving her, however, weak and thin. The appetite is now good, the strength improving. The sensibihty and power of motion in the left arm nearly restored. Dragging of the mouth ncarh- disappeared. December Wth — Since last report all trace of the pulmonarj^ disease has disappeared. A week ago, however, she experienced considerable pain in the lumbar region, and on examining tlie urine it was found that the albumen had greath^ increased. To-day microscopic examina- tion demonstrates in addition numerous fatty and waxy casts of tlie tubes. Urine pale, passed in good quantity, sp. gr. 1010. She states that tlie ankles swell towards evening. Habeat Potass. Biiart 3j ttr die. Jaiiuary \st. — Has been gradually gaining strength ; all trace of the paralytic attack has now left the face and arm. Careful examination of the left lung can detect no remains of the pneumonia. The urine is still coagulable on the addition of heat, but much le.?s so than formerlj'. But it contains no casts of the tubes, is passed in good quantity, and the oedema of the feet has disappeared. Dismissed at her own request. Commentary. — The peculiarity in this case was the sudden occurrence of palsy in the left arm and left side of the face during sleep. This was most probably owing to a limited hemorrhage compressing the origin of those nervous filaments more immediately in relation with the nerves supplying those parts. Such hemorrhage was not likely to have been extensive, as we may assume that recovery followed on the gradual ab- sorption of the clot. It is worthy of observation, that this woman had formerly sntlered fi-ora an attack of acute rheumatism, and was liable to palpitations of the heart. On admission, no valvular lesion could be dis- covered, and yet there supervened many of those phenomena supposed . to result from coagula in the blood, causing first cerebral hemorrhage, then pneumonia on the left side, tlien renal disorder. The occurrence and o-radual recovery from each of these diseases in succession is rarely observed. Case XXII.* — Apoplexy — Extravasation of Blood into the Left Corpus Striatum — Pneumonia — Arrested Tubercle of Lung. History. — Isabella Bain, set. 59 — admitted May 20, 1855. She was brought to the Infirmary by some policemen, who had found her insensible in a common stair. They supposed she was in a state of intoxication. Her daughter, however, said this was impossible, as she was a very sober woman, and had always been quite healthy, and had left her house only a quarter of an hour previous to the time she was discovered insensible. * Reported by Mr. D. Macgregor, Clinical Clerk. CEREBRAL HEMORRHAGE. 361 Symptojis ox Admission.— On admission slie was completely comatose; the breathing stertorous; pupils contracted; countenance pale; pulse 120, weak and irregular. One drop of croton oil was administered immediately on a piece of sugar, and afterwards a turpentine enema. Progress of the Case.— May 21.s<.— Coma continues. The enema brought away some scybalous foeces, and slie has since had several loose stools, which were passed in bed. There is now complete paralysis of the right side, and the mouth is strongly drawn to the left side. Head to be shaved, and cold constantly applied. May 23rf. —Has continued insensible. She now breathes wiih diflBculty, and with heaving of the chest. There is marked dulness over inferior two-thirds of right lung, but no murmurs are audible there, in consequence of the stertor. May 24^7i.— Slight occa- sional movements have been observed in left arm. In other respects the same. Paralysis of right side of face well marked. Loud moist rattles are now audible over right side of chest. Dy.spnoea more urgent. Blister to the head. Died at two A.M. on the 25th. Sectio Cadaveris. — Thirty-four hours after death. Head. — The arachnoid membrane covering the convolutioES, considerably elevated above the sulci, in consequence of fluid in the subarachnoid cavity. The veins cov- ering the hemispheres everywhere turgid with blood. On slicing the left hemisphere from above downwards, the knife passed through a clot of blood in its centre, about the size of a walnut. The left lateral ventricle was also filled with recent coagu- lated blood and sanguineous fluid. On removing the brain, and cutting through the diseased parts, it was seen that the seat of extravasation was the left corpus striatum, the posterior third of which was broken up, and reduced to a pulpy consistence of a red colour. It was surrounded by a zone of hemorrhagic purple spots closely aggre- gated together, extending half an inch into the surrounding white substance, and this again surrounded by another zone of a gamboge yellow colour, gradually dj-ing away into the healthy white structure of the cerebrum. The choroid plexuses both contained several cysts, one or two of which were the size of large peas, and filled with an opaque yeflov*- fluid. The vessels in the Sylvian fossae were unusually large, thick, and rigid, from atheromatous deposit. The right hemisphere was normal. Some of the more fluid portion of the clot on the left side had infiltrated itself below the cerebellar arachnoid, and was accumulated in a thin layer over the convex margin of the cerebellum on both sides. Thorax. — A few atheromatous patches on the lining membrane of aorta and of the mitral and aortic valves. The heart was healthy. The pleurae on the right side were everywhere united by chronic adhesions. The two inferior lobes of the right lung were hepatized, readily sinking in water, with a few scattered tubercles. The apex was oedematous and spongy. The apex of right lung was indurated, strongly puckered, of blackish colour, and contained several cretaceous and calcare- ous concretions, varying in size from a pin's head to that of a small walnut. The rest of the lung was spongj^ but at the base were two or three masses of clironic tubercle the size of filberts, surrounded by a dark ring of pneumonic condensation. Abdomen. — Abdominal organs health3\ Microscopic Examination. — The sofl;ened portion of cerebral substance sur- rounding the clot consisted of disintegrated nerve-tubes and blood globules, and contained no granule cells. The opaque fluid in the cysts of the choroid plexus contained numerous delicate cells, globular in form, and varying in size from the l-2000th to l-500th of an inch in diameter. They contained a single nucleus, also varying in size, sometimes clear, at others containing numerous granules. There were also numerous irregular masses of granules and mineral bodies, which, on the addition of nitric acid, were rendered very transparent, whUst the larger ones pre- 362 DISEASES OF THE NERVOUS SYSTEM. sented a series of concentric rings surrounding a nucleus. Tliey resembled the amyloid bodies so commonly found in the choroid plexus. (See Fig. 370.) Commentary. — This case is an example of death from pi'imarv hemorrhage into the left ventricle and corpus striatum, the result of chronic arteritis. She died five days subsequent to the attack, during which period a pneumonia had been developed in the right lung, one of the most common sequela? of severe lesion at the base of tlie brain. The woman was apparently in good health previous to the attack, which was induced bv ascendino- a stair. Case XXIII.* — Apoplexy — Hemiplegia of left side — Hemorrhage into right Cerebral Hemisphere — Diseased Heart — Pneumonia. History. — Margaret Wales, tet. 55, married, admitted January 10, 1849. On the 1st instant patient and her husband left their home quite well, and walked about the streets for about two hours, when feeling cold, they entered a spirit shop and drank each a glass of whisky. On leaving the shop she suddenly fell down on the left side, insensible. Next morning she began gradually to revive, being evidently conscious, though not speaking. Her friends say that she remained quiet in bed, with the eyes mostly closed. There was no distortion of the face. The right arm and left leg felt ver^^ cold, but were frequently moved. The left arm and leg of natural temperature, but completely' paralysed. On the evening of the 4th she became delirious, muttering and roaring out. This continued until the 7th. During this time she was seen frequently to move the right arm and leg, but not the left. On the 8tli was somewhat drowsy, but so far conscious as to speak when roused. On one occasion asked for a glass of whisky, but had some tea given her. In the evening of this day again became comatose, and has continued in this state until admission. Has had no medical attendance, and the bowels, it is said, have not been relieved since the attack. St.mptous o>j Admission. — On admission the face, hands, and feet are cold, and of bluish aspect, not unlike that of cholera. The trunk moderately warm ; eyelids closed ; pupils slightlj^ contracted, and insensible to light. She is quite insensible, the strongest stimuli failing to rouse her. There is considerable dj-spnoea (respira- tions 40 in the minute); no stertor, but some tracheal rales; pulse 100, soft and small. Bronchial moist rales are very general on auscultation over anterior surface of chest, which is also resonant on percussion, with the exception of lower half of right chest, where there is comparative dulness. Heart's sounds are weak, and masked by bronchial rales. The right arm and leg, on being pinched, move slightly, but the left arm and leg are completely paralysed. The left side of face also com- pletely paralysed, but no distortion ; slight movement of facial muscles on the right side when they are pricked with a pointed instrument. The bowels are said not to have been opened since the attack, a period of ten days. No injury of scalp or cranium can be detected, 'fy Olei croionis guft. ij ; Extr. colocynth. comp. q. s. ft. pit. to he taken imraediately. A large sinapism to he applied to each leg. Head to he shaved, and a blister applied to the occiput. Progress of the Case. — January llth. — Continues in the same condition. Bowels not open. To have a pill ivith ol. crotonis gutt. iv. A ptiece of lint 3 inches square to he d'qyped in strong aqua ammonice, and aj)p)lied to the vertex. Jamuiry 12th. — No improvement, though the Ijowels have been opened once copiously. Breathing * Reported by Mr. James Struthers, Clinical Clerk. CEREBRAL HEMORRHAGE. 863 is more rapid, with tracheal rale. Surface cold, and covered with a clammy sweat; pulse almost imperceptible. Died in the evening. Sectio Cadaveris. — Tiventy-three hours after death. Considerable livor, with oedema of hands and feet. Integuments loaded with fat. Head. — On reflecting the .scalp no wound or contusion was anywhere visible. Membranes of the brain healthy. On slicing the brain from above downwards, a slight prominence was observed over the right lateral ventricle, and the cerebral substance forming its roof was softened, and of a reddish brown colour. On opening the right lateral ventricle, its posterior half was seen to be occupied by a clot of blood, which also infiltrated the .surrounding cerebral substance to the depth of several hnes, which beyond the infiltrated portion was also softened to the extent of half an inch, the dark red gradually passing through fawn-coloured into white softening. The left ventricle was sliglitly distended with sennn. The foramen of Monro enlarged so as to admit a goose quill. Cerebral arteries studded with patclies of atlieroma. Thorax. — Heart slightly hypertrophied, otherwise healtliy. Aorta healthy. Both lungs much congested, and the bronchi filled in many places with muco-purulent matter. The lower half of the inferior lobe on the right side hepatized. On section it presents a dusky red colour, containing here and there circumscribed purulent- looking deposits about the size of a millet-seed. Abdomen. — Liver slightly enlarged, its right lobe adherent to the diaphragm by chronic adliesions. Gall bladder greatly distended ; colon loaded with indurated foeces. Other viscera healthy. Microscopic Examixatiox. — The white softening of the brain surrounding the clot externally consisted of the mechanical breaking up of the nerve tubes as figured Fig. 381. The fawn-coloured and reddish portions of the softening contained nume- rous granule cells, mixed with broken down clots of blood, some of which were of a bright orange colour, mingled with numerous crystals of hematoidine. (Fig. 326.) Commentary. — This case was very like the last, viz., chronic arteritis, followed by extensive hemorrhage into one of the ventricles, induced by walking about the streets, after the excitement of drinking whisky. Pneumonia of one lung was also induced. She rallied somewhat from the attack, but again relapsed into coma, which is a very unfavourable sign. The importance of administering a pui'gative was here well demonstrated, the paralysis liaving aftected the bowels, and caused constipation for ten days, which was with the greatest difficulty even imperfectly overcome. After death the colon was found loaded with indurated fceces. Case XXIY.* — Apoplexy — Hemorrhage at i!te base of the Brain in a boy aged 14 years. History. — Thomas Pitbladdo, a-t. 14, a house-painter's apprentice — admitted on tlie evening of June 6, 1855. His father states that he has generallj^ been a healthy lad, but occasionally complained of a pain in his head. Tliis morning he got up as usual and went to his work. He ate his breakfast and dinner at the usual times, not so heartUy, it is said, as he was accustomed to do, but he made no com- plaint. Between 2 and 5 o'clock, p. jr., he was in the streets carrying errands for his master, during which time he purchased and ate several partially-decayed oranges. On returning to the workshop he was noticed by the workmen •' nearly to fall '' from giddiness, and to vomit several times, bringing up the oranges he had eaten. At * Reported by Dr. Wilson Fox, Resident Physician. 864 DISEASES OF THE NERVOUS SYSTEM. half-past T p.m. his father was sent for, and found him complaining of pain in the head and abdomen. Subsequently he was observed to grind his teeth. An emetic of ipecacuanha was obtained from a neighbouring druggist, which operated once, slightly. He was brought to the infirmary at 10 p.m. Symptoms on Admission — On admission he complained of pain in the abdomen, on which he pressed his hands. Coma was apparently coming on. Pupils dilated. No strabismus. Pulse natural. Progress of the Case. — On being conveyed to bed an attempt was made to pass the stomach-pump, under the impression that the case was one of poisoning. This, however, failed in consequence of the firm spasmodic contraction of the jaws, accom- panied by grinding of the teeth. "Warm fomentations also were applied to the abdomen. He now became completely comatose, and it was observed that there was strabismus inwards of the left eye with contracted pupil, the right one being fixed with dilated pupiL He lay motionless, Avith the exception of slight clonic spasms of the left hand and forearm. A purgative enema was given, which returned unchanged. He was then placed in a warm bath. The spasmodic contraction of the jaws however continued, the respirations gradually became more laborious, and he expired about one a.m. on the 7th, without having had any convulsion. Sectio Cadaveris. — Twelve hours after death. Considerable rigor mortis. Sugillation strongly marked; jugular veins turgid with fluid blood. The blood in the heart and all the vessels fluid. Head. — No marked congestion of the scalp. On raising the dura mater, both surfaces of the arachnoid were observed to be unusually dry. Substances of hemi- sphere healthy. The lateral ventricles contained about § ij of sanguineous serum. At the base of the brain was a clot of blood, forming a round tumour the size of a walnut, situated below the arachnoid, and breaking up the cerebral substance sur- rounding the fifth and third ventricles, and the inferior portion of the optic thalami, between the pillars of the fornix, thereby communicating inferiorly with the lateral ventricles. The sanguineous mass was about an inch in depth. Arteries every- where healthy. TuoRAx AND Abdomen. — Thoracic and abdominal organs healthy, with the ex- ception of an ecchymotic circular patch of a brick-red colour, four inches in circum- ference, in the mucous membrane lining the great curvature of the stomach. Microscopic Examination. — The clot composed of recently coagulated blood. The surrounding softened cerebral substance exhibited the nerve-tubes broken up to a remarkable degree, and presenting numerous rounded bodies, with double out- lines either isolated or attached to the tubes. The varicosities of the tubes also could readily be increased by pressure. (See Fig. 384, which was drawn from a demonstration of the softening in this case.) Commentary. — Cerebral hemorrliage is a rare idiopatbic lesion in very young persons, and tbe canses leading to its occnrrence in tliis case are inexplicable. There was no heart disease, nor could coagula be found in any of the vessels. On receiving the patient at night, the house physician, as stated in the report, was led to suppose that the boy had eaten some poisonous substance, and the treatment was founded on this supposition. Pathologically, it is interesting to observe how tlie same lesion, which in an elderly person would have occasioned coma and paralysis, in the boy caused grinding of the teeth, trismus, and spasms. Coma subsequently came on, probably from the accumulation of serum in the ventricles. CEREBRAL HEilORRHAGE. 365 Case XXV.* — Apoplexy, followed by Delirium, and proving fatal in eight hours — Hemoirhage into the Meninges of the Brain, History. — Elizabeth Vicars, ait. 59, brought by the police to the waiting room of the Infirmary, at 2.30 a.m.. May 30, 1857. Three and a half hours before admission patient was seated in her own house (Canongate) by the fireside undress- ing. She is reported up to that date quite healthy, although of intemperate habits, and given to quarrelling with her daughter. She was not subject to giddiness ; never attacked by fits nor by palsy. Suddenly at 11 p.m., 29th of May, she was observed to fall off the seat, not striking lier head against anything. She remained insensible for 10 minutes, and on emerging from unconsciousness, rolled on the floor and shouted — "Murder — Police — I'm mad," etc., and could not be kept quiet. Symptoms ox Admission'. — When seen in No. X. she was lying quiet on her left side, as laid down by the police ; heart's sounds normal. Respiration not stertorous, but natural; pulse 80, of ordinary strength; legs rather cold; body warm. The jrapils were equal, rather contracted than dilated; Hps not blanched, face naturally pale ; the eyelids had been closed. On their being opened the patient began to show restlessness, and this increased when her lower garments wevQ being removed. She shouted and moved from side to side, putting her legs out of bed, and moving both arms freely. The mattress was laid on the floor. Warm bottles ivere ajjplied to the fed, and cold to the head. Rest and pierfect quietude enjoined. She was seen again about 3 a.m., by the house-physician (Dr. Glen); at that time she was lying quiet. She is reported to have had a spontaneous recurrence of the restlessness, and tendency to vociferate, again sinking into apparent repose. At 7 a.m. she was recognised by the nurse to be dead. Seciio Cadaveris. — Fifty-Jive hours after death. Body well formed, somewhat emaciated Head. — On removing the dura mater, a hemorrhagic extravasation was found to have occurred below the arachnoid. It covered nearly the whole of the surface of the hemispheres, and formed a thin layer, thickest towards the lateral external surface on both sides. The extravasation was still more abundant over the ba.se, where it was half an inch thick ; it extended from a little anterior to the optic com- missure to the commencement of the spinal cord; it was particularly abundant around the medulla oblongata. The blood was of a dark colour and very loosely coagulated. The fourth ventricle contained a clot of similar character. There was a cavity filled with blood in the anterior portion of the right hemisphere, communi- cating with the extravasation into the meninges. It was of the size of a chestnut, but did not extend back into the lateral ventricle — the parts contained in which were quite normal. The arteries at the base of the brain were atheromatous; numerous opaque yellowish patches being found ou nearly all the branches. JSTo ruptured vessel, however, could be made out. Thorax. — Heart weighed 11 J oz.; the left ventricle being slightly enlarged, appeared paler and browner than usual, being found on microscopic examination to be in an advanced stage of flitty degeneration. The valves were healthy. On the anterior flap of the mitral valve, and on the endocardium below the origin of the aorta, there occurred several oepaqu atheromatous patches. The surface of the aorta, chiefly in the ascending portion, but also down to the bifurcation of the * Reported by Dr. John Glen, Resident Physician. 366 DISEASES OF THE NERVOUS SYSTEM. abdominal aorta, was irregular from lij'pertrophj' of the liuing membrane, with atheromatous and slight calcareous degenerations. Various of the branches were similarly affected, but to a less degree. There were a few old adhesions of the 2ileurffi, and slight emphj-sema anteriorly of both lungs. Abdojien. — Abdominal organs healthy. Microscopic Examixatiox. — The coagula of blood presented nothing unusual, and the brain surrounding the extravasation in the anterior lobe of the right hemi- sphere was onlj-mechanicalh' broken up. The atheromatous patches in the cerebral arteries exhibited the usual structure of that lesion. Commentary. — In this, as in preceding cases, chronic arteritis had led to liemorrhage, which, however, was for the most part poured into the subarachnoid cavity. The symptoms in consequence presented a re- markable modification, for after the first apoplectic phenomena had disappeared, slie exhibited no paralysis, but great restlessness, and deHrium with vocifei'ation. These are exactly the effects which result from any acute disorder of the meninges, and indicate how all lesions, by affecting the same parts of the nervous mass, produce similar symp- toms. (See p. 120.) Case XXYL* — Hemorrhage into the Riijlit Crus Cerebri — Meningitis at the Base of the Encephalon — Serous Effusion into the Loieral Ventricles — Chronic Pldhisis — Vertigo — Paralysis — Spasnis of the Jaw — Delirium and Coma. History. — George Crichton, xt. 28, brewer — admitted Jan. 31, 1851. For tlie last six montlis he has sufiered from a short dry cougli, and has sweated profusely at night. His appetite lias been good, and he considered himself in good health. Three weeks ago he felt pain in his head, which gradually increased in intensity, although he continued at his work. On the 2Gth, feeling the headache very severe, he applied eight leeches, but without relief On tlie following day as he was going to his work, he had a severe lit of coughing, and expectorated a teaspoonful of florid blood. Immediateh' after he felt giddy and stupid, being obliged to support himself against a wall. He says he never lost his recollection, recovered himself in a few minutes, and walked home, but with difficult}' ; afterwards he felt weak, but had perfect command over all his muscles. On Tuesda}' evening he felt drowsy, and on awakening from one of his short sleeps, he discovered that the power of moving the left arm was much diminished. The left leg was unaffected. Symptoms on Admission. — On admission, appears weak and emaciated; com- plains of pain in the forehead ; most severe on the right side ; has no pain else- where. His intelligence seems but little afiected. He speaks slowly, reluctantly, and with an eftbrt. The special senses are unimpaired. The power of motion in his left arm and leg is almost entirely gone. He can neither stretch nor flex his arm or leg. His leg has become much more useless within the last twenty -four hours. Sensibility of the parts is unimpaired, and he feels impressions made upon them. His mouth is very slightly twisted to the right side ; tongue protruded straight. During the examination before the class, he was seized with spasmodic movements of the lower jaw, lasting for a minute and a half, unattended with pain. This was first observed on Wednesday, — when it occurred nine times, — and has returned at irregular periods since. Pulse 60, not increased in strengtli. Cardiac sounds normal. Appetite good. Tongue clean in centre ; covered with a white fur at * Reported by Mr. Cunningham, Clinical Clerk. CEREBRAL HEMORRHAGE. 367 edges. Bowels generally costive : not opened by mediciue last night. Urine 1027 sp. gr. — deposits a copious sediment of mucus and phosphates. Has occasional slight cough ; there is dulness on percussion under left clavicle, with harsh inspira- tion, and great increase of vocal resonance. He was ordered ice to the head; quietness to be maintained. Progress of the Case. — Feb. 2.— To-day headache is abated, he complains of weakness in the right eye, which he cannot keep open without an effort. On frown- ing, the corrugations are more distinct over the left eye. The right pupil is less contracted than the left. Ftb. 3.— Slept ill last night, had a good deal of convulsive twitching of the unaffected side. Is more confused. Tongue has a dense white fur over it. Bowels costive. 5 Olei Ricird 3 iss, to be followed by laxative enema, if required. Fth. 4. — Bowels moved after administration of the injection. Has had a good deal of muttering delirium, — passes his urine in bed. Appeal's to know he is addressed, if spoken to in a loud voice, but gives no answer. Pulse 60. Small and weak. Twitchings more distinct and decided. Breathing not laboured. 5 Carb. Ammon. gr. xij ; MM. Camph. § vj; M. Signa, two table spoonfuls every third hour; Aj^plicetur Yesicat. (3x4) ad Kucharn.— Cold to head. Ftb. 5. — Muttering dehrium last night: does not seem to feel a prick on his left leg; is restless when spoken to, but never speaks. Pulse 60, still small but stronger than yesterday; has some dysphagia. Feb. 6. — Quiet during the night; had a shght attack of general convulsions; bowels opened by enema. Pulse 75, of good strength. Feb. 7. — Was more restle.ss during the night; picking the bedclothes; no muttering; respiration is more hurried and laboured ; there is puffing of the left cheek during expiration ; left pupil more contracted than right ; jactitation of the right ann. JV5 8. — Dysphagia is increasing. Pulse 80. Twelve leeches were applied to the temples. To have one drop of croton oil every four hours. Feb. 9. — Breathing more hurried and laboured. Pulse 116, small and weak. Bowels freely opened by the croton oil. Appeared to feel the bites of the leeches. This mornuDg he had a return of the general convulsions, more severe, and lasting for a longer period than the former, accompanied with frothing at the mouth. Feb. 10. — Last night, dbout 8 P.M., he began to moan and cry out, but no convulsions. The respiration became more laboured, and accompanied by a tracheal rale. At 12 p.m., he died comatose. Sectio Cadaveris. — Thirty-six hours after death. Head. — On removing the calvarium. the smuses of the dura mater were found almost empty ; the longitudinal one contained a small decolorised coagulum. The cerebral arachnoid was veiy dry, the surfaces of the hemispheres flattened, and the convolutions pressed together. The ventricles were distended by 13 drachms of colourless limpid serum, and freely communicated with each other by means of the foramen of Monro, which was much enlarged. The fornix, septum lucidum, floor of the fourth ventricle, and corpus callosum, were of pultaceous consistence, and readily broke down under the fingers. On removing the brain, a semi-opaque exudation of yellowish-white colour was seen in the subarachnoid space at the base of the brain, extending to the sylvian fissures laterally, surrounding the chiasm of the optic nerves anteriorly, and stretching as far back as the fifth pau- poste- riorh\ Here, however, the coagulated exudation was very thin and soft, whereas immediately behind the optic commissure, it was one-eighth of an inch thick, and of considerable density. On slicing the optic thalamus from above downwards on the right side, there was discovered below that ganglion, in the eras cerebri, a clot of dark-red blood the size of a pea, surrounded by several smaller red spots, the result of capillary hemorrhage. The cerebral substance surrounding it was softened 368 DISEASES OF THE jSTERVOUS SYSTEM. to the extent of a quarter of an inch all around. In the pons varolii, two masses, the largest the size of a millet seed, of yellowish indurated chronic exudation, were discovered. Chest. — Pleurae of both lungs were adherent at the apex, especially on the left side. The lining membrane of the bronchi appeared congested, and of a reddish colour. The bronchial glands were loaded with pigment. A cavity was broken into, when separating the dense adhesion at apex of left lung, and a dirty greyish white, tolerably tenacious, fluid escaped. This cavity was capable of holding a hen's egg. Walls were irregular and lined by no distinct membrane. The surround- ino- texture was of a deep red colour, and displayed on section numerous j'ellowish hard miliary tubercles. These were also found scattered over the lower part of the left lung. The right lung was crepitant throughout, and displaj-ed here and there on section the same bodies as above described. Abdomen' — Numerous yellowish miUary tubercles were found in the cortical and tubular portions of both kidneys Other viscera healthy. Microscopic Ex.\minatiox. — The exudation at tlie base of the brain was com- posed of bands of molecular fibres, mingled with curled and spiral elastic filaments. In tlie softer parts of the exudation, tlie delicate molecular fibres at irregular inter- vals contained nuclei, most of which were oval, and a few fusiform. The centre of the clot in the crus cerebri was composed of numerous blood corpuscles, and the surrounding softened cerebral substance contained numerous granules and granular cells. The serum in the ventricles was structureless, and the cerebral softening of the white substance contained no granule cells, the normal structure being only moi;e easily separated and capable of being broken up when crushed between glasses. Commentarif. — This is an instructive characteristic case of that form of apoplexy wliicli has been called ingravescent, commencing with head- ache, followed by temporary loss of consciousness and voluntary motion, then recovery, and, after a period varying from a few hours to several days, gradual return of the coma, almost always followed by death. Such return of coma is usually the result of gradually increasing pressure on the brain, but the pathological cause of that pressure is not always easy to determine. Most commonly it is the result of a hemorrhage slowly increasing, and at length foi'miug a large coagulum. Occasionally it is caused by an etfusion of serum into the ventricles, and a few cases have been observed where it was the effect of a congestion which either mio-ht or might not leave traces after death. In the present case we found four lesions of the nervous structure, — 1st, Chronic exudation at the base of the brain; 2d, A hemorrhagic clot in the right ci-us cerebri ; 3d, Accumulation of serum in the lateral ventricles; 4th, Sottening of the central structures of the brain. Of these lesions the three first doubtless united in producing the symptoms, whilst the last was post- mortem, dependent on imbibition of the serum after death. Here it is important to observe, that the exudation of the base was chronic, for in structure it was firm and fibrous, characters which I have never seen in recent exudations into the subarachnoid cavity, which are generally purulent. It is exceedingly probable, therefore, that the headache and premonitory symptoms were occasioned by the meningitis; whilst the subsequent twitchings and convulsions were attributable to the presence of the exudation, more especially the pressure and irritation occasioned at the base of the encephalon by the subsequent changes through which it passed. Then the apoplectic attack on the 2'7th was entirely owing CEREBRAL HEMORRHAGE. 369 to tlic liemorrhage into the right crus cerebri. This hemorrhage was small in amount, and the apoplectic condition was momentary. It pro- bably, however, increased somewhat afterwards, and broke up the nervous strnctnre of the cms; and the result was interruption of the conducting power between the brain and left side of the body, — in other words, hemi- pletjia. Lastlv, the exudation and clot combined must have exercised pressure on the veins, producing dropsy of, or effusion into, the lateral ventricles, whereby was produced a gradually augmenting pressure on the whole organ, occasioning the ingravescent coma. It may be a ques- tion how far the spasms of the jaw were occasioned by the clot in the eras cerebri irritating the deep origin of the motor branch of the fifth, or by the exudation surrounding its superficial origin from the pons varolii. I am inclined to think the first theory the true one, because both divi- sions of the fifth were alike surrounded by the exudation at the base, and yet spasm only was caused, and no pain. The treatment of this case was very carefully considered, the more so as it was the evident opinion of the examining class, and of the clerks, that it should be treated actively by blooddetting. The student and voung practitioner is generally an advocate for active treatment ; and this was certainly a case in which a difference of opinion might be expected to exist, even among the most experienced. The circum- stances, however, Avhich forbade general bleeding, were, the condition of bis pulse, which, though of good strength, was never full or hard ; the paleness of his countenance, and his general habit of body, which was tar from robust. The existence of phthisis did not influence me at the time ; but I think it supports the correctness of the conclusion I arrived at. Many years ago, when studying the subject, nothing struck me more in carefully analysing the cases of Abercrombie, in reference to this question, than the fact, that notwithstanding he waited until the circulation rallied, and the pulse rose, the almost constant statement is, that a full blood-letting produced " no benefit," "no relief," " not the smallest benefit," and so on. And in such cases, when pressure is caused by a solid coagulum or local obstruction to some part of the venous svstem, inducing eftusion, how can bleeding lessen the pressure when the heart's action is not increased ? We have already seen that the idea of diminishing the amount of fluids within the cranium by bleeding is visionarv, and experience fully proves its uselessness, even in the hands of men who inculcate the practice. All agree, however, that you can only relieve pressure on the brain by influencing the force of the heart's contractions. But in the present case, so far were these contractions from being increased, that they were normal when he was first admitted, and exhibited a tendency to diminish in force. Indeed, so low was the pulse on 4th February, that I administered stimulants under which he rallied. Looking, then, retrospectively at this case, it appears to me certain that bleeding, by diminishing the force of the general circulation, would have increased the tendency to effusion in the lateral ventricles, and would have hastened rather than retarded the fatal result. 24 370 DISEASES OF THE NERVOUS SYSTEM. Case XXTII.* — Apoplexy — Hemorrhage into right Optic l?ialamus, causing Eemi- pltgia on left side — Progressive Recovery — Two months afterwards Hemorrhage into Pons Varolii and Mtmhranes on right side — Death in seven hov.rs. HiSTORT. — Margaret Lockie, jet. 57, a sempstress — admitted on the evening of December 8, 1854. A friend who accompanied her, said that the patient had been very much addicted to drinking, and had an attack of dehrium tremens a month ago, for which she was treated in the Infinnary, and dismissed cured after a week's treatment. She continued well until three days ago, when, sitting in a neighbour's house, she suddenly fell from her chair insensible This occurred about five o'clock P.M., without any obvious cause, as at the time she was pursuing her usual employ- ment of sewing. Symptoms on Admission. — On admission the face presents its natural appearance, and is in no way distorted. The intelligence is much impaired, although she is so far conscious, that when loudly spoken to, she mutters something, and with great effort can articulate indistinctly " Yes," and '• No." The eyes are suflused and red ; the pupils normal ; the right hand and arm are paralysed, though the sensibility is not absolutely gone. Sensibilitj' also is greatly dimiuished, and motion completely lost in the riglit inferior extremity. The left leg is abruptly retracted on pinching it ; the left arm and hand unaffected. There has been no convulsion, nor is there any mu.scular rigidity. She cannot protrude the tongue. State of digestive system cannot be ascertained. Heart sounds normal in character, but weak. "Pulse at the wrist 60, barely perceptible. One drop of croton oil to be administered in the fwm of boliLS immediately. A sinapism to be applied to the back of the neck. 5 i^s of sherry wine to be taken every tivo hours. Pkogress of the Case. — December dth. — Is more conscious. Urine loaded with lithates, otherwise healthy. Bowels have not been relieved. December 10th. — Has had a dose of castor oil, and the bowels have been freely relieved twice. Is now so far conscious that she attempts to speak voluntarily, and she can mutter various words. On smiling, it is distinctly seen that the mouth is dragged to the left side, and that the riglit half of the face is paralysed. She can now also protrude the tongue, which is very foul. Skin of natural temperature. Pulse 68, still weak, but of better strength. Has taken nourishment. To have § iij of sherry daily. Prom this time she rapidly recovered her consciousness. On the 20th she could readily answer questions, and the mind seemed perfect, but the articulation is still difficult. On the 31st articulation is nearly distinct. January lith. — Paralysed parts still immovable, but their sensibility has to a great extent been restored. January 2oth. — Galvanic currents to be applied to the right leg and arm. February 1st. — Can now move the right arm voluntarily to a certain extent. Right leg still immo- vable. Paralysis of jaw has disappeared. February 12th. — Had been doing well up to four o'clock this morning, when after having been assisted out of bed, she suddenly began to moan, and was seen by the nurse to apply her left hand to the head. She was seen by the house physician (Dr. M'Laren) ten minutes afterwards, and was found to be quite unconscious, breathing heavily. The left pupil dilated, the right contracted, and both were insensible to light. All the limbs were power- less, and fell on being raised like inert masses. The respirations rapidly became more laborious and less frequent, and she died at eleven o'clock. Sectio Cadaveris. — Fifty hours after death. Head. — On removing the calvarium and dura mater, the surface of the arachnoid * Reported by Mr. Almeric Seymour, Clinical Clerk. CEREBRAL HEMORRHAGE. 371 was observed to be unusually dry. la the right temporal region was a thin extra- vasation of blood, in the subarachnoid cellular tissue. The lateral ventricles con- tained above 3 ij of sanguinolent serum, and communicated freely with each other by means of the foramen of Monro, which was the size of a goose's quill. The right corpus striatum and optic thalamus were healthy, but the left optic thalamus was disorganized throughout, its centre being occupied by a clot of blood the size of a hazel nut, dark in the centre, of a brick red colour externally, surrounded by softened cerebral matter of a yellow fawn colour. On removing the brain, the extravasation formerly noticed on the right side was seen to extend downwards over the base of the brain on the right side, and over a portion of each lobe of the cerebellum, forming a thin layer of blood between the pia mater and arachnoid mem- branes. The arteries at the base of the brain presented numerous opaque patches of atheroma. On cutting into the pons an extravasation of blood had taken place into its substance, disintegrating the whole of it ; it was of a dark red colour, evidently recently poured out, and was fluid in some places, and loosely coagulate in others. Chest. — With the exception of a few atheromatous patches on the aorta and mitral valve, which latter in no way impeded efficiency, the thoracic organs were healthy. Abdomex. — Abdominal organs also healthy. Microscopic Examination. — The softening of left optic thalamus consisted of disintegration of the tubes; fatty granules accumulated in the ganglionic cells; numerous granule cells, several tinted of an orange colour, and others of a dusky red, in the immediate neighbourhood of this clot, mingled with several crystals of hematoidine, and masses of blood varying in tint. The centre of the clots presented a series of laminae of a brownish black colour. The broken up pons varolii was infiltrated with blood corpuscles, and the tubes were more or less disintegrated. Commentary. — In this case, circninscribed hemorrliage into the right optic thalamus caused apoplexy and hemiplegia on the left side, from which she was gradually recovering, when an unusual exertion caused a secondar}^ fatal hemorrhage into the pons varolii. Here the primary disease was chronic arteritis, causing brittleness of the vessels. In all such cases too mucli care cannot be taken to avoid sudden exertion, agitation of mind, and every other circumstance which is likely to pro- duce increased pressure on the blood-vessels. Case XXVIII.* — Five years iefore admission, Hemiplegia, folhwed by Recovery — Frosthotonos, if affecting the mnscles of the neck and abdomen, so as to draw^ the body forwards ; and Fleurosthotonos, if affecting the muscles of the body laterally, so as. to draw the body sideways. 3. Chorea. Irregular action of the voluntary muscles, when stimu- lated bv the will. FUNCTIONAL DISOEDERS OF THE NERVOUS SYSTEM. 403 4. Hysteria. Any kind of perverted nervous function, connected with uterine derangement. Nothing can be more vague than this term. 5. Hifclrophobia. Spasms of tlie muscles of tlie pharynx and chest, with difficulty in drinking and dread of fluids. 6. Spasms and convulsions. Tonic and clonic contractions of the muscles of every kind and degree, not included in the above, orioinating in the cord (centric spinal diseases of Marshall Hall). 7. Hemiplegia. Paralysis of a lateral half of the body, generally dependent on disorders of the cranial portion of the spinal cord above the decussation in the medulla oblongata. 8. Paraplegia. Paralysis on both sides of the body, generallv the lower haltj in consequence of disorder of the vertebral portion of the spinal cord, below the decussation in the naeduUa oblono-ata. III. — Cerebro-Spinal Disorders, in zvhich the cerebral lobes and sjii- nal cord are both affected. 1. Epihpsi/. Loss of consciousness with spasms or convulsions occurring in paroxysms. Apoplexy with convulsion or para- lysis is also cerebro-spinal, though generally organic. 2. Catalepsy. Loss of consciousness, with peculiar rigidity of muscles, so that w'hen the body or a limb is placed in any position it becomes fixed. 3. Hclampsia. Tonic spasms, with loss of consciousness in infants. The acute ejiilepsy of some Avriters. IV. — Neural Disorders, in which the nerves are affected during their course or at their extremities. 1. Neuralgia. Pain in the course of a nerve, although in fact all kind of pain whatever is owing to irritation of the nerves. Thus the sympathetic system of nerves and its ganglia, though ordinarily giving rise to no sensation, may occasion- ally do so, as in angina pectoris, colic, irritable testicle, and uterus, and other agonizing sensations, referred to various organs. 2. Irritation of the nerves of special sense. Of the optic, causing fashes of light, ocular spectra, muscce volitantes, colour blindness, etc. ; of the auditory, causing tinnitus aurimn ; of the olfactory, causing unusual sensitiveness to odours ; and of the gustatory, causing perverted tastes in the mouth. Itching, formication, and other sensations referable to the peripheral nerves, also belong to this class. 3. Irritation of special nerves of motion, as in local spasms of one or more muscles, or of the hollow viscera. 404 DISEASES OF THE KEEVOUS STSTEil. 4. Local Paralysis. Loss of motion or sensibility in a limited part of the bodv, or confined to a special sense, as in lead palsy, or in amaurosis, cojjhosis, anosinia, ageustia, ancesthesia. V. — Necro-Spixal Disorders, in tvhich both the nerves and s^nnal cord are affected. 1. Diastaltic or reflex actions. To this class belong all diseases depending on irritation of the extremity of a sensitive nerve, acting through the cord and motor nerves on the muscular system, and producing a variety of spasmodic disorders, local or general, far too numerous to mention, — -nhich can only be understood by a thorough knowledge of the physio- logy of the diastaltic or excito-motory system of nerves. Pathology of Functional Nervous Disorders. Bv the term functional disorder of the nervous system, I understand one which may produce the greatest pain, spasm, paralysis, and even death, and yet, on the most careful examination afterwards, assisted by the most minute researches with the aid of the microscope, not the slightest change from the normal structure of the nervous tissue can be observed. Such is what occurs in all the disorders we have named, some of them, moreover, almost always fatal, such as tetanus and hydrophobia. At the same time it must not be forgotten, that similar phenomena may be the result of structural disease of the nervous system. Thus tetanic rigidity may depend on a spinal arachnitis, as well as on the irritation from a wound, or poisoning by strychnine, and delirium and coma may be caused by cerebral meningitis, as well as by moral insanity, starva- tion, or poisoning by chloroform or opium. ^Yhetber in these cases there be in fact only one cause common to the whole, it is difficult to say, certainly it cannot be demonstrated. It might be contended that in every instance there is a certain amount of congestion producing unaccustomed pressure, or that a peculiar state of nutrition of the part is momentarily produced here or there in the nervous mass. But as neither theory appears to us applicable to all cases, we shall consider the pathological causes of functional nervous disorders as of three kinds — 1st, Congestive; 2d, Diastaltic; 3d, Toxic. Congestive Disorders of the Nervous System. — I have previously pointed out the peculiar nature of the circulation within the cranium and verte- bral canal, and shown that, although well defended under ordinary cir- cumstances against any mischievous change, still when such change does occur it operates in a peculiar manner. (See p. 115, e< se^r.) In other words, so long as the bones are capable of resisting atmospheric pressure, although the amount of fluid within these cavities cannot change as a whole, yet the distribution of that amount may vary infi- nitely. Thus, by its being accumulated sometimes in the arteries, at other times in the veins, or now in one place and then in another, unac- customed pressure may be exercised on ditferent parts of the nervous FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 405 centres. This, according to its amount, may either irritate or suspend the functions of the parts, a fact proved by direct experiment, as well as by innumerable instances, where depression of bone has caused ner- vous phenomena, which have disappeared on removal of the exciting cause. That congestion does frequently occur in the brain and spinal cord there can be no doubt, although it cannot always be demonstrated after death. The tonic contraction of the arteries is alone sufficient to empty them of their contents, and turgidity of the veins may or may not remain according to the symptoms immediately preceding death, and the position in which the body is placed. But it is observable that all causes which excite or diminish the action of the heart and general powers of the body, induce at the same time nervous disturbance, by occasioning a change of circulation in the cerebrospinal centres — such as the emotions and passions, plethora and anemia, uterine derangement, etc., etc. It is only by this theory that we can understand how such various results occasionally occur from apparently the same cause, and again how what appear to be different causes produce similar effects. Thus violent anger, or an unaccustomed stimulus may, in a healthy person, induce a flushed countenance, increased action of the heart, a bound- ino- pulse, and sudden loss of consciousness. Again, fear or exhaustion may occasion a pallid face, depressed or scarcely perceptible heart's action, feeble pulse, and also loss of consciousness. In the first case, or coma, there is an accumulation of blood in the arteries and arterial capil- laries, and a corresponding compression of the veins; in the second case, or syncope, there is distension of the veins and venous capillaries, with proportionate diminution of the calibre of the arteries. In either case, owinof to the peculiarity of the circulation within the cranium, pressure is exerted on the brain. Hence syncope diti'ers from coma only in the extreme feebleness of the heart's action, the cause, produc- ino- loss of consciousness, sensation, and voluntary motion, being the same in both. Indeed, it is sometimes difficult to distinguish these states from each other, and that they have frequently been confounded does not admit of doubt. In the same manner, partial congestions from either cause may occur in one hemisphere, or part of a hemisphere, in the brain, or in any par- ticular portion or segment of the spinal cord. The pressure so occa- sioned may irritate and excite function, or may paralyse or suspend it; nay, it may so operate as to suspend the function of one part of the ner- vous system, while it exalts that of another. Thus all the phenomena of epilepsy are eminently congestive, the individual frequently enjoying the most perfect health in the intervals of the attack, although the effects are for the time terrible, causing such pressure that, while the cerebral functions are for the time annihilated, the spinal ones are vio- lently excited. In the same manner are explained all the varied phe- nomena of hvsteria and spinal irritation, for inasmuch as the spinal cord furnishes, directly or indirectly, nerves to every organ of the body, so congestion of this or that portion of it may increase, pervert, or dimi- nish the functions of the nerves it gives off, and the organs which they supply. Congestion, therefore, we conceive to be the chief cause of functional nervous disorders originating in the great cerebro-spinal centre. 406 DISEASES OF THE NERVOUS SYSTEM. Diastultic or Rejlcx Disorders of the Nervous System. — We have previously seen that recent researches render it probable that the actions hitherto denominated retiex are in fact direct (p. Ill), only that the impression wliich is conveyed commences in the circumference of the body, instead of in the nervous centres. There is ever}' reason to believe that such impressions pass through the cord by means of con- ducting nerve fibres, which cross from one side of that organ to the other, and that histology will yet demonstrate that all these apparently confused actions are dependent on the existence of certain uniform conducting media. Indeed, already we can judge with tolerable exactitude, from the effects, what are the particular nerves and segments of the cord which are influenced dui'ing a variety of actions ; and not- withstanding the immense difficulties of the inquiry, we have every hope that the period is not distant when the diagnosis of many more reflex acts will also be rendered certain. The principle involved in all these acts is, that the irritation which produces them is to be sought for in the nervous extremities rather than in lesions of the centres ; and the great importance of this principle in pathology and in prac- tice cannot be too highh' estimated, although for the numerous details which illustrate it, I must refer to physiological works, and especially to those of Dr. Marshall Hall. I would point to traumatic tetanus and to the convulsions resulting from teething and gastric derangements in children, as good examples of diastaltic functional disorders. In addition to important diseases of this kind, numerous symptoms which accompany organic changes belong to the same category. In other words, the structural lesion constitutes the irritant, or cause, Avhile the effect is functional. Thus I have seen epileptic opisthotonos, after resisting for yeal's every kind of remedy, at once removed on extracting a decayed tooth. In the case of Joanna M'Gregor, admitted Dec. 4th, 1856, there was hystei'ical epilepsv, which resisted all treat- ment, and among the rest, a long-continued use of the bromide of potassium, recently recommended by Sir Charles Locock in such cases. The attacks of universal rigidity, with tremor and complete uncon- sciousness, usually lasted from three to four hours. It was observed, however, that immediately before coming out of the attack she was seized with suffocative cough, accompanied by great turgidity and redness of the face. It was thought that by exciting such cough artificially, the attacks might be shortened. Galvanism was in con- sequence applied to the larynx the moment she was seized, with the effect of at once exciting cough, flushing of the face, and immediate recovery. In this case, the spasm of the larynx, which was an excito- motory act, by pi'oducing a change in the circulation within the cranium, dispelled the congestion causing the epileptic paroxysm. Again, those compound effects Avhich require the conjunction of volition with diastaltic acts ai"e most interesting to the scientific prac- titioner, such for instance as coughing, yawning, laughing, hiccough, and sneezing. Cough more especially is a frequent and most distressing symptom, and, as we shall subsequently see, requires for its successful treatment a thorough knowledge of the causes producing it. If, for instance, it originates in irritating disease of the larynx, what permanent benefit can be produced by giving opiates which act upon the brain ? FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 407 Toxic Disorders of the Nervous System. — The influence exercised by certain drugs is of a kind which causes a close resemblance to various diseases of the nervous system. These influences, if carried to excess, are toxic, and dangerous to life ; if employed moderately and with caution, they constitute tlie basis of our therapeutic knowledge in a vast variety of diseases. AVhy one drug should possess one power, and another a diff'erent one, or why some should influence the brain, and others the spinal cord or nerves, "we are ignorant. Such facts are as much ultimate facts in therapeutics as are the separate endow- ments of contractility and sensibility in physiology. As pathological causes of functional disorders of the nervous system, their power is undoubted. By their means the five classes of nervous disorders may be occasioned in different ways, producing altogether distinct and peculiar eff"ects. Thus — Cerebral Toxic Disorders are occasioned by opium and most of the pure narcotics, which first excite and then depress or destroy the mental faculties. According to Flourens, opium acts on the cerebral lobes, while belladonna operates on the corpora quadrigemina. The first causes contraction, and the last dilatation of the pupils. Tea and coffee are pure excitors of the cerebral functions, and cause sleep- lessness. Alcoholic drinks, cether, chloroform, and similar stimulants, first excite and then suspend the mental faculties, like opium. The modern practice of depriving persons of consciousness, in order, for a time, to destroy sensation, has been very much misunderstood, in consequence of such remedies having been erroneously and un- scientifically denominated anaesthetics. The fact is, they in no way influence local sensibility, or the sense of touch. Their action is alto- gether cerebral, and hence the danger which occasionally attends their use. Spinal Toxic Disorders. — Strychnine acts especially as an excitor of the motor filaments of the spinal cord, causing tonic muscular contractions, as in tetanus from spinal arachnitis, or from the diastaltic action of a wound. Woorari produces exactly an opposite eft'ect, causing paralysis and resolution of the same parts. Conium paralyses the motor and sensitive spinal nerves, producing paraplegia, commencing at the feet and creeping upwards. (See case of Gow, p. 413.) Picro- toxine, according to Dr. Mortimer Glover, causes the animal to stag- ger backwards, as in the experiments of Magendie on the Crura Cerebelli. Cerehro-Sinnal Toxic Disorders. — Of these the poisonous eff'ects of hydrocyanic acid off'er a good example. All the animals I have seen killed by this agent utter a scream, lose their consciousness, and are con- vulsed. These are the symptoms of epilepsy. Cold is at first an excitor of the spinal functions, and is a strong stimulant to diastaltic activity, but, if long continued, produces di'owsiness and stupor. Neural and Neuro-Sjjinal Toxic Disorders are especially occasioned by the action of certain metallic poisons, such as mercury, which occa- sions irregular muscular action w^ith weakness, and lead, which causes numbness and palsv, most common in the hands. On the other hand, cantharides stimulates the contractions of the neck of the urinaiy blad- der, and secale cornutum those of the pregnant uterus. Stramonium 408 DISEASES OF THE NERVOUS SYSTEil. acts as a sedative to the nerves of the bronchi, ^vhile aconite operates powerfully in paralysing the action of the heart. Treatment of Functional JVervous Disorders. The great principle in the treatment of congestive disorders of the nervous system appears to be, the necessity of increasing the strength and nutrition of the body by all practicable means. Such, indeed, lias been the general practice, the mineral tonics, and more especially chaly- beate?, being the chief remedies administered in such cases, conjoined with the various preparations of quinine, bark, and the vegetable bitters. Stimulants of all kinds, and especially the anti-spasmodics, have also been liberally administered. It must be confessed, however, that not unfrequently antiphlogistics, with general and local bleeding, especially the latter, have occasionally been employed. Formerly it was supposed, and I shared in the opinion, that functional nervous disorders might depend upon both an increased and a diminished vital power of the eco- nomy, and that for the former, a lowering, and for the latter a support- ing plan of treatment would be necessary. Experience, however, has satisfied me, that if the former cause ever operates at all, it is extremely seldom, and that nervous disorder is almost always a svmptom of exhaustion. The relief of pain, more especially in cephalalgia and spinal irritation, appears to follow laws which have by no means been determined. Thus two or three leeches applied over the part often effect this object, under circumstances where it is impossible to imagine that thev can have dimi- nished the congestion. How, for instance, in cases of headache, if it be dependent upon congestion of the brain, can an ounce of blood, drawn by leeches from the vessels of the scalp, act in this wav ? It has often appeared to me, that the warm fomentations, usually applied to the leech bites afterwards, are more effectual than the loss of blood, and that the therapeutic action is really reflex in its character. For the same reason, dry is often as eftectual as wet cupping;. The influence of cold and heat is equally difficult to explain, and espe- cially how in some cases a diminished, and in others an elevated tempe- rature causes so much relief. Thus some kinds of cephalalgia and nervous pain are at once alleviated by cold. I know of nothing that produces such immediate ease and comfort, in cases of typhus fever, with head- ache, as gently pouring cold water over the shaven scalp. In other cases apparently similar, it is warmth which operates. I was summoned to a married lady who, during the day, had experienced several rigors, and found her in the evening with a burning skin, rapid pulse, furred tongue, intense headache, in short, all the symptoms of fever. To alleviate'the intolerable headache, I poured cold water over the head, which to my surprise caused no relief whatever. I then immediately changed the cold for hot water, and as if by magic the pain at once disappeared. This led me to suppose that, after all, the case might not be one of fever, although at the time I could obtain no information from the patient to satisfy my doubts. But in a week she aborted, having been unconscious that she was pregnant. The only practical rule I know upon this mat- FUNCTIONAL DISOEDERS OF THE NERVOUS SYSTEM. 409 ter is, if cold foils, to try warmth. Most assuredly as alleviators of local pain they are among the most powerful means possessed by the phy- sician. As a true anaesthetic, or destroyer of local sensibility, congelation has been shown by Dr. James Arnott to be a most successful and manage- able remedy. I have used it in the way he has recommended with excellent effect in a variety of local painful affections, and join him in condemning the use of chloroform in cases where this safer proceeding can be employed. Why remove the consciousness of an individual bv deep intoxication, with all its attendant risks, when the same effect can be produced by immersing the parts in a mixture of powdered ice and salt, without any risk at all ? Counter-irritation is also most useful in the relief of chronic congestive nervous disorders, and not unfrcquently produces a cure. This is well observed in certain cases of spinal irritation, in w^hich the local pain is often made to shift its position, and if followed by other blisters, is at length got rid of. I once ordered a blister to be applied over some painful dorsal vertebrjB, in a young lady, who had long suffered from dys- pnoea, cough, and supposed phthisis. Xcxt day I found her breathing easily, with no pain in the back, which, however, had shifted to the occiput, and occasioned trismus. Another blister applied to her neck perfected the cure. On other occasions, the disappearance of pain in one part of the back will bring on sudden aphonia, palpitation, colic, or other symptoms, which in their turn yield to further counter-irritation. The great principle in the treatment of diastaltic disorders of the nervous system is to remove the peripheral source of irritation from which they arise. Thus cutting the gums, diminishing acidity in the stomach, or removing undue accumulations in the intestines, are the appropriate means for combating the convulsive disorders of infancy and childhood. Attacks of hydrophobia, epilepsy, and tetanus, may frequently be prevented by attention to the local causes which induce these disorders. Hysteria is always associated with uterine derangement, to which the practitioner's attention should chiefly be directed, whilst innumerable spasms and convulsions may be traced to carious teeth, disease of the larynx or pharynx, indigestible food, worms, peculiar habits and occupations, etc. etc., on the removal of which the cure depends. The ready method of applying numerous remedies for the cure of morbid states or particular symptoms is dictated by our knowledge of excito-motory actions, and owes all its importance to the labours of Dr. Marshall Hall. Thus dashing cold water on the face and general surface in syncope, or in the suspended animation of the new-born ; the irrita- tion of the fauces to excite vomiting; the avoidance of this irritation, by pushing the bolus rapidly into the pharynx when our object is to excite deglutition ; and the series of operations lately proposed to recover asphyxiated persons, are all of this character. The great principle in the treatment of toxic disorders of the nervous system is to support and stimulate the strength of the patient, until the action of the poison is exhausted. This subject will be best illustrated by examples ; — 410 DISEASES OF THE XERVOUS SYSTEM, Case XSXIX.* — Delirium Tremens — Recovery. History. — Peter Fraser, aetat. 56, an engraver — admitted September 22, 1851. He has generally enjoyed good health. For some time his habits have been very intemperate, and he has had much domestic annoyance. A year ago lie had an attack of delirium tremens. During the last few weeks he has been drinking con- siderably, although he says not to excess. Fourteen days ago he began to feel very restless and uneasy while at work, and his sleep during the night became disturbed, but he has had no tremors or spectral illusions of any kind. Symptoms os Admission. — He now complains of severe pain in the head, referred principally to the frontal region. Xo pains in any other part of the bodj''. His hands when put out have a trembling fidgetty motion, but when kept by his side are steady. Tongue is moderately dry, and covered with a whitish fur. Bowels are generally costive, but were open yesterday. Action of the heart hurried, and occa- sionally irregular; impulse strong. Pulse 96, full and strong. Other functions normal. ^. Sol. Mar. Morph. 3 ij ; Vin. Antimon. 3 j ; Tiru:t. Aurantii 3 j ; Aqua § j. Ft. haustu-s hora somni sumendus Progress of the Case. — September 23. — Xotwithstauding the draught, pa.ssed a restless night. Bowels not open since admission. Pulse 90, of moderate strength. IJ Fulv. Fhwi Co. 3 j ; Aq. Menthce Fip. 3 j ; Ft. haicstu-s statim sumendm. September 24. — Passed a more quiet night. Bowels open. From this time all tremor in the hands and cephalalgia left him. He was dismissed quite well September 27. Case XL.f — Delirium T)-emens with Ocular Spectra — Recovery. History. — Elizabeth Banks, ajt. 34, married — admitted April 7, 18-51. She states that a fortnight ago she was suddenly seized with pain in the head, trembling and dizziness, so that she was obliged to be supported. She ascribes the attack to the receipt of unpleasant intelligence. There have been several of these attacks since, during some of which, her husband says, she has been very violent in her attempts to escape from imaginary enemies. She confesses to have been for some time addicted to spirit drinking, and states that up to the time of this iUness she has enjoyed good health. Symptoms ox Admission. — She has a healthy but somewhat restless appearance. She answers questions rationally and is quite calm, remembering everything that has occurred, except during the sudden attacks of trembling, etc. She has pain over the whole head ; there is, however, no heat of scalp or suffusion of the eyes. The pupil is natural, and the iris contracts readily. She sees various things before her, especially different kinds of animals running about, which are most numerous and vivid at night. She feels also at times as if persons were making attempts upon her life. For the last three nights she has had no sleep, in consequence of these ocular appearances. Her hands are very unsteady, and the fingers are constantly playing with the bed clothes. Pulse 90, of good strength. Tongue furred, and rather dry. Bowels habitually constipated and unrelieved for three days. Other functions normal. 5 Elaterii gr. .s.s. ; Fulv. Gamb. gr. ij ; Fotass. Bitart. gr. x. ; Ft. pulvis statim sumendus. 5 Sol. 3fur. Morphice 3 j ; Aquce 3 vij ; Ft. hausttus hora somni sumendus. * Reported by ^Ir. Scott Sanderson, Clinical Clerk, f Reported by Mr. "W. H, Pearce, Clinical Clerk. FUXCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 411 Progress of the Case. — A^rril 8. — Has slept tolerably during the night. Is not so restless, and has seen few ocular spectra. The hands and her whole appearance calm. The purgative powder only occasioned one stool. From this time she gradually recovered, and was discharged quite well on the 24th. Case XLI.* — Delirium Tremens tviih Convulsion and Coma — Recovery. History. — David Seaton, fet. 25, a chimney-sweep — admitted on the evening of September 10, 1849. His friends state that he has been greatly addicted to the use of spirits, and that during the last three months he has had several apoplectic attacks. He has, notwithstanding, continued to indulge in drink; was this morning extremely violent, and during the afternoon became insensible. Symptoms on Admission. — On admission the countenance is bloated and flushed, and his short stout figm-e gives evidence of great strength. He is now comatose, breathes stertorou.sly ; pulse 60, full and strong. The head io be shaved, 12 leeches to be applied, a drop) ofcroton oil to be placed on the hack of the tongue with sugar, so as io insure deglutition, and to be repeated in an hour if necessary. Progress of the Case. — September 11. — During the night he several times partially recovered his senses, and again relapsed. To-day is much better, and can answer questions in a confused way. Four drops of croton oil have been given, and operated once. To have one drachm of sol. of morphia at night. September 12. — Violent delirium during the night, with insomnolence. It became necessary to employ the strait waistcoat. Pulse quick and feeble. Ice ivater to be applied io the liead. One drachm of sol. of morphia to be repeated at night. To have a turpentine enema. September 13 and 14. — Xo improvement. September 15. — Is somewhat sensible; pulse rapid and feeble. To discontinue the morphia. To have 3J of whisky every two Jwurs. September 16. — Slept a little last night. To-day talks sensibly. Pulse 80, stronger. Bowels open by means of an injection. From this time he gradually recovered, and was dismissed well September 27. Case XLII.f — Co7na and Death frorn Excessive Drinking — Opacity of Arachnoid — Sub-arachnoid Effusion — Fluid Blood. History. — James Dick, wt. 48. a joiner — admitted on the evening of January 31, 1851, in a moribund condition. He has been habitually intemperate for many years. For the last week has been in a constant state of intoxication. This evening' became suddenly ill, and lost his consciousness. Shortly afterwards he was conveyed to the Infirmary. Appearance on Admission. — On admission he presented all the appearance of a corpse. No breathing was perceptible ; no beating of the heart could be heard with the stethoscope. The countenance pale ; head thrown back ; mouth open and frothy ; eyes turned up, and pupils dilated. AU efibrts at re-animation were of no avail ; he was dead. Sectio Cadaveris. — Thirty-eight hours after death. Body well formed and strong, not emaciated. A little tumidity of depending parts. Head. — On removing the calvarium, the sub-arachnoid tissue was seen to be * Reported by Mr. Alexander Christison, Clinical Clerk. f Reported by Mr. Sanderson, Clinical Clerk. 412 DISEASES OF THE NERVOUS SYSTEM. infiltrated witli fluid, raising the araclmoid to tlie level of the convolutions. The sinuses were distended with fluid blood. Tlie cerebral arachnoid presented consider- able opacity all over the hemisphere, in some places difl'used, in others exhibiting minute points closely aggregated together. The ventricles contained a small amount of fluid, and several simple cysts in the choroid plexuses. Cerebral arteries and other portions of the brain perfectly healthy. Chest. — Both pleurae contained several ounces of serum, and were slightly adherent at the apices. Both lungs were health}', with the exception of unusual engorgement, posteriorly and inferiorly. A cretaceous concretion, the size of a barley-corn, in apex of riglit lung. Bronchi contained a moderate quantity of frothy mucus, which was more abundant in trachea and larj-nx. Pericardium contained one drachm of serum. Heart healthy. The blood in the cavities and large vessels remarkably fluid. Abdomex. — The liver pale in colour, and very soft, weighed 3 lbs. 14 oz. A few serous cysts in the kidney. Other abdominal organs healthv. Microscopic Examikatiox. — The cells of the liver were loaded with oil granules of large size. The tubercles of the kidney here and there also contained several fatty granules. Cerebral substance healthy. Commentary. — Yarions opinions as to the nature oF delirinm tremens have been held by medical men, who have successively placed it among the neuroses, the phlemnasise, and the pyrexiae. Until recently, it was held that whilst drinking was its predisposing cause, the sudden abstrac- tion of the accustomed stimulus brought on the attack. This theory has been very successfully combated by Dr. Peddie,* who has shown that the disease is seldom observed in our prisons, notwithstanding the large number of confirmed drunkards admitted there and immediately placed upon low diet. The view of its pathology now prevalent is, that alcohol, a poison dangerous to life in large doses, is also cumulative taken habitu- ally in small quantities. Like many others, it is one which especially affects the nervous system, and more particularly the brain, as shown by Percy, Huss, and other writers. Hence those effects denominated intoxi- cation, delirium tremens, etc. Formerly the treatment used to consist of supplying the accustomed stimulus; but now, whilst theoretically it is clear that this is tantamount to adding coals to fire, it has been shown by experience that patients more rapidly recover under the use of anti- monials and nutrients. In the vast majority of cases of delirium tremens, the poison becomes eliminated from the system in a certain time ; whether antimony, in half or quarter grain doses, assists this process is not known. Generally speaking, if a good sleep can be obtained, it is critical, and the patient at once recovers. Opium has been largely given to obtain this result, but it is much to be doubted whether its supposed beneficial action is not dependent on coincidence with the muscular fatigue and exhaus- tion which, with the tendency to repose, accompanies the elimination of the alcoholic poison. Practically it is of great importance that the "windows and doors of the room in which patients with delirium tremens are, should be well closed, because, although there is no violence, a tendency to escape from imaginary enemies has led to some deplorable accidents. Personal restraint should be avoided. Nutrition also should * Monthly Journal of Med. Science. June, 1854. FUXCTIOXAL DISORDERS OF THE XERYOUS SYSTEM, -ilo be carefnllv maintained, as death, when it occurs, is for the most part the result ot" exhaustion, with serous effusion into the subarachnoid cavity. Case XLIIL* — Poisoning hy Opium — Recovery. History. — Helen M'Dermott or Cuthbertson, xt. 33, but looking ten years older, residing in the Cowgate as the wife of a cooper, was admitted at 3 p.m. May 25th, 1857. She has not iinfrequently been drunk, and had a quarrel lately with her hus- band. On the preceding day she had gone out and purchased two ounces of lau- danum, namely, one ounce at two diflerent druggists' shops, and had swallowed them (it is said) half an hour before admission. Symptoms on Admission. — On admission, contracted pupils, great drowsiness, relaxation of muscles, and tendency to cold ; with lividity of face and extremities. The stomach-pump was employed to wash out the stomach; this was first done with warm water, and twice subsequently with mustard and water. The first vomited matters smelted of laudanum. The patient was stimulated to walk about until toward 4.30 p.m. By that time her limbs became so relaxed that she sank to the ground ; and she was so drowsy as to flill asleep unless pushed or pricked. The galvanic battery was then applied to the popliteal spaces, and to the hands, breast, and neck — (Kemp's battery being the instrument employed). Meanwhile, as patient was in bed, warmth was maintained by clothes and hot bottles. Under stimulus of the battery, patient was also mduced to swallow some coffee. At 6.30 p.m. she was so easily roused by galvanism — the skin warm, the pulse (small and weak before) becoming more perceptible and strong — that the stimulus was more rarely applied, merely to prevent the sleep into which from time to time she fell from becoming pro- found. At 8 p.m. a drachm of brandy, and half a drachm of Sp. Ammon. Aromat. were administered, to be repeated every hour. During the first three administrations of this stimulant vomiting occurred, the vomited matter consisting of the coflFee that had previously been swallowed. At ten, eleven, and twelve, she was seen dozing slightly, but was easily roused. Xext morning complained of sickness, and of not having been able to sleep during the night ; was quite conscious and thankful for her recovery. Slept during the day, taking tea and beef-tea. On the 27 th, ha\-ing fully recovered, she was discharged. Commentari/. — The symptoms of poisoning by opium in man are altogether cerebral, the danger to be apprehended being a fatal stupor. To prevent this, the practice successfully carried out in the above case is the one now generally considered best. The dose of the poison taken was large, but fortunately the time after its administration was not great. Case XLIY.* — Poisoning hy Hemlock — Death. History — On Monday, AprQ 21st, 1845, about seven o'clock in the evening, a man, called Duncan Gow, was brought into the Infirmary by two pohcemen. It was stated that he had been found lying in the street, apparently in a state of intoxication, or in a fit. On being taken into the waiting-room, he was found to be dead. I subsequently learnt from his wife that the man, forty-three years of age, a tailor * Reported by Dr. John Glen. Resident Physician. ■j- Publislied by me in the Edin. Med. and Surg. Joum., Xo. 164. 1S45. 414 DISEASES OF THE NERYOUS SYSTEM. by trade, was in such reduced circumstances that he had not eaten anything on Monday, until he took the substance wliich caused his death. Two of his children, a boy and girl, aged respectively ten and six years of age, found what they took for parsley growing on the bank under Sir Walter Scott's Monument (which was then buUdiiig), and knowing tliat their father was very fond of this, as well as other green vegetables, they gathered some to take to him. On visiting the place with the boy four days afterwards, I found that the spot from whence the plants were gathered had been covered over with fresh rubbish. But on the uncovered part of the bank, eighty yards westward, the Conium maculatum could be seen growing in considerable quantity. The children returned home between three and four o'clock P.M. The father, who had fasted the whole day, greedily ate the vegetables, together with a piece of bread, and said more than once how good they were. The quantity consumed could not be ascertained, for he ate nearly all that was brought. On finishing his meal, he rose, saying he would endeavour to get some money, in order to procure food for his children. At this time he was in perfect health. From his own house, at the head of the Canongate, Gow walked about half a mile to the house of one Wright, in the West Port, with the view of selling him some small matter. Wright, on his entering the room, thought at first that he was intoxicated, because he staggered in walking. On passing through the door also, which was narrow, he faltered in his gait, and afterwards sat down hastily. He stayed ten minutes, during which tune lie conversed readily, drove a hard bargain, and obtained fourpence for what he sold. He did not complain of pain or un- easiness, was not excited in manner or speech, and his face was pale and wan. On rising from his chair, he was observed by Wright's boy to fall back again, as if he had some difficulty in rising. On making a second effort he got up, and was seen by Wright's wife to stagger out of the house and down the stejas. This was a little after four o'clock. On leaving Wright's house, he was next seen standing with his back against the corner of the street, by Andrew Mc'All, a meal-dealer in the Grassmarket, about 200 yards from Wright's house. Mc'All saw him leave the corner he was leaning against, and stagger to a lamp-post a few yards further on. Here he again paused for a few minutes, and then again went forward in the same vacillating manner, passed Mc'AU's shop, and sat down at the opening of the common stair next to it. Mc' All's words are, " He could not walk rightly, and was staggering as a man in liquor." His mode of progression attracted a number of boys and girls, who laughed at him, believing him to be intoxicated. He was heard to speak to them, but what he said is not known. He was also seen by two women, who told a policeman to take him away. The policeman (James Mitchell, No. 161) told me that, on finding Gow sitting at the foot of the common stair, he thought he was drunk. He spoke to him, and in reply Gow desired to be taken to his own house, at the top of the Canongate. He also said that he had completely lost his sight, and had not the perfect use of his limbs, but expressed his wiUingness to walk forwards, until the policeman could obtain the assistance of his comrade in the Cowgate. He was then raised up and supported by one arm, but, after moving with great difficulty past four or five shops, his legs bent under him, and he fell upon his knees. Mitchell then gave him some water to drink, wliich he was incapable of swallowing, and left him to get a barrow. On his return he found him surrounded bj' women, who were pouring cold water on his head, and sprinkling his forehead. With the assistance of anotlier policeman (James Hastie, Xo. Ill), he was then placed on the barrow. One of the women, Mrs. Anderson, on his being raised, saw that he made no attempt to walk, FUNCTIONAL DISORDEES OF THE NERVOUS SYSTEM. 415 but that, as he was i:)ulled away by tlie policemen, his legs were dragged or trailed after him. The second policeman, Hastie, on first seeing him, told Mitchell that it was not drink, but a fit, that was the matter with him. He lifted up his eyelids and found the eyes dull. He seemed sensible, and endeavoured to say something, but could not articulate. He was now slowly conveyed to the main police-office in the High Street, where he arrived about six o'clock. Mitchell told the police lieutenant on duty that, from the manner in which the man was lying, and from the loss of power in the legs, he now thought he was not intoxicated. At this period it would seem that, although the limbs were completely paralysed, the intelligence was still perfect, for he told the turnkey his exact address in the Canongate, in reply to a question. Dr. Tait, surgeon to the police force, was now sent for, and saw him about a quarter past six. In reply to a note which I addressed to him on this subject, he says : — " The first impression produced on my mind from his appearance was, that he was in a state of intoxication ; he was then lying on his back, with his head and shoulders elevated upon a board we have in the office for that purpose. He was sensible when I spoke to him, and tried to turn his face towards me, and slightly raised his eyelids, but appeared unable to speak. His power of motion appeared completely prostrated, for when I lifted his arm, and laid it down, it lay where it was put; and when his arm-pits were tickled, he seemed to manifest a little sensi- bility, but could make no exertion to rid himself of the annoyance. There were occasional movements of the left leg, but they appeared rather to be spasmodic than voluntary. Several efforts were made to vomit, but these were ineffectual. His pulse and breathing were perfectly natural. He had spoken to the turnkey a few minutes before I arrived. Heat of skin natural. I visited him again, about ten minutes before seven o'clock, at which time all motion of the chest appeared to have ceased ; the action of the heart was very feeble, and the countenance had a cadaveric expression ; pupils fixed. He was then sent to the Infirmary." He was conveyed to the Infirmary by Hastie and another policeman, M'Pherfeon. After being put on the stretcher, Hastie saw him draw the legs gently upwards, as if to prevent their hanging over the iron at its extremity. This was the last move- ment he was seen to make. On being carried into the waiting-room of the Infirmary, he was visited by the house-clerk on duty, who found him pulseless, and declared him, as previously stated, to be dead. This was shortly after seven o'clock p. m. Sectio Cadaveris. — Sixty-three hours after death. The body was well-formed and muscular. There were no external marks of vio- lence. The back and depending portions were livid from sugillation. Head. — An unusual quantity of fluid blood flowed from the scalp and longitu- dinal sinus when divided. There was slight serous effusion below the arachnoid membrane, and about two drachms of clear serum in the lateral ventricles. The substance of the brain was soft throughout ; on section presented numerous bloody points, but was otherwise healthy. No fracture could be discovered in any part of the cranium. Chest. — There were slight adhesions between the pleuras on both sides superiorly. The apices of both lungs were strongly puckered. On the right side below the puckering, were two cretaceous concretions, the size of peas, surrounded by chronic pneumonia and pigmentary deposit. On the left side only induration, with hard, black, gritty particles, existed below the puckering. The structure of the lungs otherwise was healthy, although they were throughout mtensely engorged with dark- 416 DISEASES OF THE NERVOUS SYSTEM. red fluid blood. The heart was healthy in structure, but soft and flabby. The blood in the cavities was mostly fluid, presenting only here and there a few small grumous clots. Abdomen. — The liver was healthy ; the spleen soft, readQy breaking down under the fingers. The kidneys were of a brownish-red colour throughout, owing to venous congestion, but healthy in structure. The stomach contained a pultaceous mass, formed of some- raw green vegetable resembling parsley. Its contents weighed eleven ounces, and had an acid and slight spirituous odour. The mucious coat was much congested, especiallj'' at its cardiac extremity. Here there were numerous extravasations of dark-red blood, below the epithelium, over a space about the size of the hand. The intestines were healthy, here and there presenting patches of congestion in the mucous coat. The bladder was healthy ; its inner surface much congested from venous obstruction. The Blood throughout the body was of a dark colour and fluid, even in the heart and large vessels. Commentary, — From the absence of structural lesion, and the general fluidity of the blood, I was induced to suspect that the vegetable matter found in the stomach was of a poisonous nature. On examining this more minutely, it was seen to be composed chiefly of fragments of green leaves and leaf-stalks. Althongh much was reduced to a pulp, a con- siderable quantity of both had escaped the action of the teeth. The same afternoon, I carried as perfect a specimen of the fragments as could be found to Dr. Christison, who pointed out that they could scarcely be anything else than the lacinice of the Conimn niaculatu77i, or common hemlock. Next day I bruised some of the leaves in a mortar, with a solution of potash, when the peculiar mousy odour of conia was evolved so strongly that Dr. Douglas Maclagan and others, although previously unacquainted with its nature, at once pronounced it to be hemlock. Dr. Christison also procured a recent specimen of the Conium mar.ulatum, fro*m Salisbury Crags, the botanical characters of which, on being com- pared with the fragments found in the stomach, were proved to be iden- tical. No doubt could exist, therefore, that the man died from having eaten hemlock. Few cases of poisoning with this plant have hitherto been published, and none have been minutely detailed. The eff'ects imputed to it in the notices given of prior cases are very contradictory. In some it is said to have caused death, like opium, by stupor and coma. In others, con- vulsions of the frantic kind are symptoms stated to have been present. But the eff'ects observed by Dr. Christison in the lower animals, in his experiments with extract of hemlock and its alkaloid conia, are totally different, viz., " palsy, first of the voluntary muscles, next of the chest, lastly of the diaphragm ; asphyxia, in short, from paralysis, without insensibility, and with slight occasional twitches only of the limbs."* On this account, as well as from the circumstance that considerable interest is connected with the question, as to whether the hemlock of modern times be the Kwvaiov, or state poison of the Athenians, great pains were taken to obtain a perfect history of the case. In preparing it, I endeavoured to insure accuracy, by carefully interrogating all who * Treatise on Poisons, p. 855, 1845. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTE:\r. 417 saw him from the time of his eating the hemlock until the period when he was brought into the Infirmary. Fortunately, he was seen by many persons, and tlieir several accounts are, on the whole, consistent, and render the case tolerably perfect. The time of day mentioned by the different narrators shows that the poison, shortly after it was taken, produced want of power in the inferior extremities, without causing any pain. This is proved by what took place in "Wright's house. His gait, which at that time was faltering, afterwards became vacillating ; he staggered as one drunk — at length, his limbs refused to support him, and he fell. On being raised, his legs dragged after him; and lastly, when the arms were lifted, they fell like inert masses, and remained immovable. Perfect paralysis of the inferior extremities was ascertained to exist one hour and a half after the poison was taken, and that of the arms half an hour later. As regards the existence of sensibility, we have only the evidence afforded by tickling the arm-pits, which, according to Dr. Tait, seemed to excite it a little. Tlae amaurosis, however, is a proof that one nerve of sensibility, at all events, was paralysed. This seems to have happened when perfect paralysis of the inferior extremities was manifested. The excito-motorv functions seemed also paralysed. Tickling the arm- pits failed in producing movements. He lost the power of deglutition. Dr. Tait says his efforts to vomit were ineffectual. There were no con- vulsions, only slight occasional movements of the left leg ; and lastly, both inferior extremities were slowly drawn upwards, when placed over the iron of the stretcher. Three hours after taking the poison, the re- spiratory movements had ceased ; the pupils were fixed. At this time the heart's action was felt very feeble. These also ceased about ten minutes afterwards. The intelligence remained perfect up to a very late period. When his movements were vacillating, he was seen to direct his steps from one fixed point to another. After paralysis of the inferior extremities was fully developed he gave accurate directions how he was to be taken home, and described his principal symptoms. Two hours after taking the hem- lock, when brought into the police-ofiice, although he could not swallow, he gave his address; and a quarter of an hour afterwards, when seen by Dr. Tait, though he could not speak, he appeared sensible, and tried to turn his face towards him. Death took place about three hours and a quarter after eating the poi- son, and was evidently occasioned by gradual asphyxia fi-om paralysis of the muscles of respiration. The appearances observed in the mucous membrane of the stomach were most probably caused by the unusual fluidity of the blood, and this, in its turn, by the gradual asphyxia. The phenomena, therefore, observed in this case fully corroborate the physiological action of hemlock, as described by Dr. Christison, from his experiments on animals.* It evidently acts upon the spinal cord, pro- ducing directly opposite effects to those occasioned by strychnia. Para- lysis of the voluntary muscles, creeping from below upwards, is the cha- racteristic symptom, unaccompanied by pains or derangement of the intellectual faculties. Some authors have desciibed delirium and frenzy, * Transactions of the Royal Society of Edinburo;h, vol. xiiL 27 418 DISEASES OF THE NERVOUS SYSTEM, and others giddiness and convulsions, to have been occasioned. But such symptoms were not observed in the case of Go\y, nor in the experiments on tlie lower animals bv Dr. Christison. Indeed, the symptoms described by Plato in the case of Socrates, resemble as nearly as possible those which appeared in Gow. "U"e are told that Socrates was directed by the executioner to walk about after swallowino; the poison, until his limbs should grow heavy. He did so, and then lay down. On his feet and legs being squeezed, thev were found insensible ; they were also pointed out by the executioner to be cold and stitF. When paralysis had pro- ceeded upwards to the abdomen, Socrates made a request to Crito, prov- ing that his intellect was then unaffected. In a short time aftei-, he be- came convulsed, his eyes were fixed, and he died. Whether stiffness was present in Gow's case was not ascertained. The nature of the convulsions, whether violent or otherwise, is not stated in the account by Plato, but slight spasms were observed in Gow. It will be observed, that when Socrates felt paralysis coming on he lay down. Hence the staggering and falling in the street, observed in Gow, did not take place. The description of the effects of the Kiivsiov giveu by Xicander, however, would in this case apply with great accuracy. He says (I quote from Dr. Christison's paper): — "This potion carries destruction to the powers of the mind, bringing shady darkness, and makes the eves roll. But staggering on their footsteps and tripping on the streets, thev creep on their hands. Mortal stifling seizes the upper part of the neck, and obstructs the naiTow passage of the throat. The extremities grow cold, the strong vessels in the limbs contract, he ceases to draw in the thin air, like one fainting, and the soul visits Pluto." If we abstract the poetical parts of the description, and remember the loss of sight, staggering and tripping in the street, the difficulty of deglutition, and place the loss of the intellectual faculties last, this account of Xicander agrees very well with what was observed in Gow. A difference of opinion exists as to whether the Conium maculatum of modern botanists be the Kuvciov of the ancient Greeks. Into the botani- cal controversy I do not feel myself qualified to enter. But, if the symp- toms ascertained to have existed in the case I have related be compared with the accounts of Plato and Xicander, I cannot help thinking that it will be found to favour the opinion of those who believe in their identity. Case XLT.* — Poisoning with Lead — Painter's Colic — Lead Paralysis — Partial Recovery. HiSTOKT. — Peter Taylor, set. 50, a brewer's servant, admitted September 26th, 1851. At his occupation in the brewery he frequently uses half a hundred weight of white lead at a time, for jointing pipes, and is in the habit of painting with the same material. Twelve months ago had a severe attack of Colica Pictonum, from which he slowly recovered under medical treatment, and then resumed hLs work, being always subject, however, to transient twinges of pain in the bowels, as well as in the joints, which latter he attributed to rheumatism. Six weeks ago he first expe- rienced debility and want of power in both hands, which has gradually increased since. His speech also has become slightly affected. * Pieported by Mr. Scott Sanderson, Clinical Clerk. FUNCTIONAL DISORDEKS OF THE NERVOUS SYSTEM. 419 Symptoms on Admission. — He has at present no pain anywhere, and only com- plains of want of power in both wrist joints. Both hands drop down from the arms, especially the right, which forms a right angle with the fore-arm. He can flex them voluntarily when elevated by another, but cannot raise them himself. When the metacarpal bones are supported by the hand of another, he can extend the last joints of the fingers. He has perfect command of the shoulder and elbow joints. His grasp of an object is little impaired ; there is no wasting of the extensor muscles of the arm, though they feel soft; and sensibility in the paralysed parts is normal. Bowels still somewhat constipated, but were opened freely yesterday. Speaks with unusual slowness, which he thinks has increased lately. All the other functions are healthy. Progress of the Case. — October Isl— Since admission the hoivels have been kept open daily by small doses of the sidphate of magnesia. The ar7723 have been put up in splints, keeping the ivrist and hand extended straight out. Galvanism has been applied twice daily for several minutes in the course of the extemors, and frictions over them are occasionally employed in the interval by means of flannel cloths. Oct. I5th. — He was ordered § Potass. Hydriod. 3 ss ; Aquce, Cinnam. ; Aquoi font, aa § iij. M. Sumat § j ter indies. To-day the splint was removed from the left arm, which still droops, but is more readily extended. Oct. 30th. — Has complained of numbness in the right arm, attributed to the bandage. The splint was, therefore, to-day taken off", but the hand droops as much as ever, although he can move the metacarpal joints and fingers a little better. Nov. IQih. — There is decided improvement in the power of motion in both wrist joints, especially the left. ^. Extract. Nucis Vomica}, gr. vj ; Confect. Rosar. q.s. ut fiant pil. vj. Sumat imam ter indies. Nov. 21st. — The pills appear to cause occasional pain in the stomach and bowels, but have occasioned no spasmodic twitches in the muscles generally. The joints have not improved since last report, but he insisted on going out. He was therefore dismissed, with the advice to exercise the wrists in pumping water. Comm.entary. — Lead, as a poison, appears to act first on the peripheral nerves of the body, and subsequently on the nervous centres, its (jhief manifestations being in the nerves of the intestines, causino- colic, and those of the arms producing paralysis. Why this substance should espe- cially affect these parts, is as much unknown as why any other poison should exert a special influence on particular portions of the nervous system. It has been recently pointed out that the metal exists in the tissues (in the form of carbonate), and sulphur consequently has been recommended internally and externally, with a view of causing its more rapid decomposition and elimination as a sulphuret. For this purpose the sulphurous mineral waters have been recommended. Common alum was given by Gendrin, and an acidulated drink made with sulphuric acid by others. Theoretically, this treatment has its difficulties; for supposing the lead to be converted into a sulphuret, how is this in its turn to be removed from the tissues, any more than the carbonate, with- out being first rendered soluble, and therefore poisonous ? On the other hand, some physicians in France who have tried the chemical treatment extensively, and among others Andral, Sandras, Piorry, and Grisolle, assert that it has no influence whatever, and that patients abandoned to themselves get well just as soon. In most cases the disease yields to time and slow elimination of the poison from the economy. Iodide of potassium also is said by Melsens to have decomposing and eliminating 420 DISEASES OF THE XERVOUS SYSTEiT. powers. The latter was employed in the above case, but with no great success. Dr. Christison informs me, that " long ago, when tlicre was a white lead manufactory at Portobello, I used constantly to have in the Infir- mary a case or two of lead colic or lead palsy and neuralgia. Every case of colic I saw got speedily well by the alternate use of opium and aperients, and every case of paralvsis by generous living, stomachic tonics, warm baths, and especially support and regulated exercise of the arms. One man I well remember, who was three times under my care, in consequence of his always returning to the factory — had colic, palsy, and also neuralgia ; but he got well in no long time by attention to the above means." M. Duchenne has pointed out the great advantage of applying gal- vanism not generally to the arm, but more especially to the muscles atFected, which in these cases are most commonly the extensores digi- tornm, and not the lumbricales nor interossei — hence why the first phalanges only cannot be extended, whilst when these are supported, the second and third phalanges can be voluntarily raised without difSculty.* * For a case of Poisoning by Aconite see Aneurism, case of Henry Smith. SECTION V. DISEASES OF THE DIGESTIVE SYSTEM. Under this lioad I include derangements of all those parts which are concerned in the primary digestion — that is, not only the different por- tions of the alimentary canal strictly so called, but the liver, pancreas, and peritoneum. The lesions of the spleen I shall consider in the section devoted to diseases of the blood, as there can be little doubt that this, with the mesenteric and other ductless glands, is not only concerned m the formation of blood, but is most commonly disordered during its unhealthy states. DISEASES OF THE MOUTH, PHARYXX, AND (ESOPHAGUS. Case XLYL^—Tomimtis. History.— Christina Slater, fet. 22, a well-nourished servant girl— admitted May 6th, 1857. Three weeks ago, after exposm-e to cold, during the family washing, she experienced rigors, headache, and thirst, with a sense of dryness and swelling in the throat, especially on the right side ; could with difficulty swallow either solids or fluids, the latter occasionally regurgitating through the nostrils. These symptoms continued to increase tOl the night before admission, when she felt something give way in her throat. She spat up some matter, and thereafter felt general rehef. SYMPTOiis ON Admission. —Pulse of moderate strength and frequency ; no cardiac hypertrophy nor abnormal murmurs. Respirations easy and not hurried. The voice is soft and natural, but articulation is indistinct and hissing. The jaws are so immo- vable as to be separable only to the extent of a quarter inch ; neither by the finger, therefore, nor by inspection, can the tonsils be examined ; but there is tenderness on pressure, and considerable fulness in the right sub-parotidean and sub-maxillary regions. The tongue, as far as can be exposed, is covered centrally with a thick white creamy coat ; the edges being of a bright red colour. Can now swallow fluids ; * Reported by Mr. "W. Guy, Clmical Clerk. 422 DISEASES OF THE DIGESTIVE SYSTEM. appetite returning ; bowels regular. The urine is non-albuminous, slightly hyper- phosphatic, with a mucous sediment. The other functions are normal. Progress of the Case. — Poultices were applied from time to time; on May lltU, she was able to open her mouth to the full extent. Both tonsils were then seen to be enlarged, the one on the right side being the size of a walnut. Anteriorly it pre- sented two or three ulcers, with dense yellow margins, about the size of split peas. Lunar caustic is to be applied to the ulcers, and she is to use an astringent gargle. The right tonsil still continuing enlarged, was scarified May 2,\st, with marked relief, and diminished slightly in size afterwards, under the action of tincture of iodine applied locally. The diminution being very slow, and patient otherwise in good health, she was sent, June Sth, to Mr. Syme, who excised one half of the gland. June lOth. — "Was dismissed cured. Commentarij. — Hypertropliy of the tonsils is so common in young children as scarcely to demand notice, unless suspicions of croup are entertained, when they should invariably be examined. I have frequently seen the fences almost closed from the contact of enlarged tonsils, so as to cause croup-like breathing, and give rise to great alarm. Painting them with the tincture of iodine is the best remedy, and excision may be practised if much permanent inconvenience be occasioned. In the above case, all the three lesions which affect the tonsil were produced, namely, abscess, ulceration, and enlargement. The former bursts, the two latter were treated successfully by local applications of the solid nitrate of silver, and subsequently half the gland was excised. Case XLVIL* — Follicular Pharyngitis. History. — Peter M'Donald, set. 42, a hammerman in an engine foundry — admitted December 1st, 1856. Four months ago, being previously healthy, he was attacked with severe sore throat, difficulty of deglutition, and subsequently deafness in the left ear. He could not swallow sufficient food, became weak, and in a fortnight gave up work. He ascribes his attack to the sudden changes of temperature to which he was exposed. The dysphagia did not continue, but he still is weak, feels a dry- ness in the throat, with frequent desire to swallow his saliva, but great difficulty in so doing. Symptoms on Admission. — The voice is hoarse. On examination with a spatula, numerous red bodies, of a somewhat spherical shape, about the size of a large pin's head, are seen scattered over the mucous membrane of palate, fauces, and pharynx. The mucous membrane of the fauces and pharynx is of a deep red colour ; no ulcers visible; no cougli ; no expectoration. Digestive, respiratory, and other symptoms are normal. Progress op the Case. — Under local application to the pharynx with a sponge, of the nitrate of silver solution ( 3ss of crystallized nitrate to § j of distilled ivater) the sense of dryness and the difficulty of swallowing saliva were reheved; his strength improved under good diet, and he was dismissed Dec. 29th. CommentarT/. — Pharyngitis is generally indicated by a high degree of redness with thickening of the mucous membrane ; and in certain specific forms of it, ulceration is likely to occur. For a knowledge of follicular pha- * Reported by Mr. Alexander Turnbull, Clinical Clerk. DISEASES OF THE MOUTH, PHAEYXX, AND (ESOPHAGUS. 423 ryngitis, and its importance in relation to diseases of tlie larynx, we are indebted to Dr. Horace Green of Xew York. There can be no doubt that many cases of chronic cough, generally denominated bronchitis, chronic laryngitis, or clergyman's sore throat, are dependent on this lesion, and as "little that they are to be cured or greatly alleviated by appropriate applications made to the part. For an account of these, however, i must refer to what is said under the head of Laryngitis. Case XLYlll.*— Stricture of the (Esophagus from EpUMionM. History.— William Porter, set 68, a brassfounder — admitted May 2d, 1855. Two years ago a cab ran over his abdomen, across the epigastric region. He vo- mited a considerable quantity of blood for a few days afler, and felt a pain in the back. From the pain then felt he soon recovered, and enjoyed ordinary health till four months before admission. He then for the first time experienced a sense of obstruction to the p.agsage of food at the lower part of the gullet. The dysphagia had gradually increased, and has latterly been attended with paui. He has had no cough, and no haemoptysis. Symptoms ox Admission". — Skin dry, patient greatly emaciated; pulse, 68 per minute, weak and irregular ; the tongue is covered with white fur. The fauces are natural ; his food consists of bread or biscuit steeped in tea, milk, or water ; he does not dare to swallow more sohd food. That which he takes (in the presence of the clerk) is returned within two or three minutes. The patient believes that the food vomited has not entered the stomach ; being asked to point to the spot where he feels it stop, he puts his finger on the sternum, at the level of the fifth costal cartilage. He feels pain when the food reaches this spot. Three weeks ago, for a fortnight, the pain was felt constantly, even when no food was being taken. The smaller portion of food, wliich passes the obstruction and enters the stomach, is retained with only sliglit uneasy sensations. There is no tumour to be detected in the epigastrium ; the hepatic organ is normal in size ; the abdominal walls are easily excited to rigidity. The bowels are costive ; no blood has ever been passed by stool. Nervous and other systems normal. Nutrients to be taken in small quan- tities, in a liquid form, often repeated. Progress of the Case. — May ith. — Tongue clean ; pulse 68, stronger than on admission. Vomiting appears to be longer delayed. 3Iaij 8th. — A probang passed readily along the oesophagus to-day ; there is less uneasiness, but no greater power in swallowing. Jlay 9th. — Complains of extreme weakness; asks for beer, which is granted. May lOth. — About 2 p.m., while taking a mouthful of beer, he sud- denly fell back ; the mouth open ; the neck stiff ; the pupils slightly contracted ; the eyes turned upwards ; incoherent muttering, without consciousness. His face was pale ; he lay gasping for breath ; there was a tracheal rale, and a fremitus was felt over the whole chest. An inefiectual attempt to vomit was followed by in- creased distress. He rapidly sank, and finally expired at ten minutes to three o'clock. Sectio Cadaveris. — Twentij-two hours after death. Chest. — Tliere was a little recent soft yellowish lymph over the pleura, covering the lower part of the left lung. The subjacent pulmonary tissue felt firm, was of a dark colour, and presented a granular section ; it was also friable, and portions of * Reported by Mr. Q. M. Reid, Clinical Clerk. 424 DISEASES OF THE DIGESTIVE SYSTEM. it sank iu water. About two inches above the cardiac extremity of the oesophagus there was found an epithehal ulcer, nearly encircling the tube. On slitting it up, this ulcer was seen to be of a circular form, an inch and a half in diameter. Its surface was raised about one-eighth of an inch above the level of the mucous mem- brane, and presented the appearance of a pultaceous mass, of a dirty white matter, resembling gruel On scraping a portion of it, its base was seen to be composed of a whitish curdy matter, easily breaking down when pressed between the fingers. The muscular coat below was incorporated with the ulcer, and much thickened, so as to produce a stricture of the tube, through which, however, the forefinger could be readily passed. Above the stricture the oesophagus was dilated into a pouch the size of an orange. All the other organs were healthy. Microscopic Examixatiox. — The ulcer presented the usual structure of epithe- lioma, as described and figured pp. 177. Case XLIX.* — Epithelmnatoics Ulceration of the (Esophagus, communicating with the Lung. — Pneumonia terminating in Gangrene. History. — John Eraser, set. 55, a flesher — admitted September 19tli, 1855. States that for five or six years previous to admission, his health had been excellent ; and that he took his food without any sense of uneasiness, until three or four weeks ago. He then for the fii'st time felt as if a ball of wind rose from his stomach to meet the food, and the food in its passage also gave him pain. The pain was gnawing and paroxysmal. During the last eleven days he has brought up his food after abortive attempts to swallow it, and for four days he has lived on gruel, not being able to swallow any solids. Symptoms on Admission. — Tongue covered with white fur; fauces natural; appetite reported to be good ; thirst not great ; food consists of gruel or bread and biscuit soaked m fluid. Says that the food iu passing down into his stomach gives him great pain opposite a point half an inch above the lower end of ensiform carti- lage ; it is returned from the stomach in a few minutes, again causing him pain at the same spot. He adheres constantly to this declaration. Has no nausea ; never vomited blood or dark-coloured matter. Abdomen is everywhere tympanitic. No tumour can be detected. Dulness of the liver normal The bowels are very rarely opened. The pulse is 82, rather small and weak. Respiratory and other symptoms are normal To have nutritive diet in a fluid form, in small quantities often re- peated. Progress of the Case. — From September 22d to October 2d. Has been taking thrice daily the following powders: — IJ Bismuthi Trisnitrat. 3 j; Pulv. Opii gr. ij. M. et divide in pmlveres duodecem-. The dysphagia continues unrelieved ; the pain over ensiform cartilage is felt as formerly ; and there has been also a sharp internal pain over the mammaiy regions. October Wth. — Describes a pain, as if his flesh were being torn away, passing from the lower dorsal vertebrae to the epigastrium. Ex- perienced temporary and partial relief from a Mister a2}plied to the epigastrium. Oct. IQth. — Ordered three ounces of sherry wine daily, and scruple doses of the hyjMstdphite of soda. Nbv.Sth. — No diminution in the pain, dysphagia, or vomiting. Oi'dered one drop of Fleming^s tinctuix of aconite thrice daily. Nov. IZth. — Vomiting, pain, and weakness continue. The aconite is discontinued, and naphtha medicinalis in ten- drop doses, with compound tinct. of cardamoins, is substituted. On the 26th Nov. this mixture was also slopped, and ice was ordered. Dec. 7th. — Strong beef-tea injec- * Reported by Messrs. G. M. Reid and R. P. Ritchie, CUnical Clerks. .' DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 425 tions per rectum are now ordered night and morning. Dtc. IGih. — To-day vomited round masses looking lilce blood, and under microscope, blood corpuscles are recog- nised ill them. Dec. 23d. — Blood corpuscles are found in the vomited matters to- day. Pulse small, weak, 120 per minute. Dec. 28th. — Has had a hiccup for a few days past; pulse, 100, very feeble, sometimes intermitting. Thirst, which he did not feel on admission, has lately been urgent. Jan. 4th. — Has slight pain over right hypochondrium ; increased on pressure ; fine moist rales are audible over base of right lung posteriorly, with inspiration. The urine is not coagulable, but is defi- cient m chlorides. Jan. 5lh. — Deficiency of chlorides confirmed to-day. Dulness, increased vocal resonance, and crepitation with inspiration, are detected over lower two-thirds of right lung posteriorly. Pulse weak, small, and scarcely perceptible. To have § ij. of wine additional. Jan. 1th — Same signs as in last report. Chlorides are more abundant. Weakness extreme. Jan. 8th. — Chlorides again decreased; the pulse is imperceptible ; the skin cold ; in the evening vomited three ounces of bright red blood. He died almost immediately afterwards at 9 p.m. Seciio Cadaveris. — Sixty-two hours after death. The body was much emaciated. Throat. — The larynx, pharynx, and cervical portion of oesophagus were natural. Thorax. — The heart was natural. There were a few adhesions in the left pleura, but the lung was healthy. On the right side of the chest there were firm adhesions superiorly, and on the external lateral aspect. In attempting to remove tlie lung a fuugating growth situated over the spinal column was broken into. This growth (connected with the oesophagus) was found to have involved a portion of the tissue of the right lung near its root. On removal of the oesophagus, it was seen that a portion of it, about three inches in length, commencing a little above the root of the lung, and going down to about an inch above the diaphragm, was converted into a fungating substance of soft cheesy consistence. A part of anterior wall of the oesophagus had been broken down and removed in taking out the right lung; the whole of the internal aspect of the affected portion of the oesophagus presented a fungating ulcerated surface. The calibre of the tube must in consequence have been much diminished. The lower end of the oesophagus, as well as the stomach and pylorus, were natural. In the stomach there were three ounces of a brownish fluid resembling coflee grounds. On removing and cutting into the right lung, a cavity about the size of a walnut was found in its posterior part, a little above the root of the lung. This cavity was filled with a brown foetid fluid, and the surrounding pulmonary tissue was softened, hepatized, and broken down. Higher up were two smaller cavities, presenting similar characters, and surrounded by a layer of condensed pneumonic substance. The abdominal organs were natural. Microscopic Examination. — The fungating mass presented all the usual appear- ance of epithelioma, containing imbedded in the deeper friable portion of the growth, numerous masses of concentrically arranged cells, such as are rej^resented Fig. 212, p. 177. Comynentary. — Epithelioma of the oesophagus was present in the two cases above recorded in different degrees. In Case XLVIIL, the disease was limited to a patch about one and a-half inch in diameter, causing at that point a stricture of the tube, and immediately above it a considerable dilatation. From the impossibility of taking nourish- ment, extreme debility was induced, of which he died. In Case XLIX., the epithelioma was more extensive, surrounding the oeso- 426 DISEASES OF THE DIGESTIVE SYSTE^I. phagns internally over a space three inches in depth, causing great thickening of the tube extending through all the coat, and even affect- ing the root of the right lung. The whole of the involved tissues were of the consistence of soft cheese, and here and there pulpy and even diffluent. It was evident that at length a comniuuication was formed between the oesophagus and the lung, the occurrence of which was indicated by a pneumonia, v\ith all the physical signs and general symptoms characteristic of that lesion. Case L.* — Carcinomatous Stricture of (EsopJia^us — Cancer of the Liver — Pidmonary Emphysema and Tubercle — Pneumonia. History.— John Currie, set. 53, a cooper— admitted 18th February, 1857. "Was accustomed to drink hea-vily tiU within the last half year. Was weU fed, strong, and healthy. Has had rheumatic fever thrice, the last time being twelve years ago, without any cardiac symptoms which he can remember. Had inflammation of the chest eighteen years ago. Had general dropsy nme months ago ; entered the hospital and was discharged cured in three weeks. It is about six months ago since the patient first experienced pain in the epigastrium after taking food, with pyrosis and anorexia For three months he continued in this state, losing flesh and becoming weaker. Three months ago he began to vomit his food, at first m the evening, and subsequently during and after all his meals. He has vomited a little blood on three or four occasions. The character of the vomited matters is reported by him to have been as at present. STiiPTOMS ox ADinssiox. — The tongue is clean ; there is no pain nor any diffi- culty in swallowing tiU the food readies a point which he indicates as beneath the lower part of the sternum and the epigastrium He has to rest after each mouthfiil tin the food passes this point. If it passes, he has no further pain ; but the greater part does not pass, and causes him great pain tUl it is dislodged by vomiting. The matter vomited consists of undigested food and clear mucus. Fluids and sohds are equally troublesome for him to swallow. He has often hiccup while eating, and brings up flatus with great relief He feels a constant '• working" at his stomach. There is a fulness and resistance on palpation over epigastrium ; but little tender- ness, and no tumour. The area of hepatic dulness vertically below the nipple mea- sures three inches, and laterally three and a-halC Xo splenic enlargement detected. Xo abnormality on examination of abdomen. Bowels are rather costive. The cardiac dulness at the level of the nipple is If inch. The apex is felt and distinctly seen beating in the sixth intercostal space, and it is seen also in the fifth intercostal space. These two pulsations alternate, or are not exactly synchronous. At the apex, over a Umited area of about one square mch, a short, blowing murmur, not loud, is heard with the first sound, the second sound being healthy. At the base, both sounds are feeble, but fi-ee from abnormal murmur. The pulse is 76 ; irregular in rhythm. The respiratofy system is normal, with the exception of a few snoring rales posteriorly. The urine is high-coloured, sp. gr. 1027; not albuminous. Progress of the Case. — I took charge of this case on the 1st of May, up to which time his symptoms had continued the same, notwithstanding careful regula- tion of his diet and the administration of morphia, tr. ferri muriatis, creosote, wine, and the application of a blister. The report on May I2this: — Xo improvement; pain in the epigastrium stUl severe. He is weaker, much emaciated, and destitute * Reported by Messrs. J. T. Walker and VT. H. Davies, Clinical Clerks. DISEASES OF THE MOUTH, PHARYNX, AXD CESOPHAGUS. 427 of appetite. Jfaij 80th. — Patient's diet now consists of arrow-root twice daily, beef-tea, tea and bread, and § iv of sherry wine. He is unable to take any other nourishment. Since admission, has been rarely out of bed. June lOth. — No change in symptoms. Continues same diet. July 1st. — For the past week the strength has gradually increased. He has been up out of bed for several days, and to-day he ventured into the green for a short time. Has some calf's foot jelly. July I9th. — Has relapsed: he now feels a constriction higher up in the oesophagus, opposite the lower part of his throat, and is unable to swallow even the little he has hitherto taken. Is greatly emaciated. Weakness extreme. July 21 ih. — Complains now wholly of the restriction superiorly. Beef-tea enemata with port wine have been ordered four times a day. July 30ih. — Enemata discontinued from the resistance of the patient. He is able to swallow wine, which he relishes. Aug. 2d. — Since last report, in same state, but more feeble ; Ues very much on his left side ; groans at intervals, his voice being comparatively strong ; but articulation is very indistinct. Has no cough nor apparent dyspnoea. Not taken any food for four days. Aug. 3d. — Died apparently from exhaustion at 10.30 p.m. Sectio Cadaveris. — Thirty-nine hours after death. Body presented the last stage of emaciation, the abdominal wall at the umbilicus being so retracted as to be in contact with the vertebral column. Thorax. — The pericardium was universally adherent ; the adhesions were old and firm. The lower half of each aortic valve was thickened and almost rigid; but on trial there is no incompetence. The heart weighed nine and a half ounces, the left ventricle being slightly thinner than usual. Both lungs were emphysematous anteriorly ; and throughout the spongy portion, indurated nodules could be felt, vary- ing in size from a coffee bean to that of a hazel nut. On section, these presented aggregations of miUary tubercle of a yellow colour, for the most part of cheesy con- sistence, but here and there softened, forming purulent collections and small abscesses the size of a pea. In the left lung, the posterior third of the lower lobe presented all the characteristics of red, in one or two places passing into grey, hepatization. In the right lung, posteriorly, were two or three masses of red hepatization the size of a walnut. Digestive Orgaxs. — The posterior third of the tongue presented a tuberculated appearance ; the mucous membrane on section was found thick, dense, almost carti- laginous, of greyish colour, and yielding on pressure a thin greyish-white juice. The mucous membrane of the pharynx was natural. In the oesophagus, an inch and a half above the bifurcation of the trachea, there existed a stricture admirting only the point of the little finger. When opened, the mucous membrane appeared natural, the sub-areolar tissue somewhat thickened. Lower down the cardiac orifice was felt excessively contracted, so that nothing larger than a crow's quill could be passed through it. The stricture extended along nearly two inches in length, being strictly limited to the oesophagus. The liver and stomach being removed together, a large mass of greyish-white colour and firm consistence was found projecting from the posterior surface of the liver, and firmly adherent to the cardiac portion of the stomach just where the oesophagus enters it. From the surface of the hver there projected other rounded masses of greyish-white colour, with central depressions, and so firm as to creak under the knife. On laying open the stricture, the mucous membrane was found not ulcerated; but in the sub- mucous tissue was deposited hard, cancerous matter, not separable by any margin from the similar substance already described as projecting from the liver. The stomach was contracted, but otherwise healthy. Abdomen. — The kidneys felt indurated ; but when examined, appeared natural. 428 DISEASES OF THE DIGESTIVE SYSTEM. The spleen weighed onlj' two ounces; its structure was natural Other organs healthy. Microscopic Examination. — The cancerous masses in the liver and in the oesopha- gus contained numerous large cancer cells in all stages of development, embedded in a fibrous stroma. The tubercles in the lungs exhibited the usual appearance of mDiary tubercle in various stages of disintegration, associated with pus. The red and grey hepatization was composed of an exudation in the air-cells and smaller bronchial vessels, which presented various stages of transformation into pus, being most recent in the former, and most perfect in the latter. Many of the pus cells contained fatty granules, and exhibited different degrees of disintegration. Commentary. — This man literally died of starvation, from tlie utter impossibility of introducing nourishment into tlie system. The cancer- ous mass originally formed in the liver, had surrounded and compressed the cesophagus and cardiac orifice of the stomach, so as to reduce the canal to the size of a crow's quill, a stricture that extended through a curved line, nearly two inches long. A second stricture, but not to so great an extent, existed above this in the oesophagus. It is not surpris- ing, therefore, that at last no kind of nourishment could pass these ob- structions, the absence of contractile power in the diseased oesopliagus above being insufficient to propel even fluids through the stricture below. What appears to me, however, the most remarkable feature in this case, is the occurrence in the same individual of recent cancer, tubercle, and pneumonia. Whether the tubercle or the cancer was first formed, it becomes exceedingly difticult to determine, but certainly the nodulated groups of miliary tubercle in the lungs were in every respect similar in general appearance and structure to what is observable in phthisical cases. It is true there was no especial accumulation of tubercle at the apex of either lung, neither was there cough, nor any symptoms of pulmonary disease shown throughout the whole course of his disease. But as a decided form of exudation its presence was undoubted. The pneumonia must have come on during the latter days of his life, when he was in a state of extreme weakness. But it occasioned no active symptoms, and though conjoined with great emphysema anteriorly in both lungs, produced no dyspnoea. The pathological fact, however, of the occurrence of these three forms of exudation in one individual is, though undoubtedly rare, well calculated to demo.nstrate the fallacy of all exclusive views as to their production in individuals of a peculiar diathesis. Temporary dysphagia occasionally occurs in cases of hysteria or of spinal iiTitation, but when permanent it is always the result of organic disease of the pharynx or oesophagus. In the great majority of cases it is owing to some growth, cancerous, epitheliomatous, aneurismal, or of some other form, which, by attacking the parts themselves, induces stricture of its walls, or by compressing them from without, causes a mechanical ob- struction to the tube. In a few rare cases it has depended on pouch-like, or spindle-form dilatations, which, by becoming impacted with food, have caused the impediment. In all these cases the cure will depend on the means at our disposal of removing the obstructing cause, such as exter- nal tumours compressing the part ; but if it depend on disease of the harynx or oesophagus, the treatment must be for the most part pallia- FUNCTIONAL DISOKDERS OF THE STOMACH. 429 tive. There may be a simple stricture, which may require surgical in- terference by bougies or catheters, but more generally as observed by the physician, it is the result of cancer or epithelioma, as in the cases nar- rated. Under such circumstances, the treatment must be directed to support nutrition by unirritatingfood, given in small quantities and in a form that the patient can most easily swallow. Remedies of various kinds to alleviate or check the vomiting may be tried, but are seldom of permanent benefit. Very rarely, an effort at healing is set up by nature, which for a time causes diminution in the more distressing symptoms, of which Case XIII. is a remarkable example. FUNCTIONAL DISORDERS OF THE STOMACH. Case LI.* — Dyspepsia. History. — James Scott, set. 51 — admitted 27th September 1852. He states that, about two months previous to admission, he experienced severe shooting pains dart- ing from the left scapula to the epigastrium and left hypochondriura. For many j'ears back he has been much addicted to intemperate habits, and latterly his appe- tite for food has been considerabl}^ impaired. Syjiptoms on Admissiox. — On admission, the tongue is furred, and cracked in the centre ; he has almost constantly a sour taste in the mouth, worse in the morn- ing after taking food ; frequent acid eructations ; bad appetite, and considerable thirst. About a quarter of an hour after meals he experiences a feeling of heat and pain in the epigastrium, with acid eructations and flatulence; the latter also troubles him during the night, when the stomach is empty. These symptoms continue generally for about an hour and a half, when they gradually abate, and soon after disappear entirely. He then again takes food, and the symptoms return in about a quarter of an hour afterwards, as already noticed. He does not think that one kind of food disagrees with him more than another. He has often much nausea and loathing of food, but no vomiting. There is some tenderness on pressure at a point about the centre of the epigastrium, where he states there is always more or less pain, gene- rally of a dull, heavy character, but sometimes occurring in sharp twinges, shooting to the left scapula, and somewhat increased on pressure. There is no unusual hard- ness or tumour to be felt ; and there is no dulness on percussion. There is no ten- derness or enlargement of the liver ; urine normal. He is of a very desponding dis- position, and does not sleep well at night. Other functions normal. 5 Poiassce bicarbonatis, 3ij; Tind. Gentian Co. ^i; Infus. Gentian Go. ?v. M. ft mist. Half a loine- glassful to be taken thrice a-day. Progress of the Case. — December 31s<. Still complains of flatulence and distension of the abdomen ; considerable pain in the epigastrium, increased on pres- sure. A'pplicentur hirudines quatuor epiga^tr-io et jyostea foveatur. Jan. 3d — Appetite improved ; still acid eructations, with sour taste in the mouth ; pain in the epigastrium relieved after the application of the leeches and warm fomentations. He is very desponding about his complaints, which he much exaggerates. Jan. 10th. — The sour taste and flatulence diminished ; pain and uneashiess in the stomach much relieved ; no tenderness on pressure ; appetite much improved ; no sickness * Reported by Mr. James D. Maclareu, Clinical Clerk. 430 DISEASES OF THE DIGESTIVE SYSTEM. or vomiting; bowels regular; stools natural. Dismissed in order to return to his work. The diet ordered has been of a gentle, unstimulating, but nutritious kind. Commentary. — In this case derangement of digestion depended on intemperate habits, and was accompanied by excess of acidity in the stomach. The treatment was directed to counteract this condition by alkahes, vegetable bitter,s, and a regulated diet, which, to a certain extent, succeeded. But all such cases require exercise, regular habits, and moral control, without which medical treatment is unavailing. Case LII.* — Dyspepsia — Oxaluria. History. — John Millar, a>t. 28, a typefounder— admitted December 26th, 1852. He states that he had always enjoyed good health, with the exception of occasional palpitation of the heart, until about eight months ago. Vertigo came on suddenly when he was at work, but disappeared in a few minutes. Smce then, he has had many attacks of the same kind ; and of late, these have been accompanied with pain and palpitation of the heart, and tinnitus aurium. Some years ago he was much addicted to drink, but for the last four years he has been more temperate. Symptoms on Admission.— On admission, the heart was found to be healthy, and the pulse natural. The tongue was dry in the centre, moist and white at the edges, with numerous transverse fissures. He had a disagreeable taste in his mouth in the morning, and no appetite for food ; had never vomited, nor experienced pain in the stomach ; bowels constipated. There was an anxious, haggard expression of countenance, and an evident tendency to exaggerate his symptoms ; he complained of vertigo, tinnitus aurium, and muscffi volitantes. The urine, after standing some time, exhibited a slight deposit, in which numerous large crystals of oxalate of lime were visible on microscopic examination; sp. gr. 1028; otherwise normal. The other functions were normal. 5 Acid. nii. ; Acid mtriat. aa 3 iss ; Tinct. gent. co. § i ; Infus. gent. co. "^y. M. A table-spoonful to be taken three times a-day. Progress cf the Case. — January 8Wi.— Since last report, tlie oxalates have dis- appeared, the appetite has improved, the cardiac and cerebral symptoms are removed, and he is to-day dismissed cured. Commentary . — Dr. Golding Bird was the first to point out that oxaluria, associated with dyspepsia, was a very common disorder, and that its treatment by nitro-mnriatic acid was the most successful one. The oxalic acid is probably derived from urea or uric acid, and its pre- sence in the urine is often associated or alternates Avith these compounds. No doubt the tonic treatment practised in the above case is the best mode of relief, but here also a regulated diet, with exercise and mental occupation, are necessary to render the benefit permanent. Case LIII.| — Dyspepsia — Hypochondriasis — Oxaluria. HiSTORY.—Thomas Pollock, set. 24, hawker— admitted 25th December, 1852. He says that, three years and a half ago, when stooping down in a field during a dark night to evacuate his bowels, he felt a sharp, hard body, like the stump of a shrub, * Reported by Mr. James D. Maclaren, Clinical Clerk. ■J- Reported by Mr. William Calder, Clinical Clerk. FUNCTIONAL DISORDERS OF THE STOMACH. 431 penetrate his anus, causing acute pain, which continued for a fortnight, and has occasionally returned ever since. No blood passed at the time, but he has been under the care of various medical practitioners, and undergone numerous kinds of treatment. He has never had diarrhoea ; but is addicted to masturbation. He has consulted the numerous works advertised in the papers on manly vigour, etc., but has derived no benefit from them. SyJiPTOMS ON Admission. — On admission, tongue moist, but furred, cracked, and fissured in the centre ; says he experiences a feeling of load after taking food, with occasional nausea. He has no vomiting, but an acid and sometimes disagreeable taste in the mouth ; frequent flatulence and constipation, for which he is in the habit of taking aperient medicine. ' On placing the hand on the epigastrium, he says that there is soreness beneath the xiphoid cartilage, increased on pressure. Has occa- sional involuntary emissions of semen. The urine contains a slight sediment on standing, which is crowded with large and small crystals of oxalate of lime ; sp. gr. 1020; otherwise normal. Sleepless at night; anxious and desponding about his complaints, which he attributes to the accident formerly mentioned, although it produced no local effects at the time, nor any structural change since. Says that he has frequent vertigo, tinnitus aurium, muscie volitantes, and cephalalgia. The other functions are normal. 5 Acid, nitrici ; Acid, muriat. aa 3 i ; Tinct. gent. co. 1 1 ; Infus. gent. co. § v. if. A table-spoonful three times a-day. Progress of the Case — January 3d — He has continued to take the acid mix- ture, bat does not admit that he is in any way better. On the 2d, the oxalates dis- appeared from the urine, and were replaced by a copious deposit of amorphous lithates. Omittatur mist. a.cid. ^ Liquoris potassce, Z ii ; Tine, cardamom, co. §i; Infus. quassias, § vii. M. Two table-spoonfuls night and morning. Jan. Aih.— As he still continues to complain of pain in the sacral region, which he attributes to the accident, a blister, three inches by four, was ordered to be applied there. Jan. lOth. — Since the apphcation of the blister the pain in the sacrum has disappeared. He expresses himself as being much better, and was now dismissed. Commentary. — In tins case the presence of oxalates in the urine was associated with the same class of symptoms as in the former one, but the tendency of the patient to exag-geratc his complaints was more marked. He had also a firm belief' in their being- caused by an acci- dent, wliich possibly never happened, and even if it had, conld not have occasioned his symptoms. The acid and tonic mixture removed the oxalates, bnt lithates took their place in tlie urine, which, in their turn, were got rid of by alkalies. Still, the fixed idea as to the cause of the disease continued,' and he seemed no better. A blister was now applied to the sacrum, and he readily adopted the idea that his local com|'laints disappeared with the pain of the blister, and became cheerful and well. No case could better illustrate the efi'ccts of mental depression on the digestive organs than this. For a period of three years he had been the subject of delusion and genital irritations, heightened by the study of those publications, which, to the disgrace of the newspaper press, are daily advertised to the people as the only means of restoring vigour to the constitution. At length, satisfied with their ineflficiency, he entered the Infirmary ; the error of his practices was kindly pointed out to him, nutritious diet, regular habits, and tonic treatment were obviously beneficial ; and fortunately his hypochondriasis yielded to the shnple expedient of substituting 'real for supposed pain, and leading him to imao;ine that the one had cured the other. 432 DISEASES OF THE DIGESTIVE SYSTEM. General Patholoc/y and Treatment of Dyspepsia. Bv dyspepsia (from (Jjo'irs'rrw; I digest with difficulty) is generally understood, all those functional derangements of the stomach which are primary in their origin, that is, not dependent upon, or symptomatic of, inflammation or other disease in the economy. Such a disordered con- dition is exceedingly common, and often constitutes the despair of the physician, arising, as it frequently does, from causes which are obscure, or, if discovered, are beyond his control. This will become apparent by considering, in the first place, those circumstances which require to be imited to secure a healthy digestion. These are — 1st, A proper quantity and quality of the ingesta. 2d, Sufficient mastication and insalivation. 3d, Active contractility in the muscular coat of the sto- mach. 4th, Proper quantity and quality of the gastric, biliary, and pancreatic fluids. 5th, A consecutive and harmonious action of the intestinal canal. Dyspepsia, or indigestion, may be produced by any cause which occasions derangement of one or more of these conditions ; and hence it is why so many different circumstances may produce some- what similar symptoms, and why so many different remedies have been found effectual in various cases. Xotwithstanding that you will fre- quently meet with instances which baffle all preconceived rules, there can be no doubt that a careful attention to the essential physiological conditions above enumerated will, in the great majority of cases, conduct Tou to a successful rational treatment. Thus — 1. Of all the causes of dyspepsia, excesses in eating and drinking are the most common. An over-distended stomach, or too rich a meal, not unfrequeutly induces a feeling of weight or fulness in the epigas- trium, nausea and eructation of acid, bilious, or gaseous matters, with a loaded tongue, headache, and other general symptoms. This is acute dyspepsia, or the embarras gastrique of the French. Occasionally, there is more or less vomiting of bilious matter, when the attack is vulgarly called a bilious seizure. If called to see such a case, immediately on its occurrence, and before the ingesta have left the stomach, as determined by the sense of load at the epigastrium, and by percussion, an emetic should be given ; and if vomiting be present, it should be assisted by warm diluents. As soon as the stomach is quieted, or, if you have been called in at a late period, when the ingesta have passed into the intes- tines, a purgative should be administered, consisting of four grains of calomel, with four of compound extract of colocynth, followed in a few hours by a draught of salts and senna. If necessary also an enema may be given. The purging, with a day or two's confinement to farinaceous food, will generally get rid of such an attack ; but their fi-equent repeti- tion leads to the chronic form of dyspepsia, in which careful regulation of the diet, with exercise, must constitute the chief treatment. Hence the advantage of what is called " change of air," and much of the benefit which is derived from watering places. Chronic dyspepsia, however, is far more commonly caused by excess of spirituous and vinous drinks, than by eating, and, in such cases, abandonment of the evil habit is a si7ie qua non in the treatment. Tea drinkers are very liable to the dis- FUNCTIONAL DISORDERS OF THE STOMACH. 4:33 ease, and its frequency among female servants is probably owing to over indulgence in this beverage. 2. It may frequently be noticed, that those who liave acquired the habit of eating rapidly are more or less dyspeptic. I knew a journey- man printer, who had been much tormented with indigestion, but who was cured by changing his residence. The reason of this cure was for some time a mystery ; on again changing his house, the disease returned ; still no apparent cause couhl be discovered. I ascertained, at length, that it depended not on the locality per se, but on its distance from the printing house. When far off he ate his dinner with his family rapidly, having only just time enough to walk home and back within the hour. When he lived near, the time otherwise spent in walking was occupied in eating, or in oheerfal converse with his wife and family. Since I made this observation, it has often occurred to me that the distance of the residences of artisans from their place of employment may be the occasional cause of the dyspeptic symptoms they frequently suffer from. The exact object of the saliva in the process of digestion, whether it be to convert the farinaceous compounds of the food into glucose, or by its viscidity to mix up air with the portions swallowed, is not positively determined; but its necessity for digestion is shown by what happens in cases where the under lip has been lost by accident or disease, or where salivary fistulte have formed ; in such cases dyspepsia is generally pre- sent, and in some the disordered digestion has been cured by operations that, by restoring the parts to their normal condition, prevent the escape of saliva. Again, persons habituated to the dirty habit of spitting, are for the most part dyspeptic. In all cases where dyspepsia can be traced to this source, the treatment becomes obvious. 3. The contractile movements of the stomach which, by kneading the ino-esta, and keeping them in constant motion, secure their intimate admixture with the gastric juice, and the rapid transference to the duo- denum of such portions of it as are transformed into chyme, are evidently of great importance to the proper performance of digestion. The experi- ments of physiologists have shown that digestion goes on in gastric juice taken out of the stomach much slower than in the stomach, and that section of the pneumogastric nerves, by arresting the contractile move- ments, permits only the circumference of the mass in contact with the secreting surface to be digested. These facts at once explain the well- known influence of mental emotions upon the stomach. Contentment and hope are as favourable, as dissatisfaction and despondency are inju- rious, to good digestion. Nothing is more common than dyspepsia among literary men wdio overtask their mental faculties; among young persons of very excitable minds ; and among individuals of a melancholy temperament, hypochondriacs, etc. etc. It is in such cases that cheerful society, active and appropriate occupations, change of scene, removal from mercantile or literary employments, variety in trains of thought, and so on, are beneficial. Hence also many of the good effects of travel, visits to watering places, etc. etc. 4. Our knowledge with regard to the offices performed by the gastric, 28 434 DISEASES OF THE DIGESTIVE SYSTEM. biliarv, and pancreatic juices in digestion Las of late years been much advanced. Thus, the gastric juice operates more especially on the albu- minous, and the pancreatic juice on the fatty compounds of the food. The function of the bile is more obscure ; it probably acts as a means of precipitating or separating some of the excretory matters from chyme, and so facilitates assimilation of the nutritive portions. Digestion may be deranged by all tliose causes which increase or diminish too much the secretion of these three fluids. Thus excess of acidity in the stomach is one of the most conmaon causes of dyspepsia, and is associated vvith that form of it which accompanies scrofulous and tubercular diseases. It may be in such excess as to neutralise the alkaline action of the pan- creatic juice, and I'ender it incapable of emulsionising fatty matters. In such cases the alkalies, with bitter tonics and the direct introduction of animal oils in excess, are indicated. On the other hand, the gastric juice mav be diminished in quantity, as frequently occurs in persons who sud- denly overtask the powers of the stomach at feasts, or in old persons w'ith feeble digestion. The sense of load after eating is generally indi- cative of slow digestion from this cause. In acute cases, a stimulant rouses the stomach to increased action, and hence the moderate use of drams and generous wines after dinner is occasionally useful. In old persons the sense of load and feebleness is best removed by giving up tea, and drinking at night a little weak brandy and water. In chronic cases, acids are indicated, especially muriatic acid. The Tr. Ferri co. of the pharmacopoeia is a useful preparation in chlorotic females. The pre- pared gastric juice of the calf has been lately recommended as a remedy in these cases ; and is undoubtedly in some cases of much service. We have no distinct means, as far as I am aware, of rousing the pancreas into action, and yet many cases are on record in which fatty matters have passed undigested through the alimentary canal in conse- quence of obstruction to the pancreatic duct. In such cases, and in all those in which fatty matters are difficult to digest, alkalies, especially the sodce bicarb, with vegetable tonics, are indicated. When the bile is deficient, constipation and dyspepsia are usual results, and are to be relieved by gentle mercuidal purgatives, with extract of taraxacum, and by remedies, such as rhubarb, and especially the compound rhubarb pill, which, by acting on the duodenum, also favour the flow of bile into the upper part of the alimentary canal. Dr. Clav of Manchester has recommended in such cases the administration of ox-gall, a remedy which, althoagh not extensively given, is evidently rational, and calculated by its purgative action to be highly serviceable. Excess of bile, on the other hand, ought to be treated by drastic purga- tives, diuretics, and diaphoretics, according to circumstances, to cause excess of excretion. Exercise should also be insisted on to call the lungs into action, and thus relieve the liver in its ofllce of separating hydro-carbon. 5. A derangement of the consecutive and harmonious action of the alimentary canal is another frequent cause of dyspepsia, for it is as necessary that those portions of the food which are not assimilable should be removed out of the economy, as that the nutritive materials should be absorbed. Hence, whatever impedes the contractility of the FUNCTIONAL DISORDERS OF THE STOMACH. 435 intestinal canal, whatever alters the structure of its nnicous membrane, or whatever mechanically obstructs its calibre, induces dyspeptic symptoms. The removal of these various conditions, whether by stimulating the nervous centres, by appropriate diet, or by purgatives and astringents, need not be more particularly dwelt upon here. I would only observe that the constant use of laxatives, however they may temporarily relieve, cannot cure, and that in all chronic cases a proper action of the bowels must be obtained as much as possible by means of dietetic and hygienic regulations. In many cases of dyspepsia, two or more of these classes of causes may be combined so as to render the indications for treatment complex and apparently contradictory. In other cases, one or more causes may exist, although from the indications present their nature cannot be deter- mined ; in such cases, our treatment must always be more or less vague and unsatisfactory. Lastly, there are a few instances where dyspepsia can only be explained by idiosijncrasy, in which we find this or that particular article of diet to derange the digestive functions, and in which avoidance of the oftending cause is the only plan of treatment that is attended with success. In addition to the different kinds of dyspepsia to which I have directed your attention, it is practically important to keep in remem- brance the leading symptoms which may be present, and the remedies by which they may be removed. The symptoms are anorexia, acid eructations, sense of load at the stomach, cardialgia, vomiting, flatulence, palpitations of the heart, and cephalalgia. Some persons talk of a sto- mach cough, but this is more commonly dependent on sources of irrita- tion in the oesophagus or pharynx, which have hitherto been overlooked. I have already alluded to the mode of treating most of these symptoms. Palpitations of the heart often occasion alarm in young dyspeptic per- sons ; and in such cases, besides remedies directed towards the stomacli, change of scene, removing attention from the affected organ, and varied reading, should be enjoined. The sense of load in the stomach is most frequently removed, as I have previously said, by acids ; and sour eruc- tations and cardialgia are best relieved by alkalies and bitter tonics. Vomiting and flatulence are often very troublesome symptoms. The varied remedies which may be employed in a case of chronic vomiting may be gathered from the following history : — Case JAY* — Dyspepsia — Vomiting of fermented matter containing Sarcirm. History. — Thomas Spence, set 53, a weaver, — admitted September 6, 1852. He states that, for fourteen or fifteen years past, he has been subject to occasional vomit- ing, which generally occurred on Sundays, owing, he supposes, to want of exercise at his usual employment. On these days he scarcely ever took his meals from fear of the almost certain vomiting which would follow. For two or three years past he has been liable to frequent heartburn, waterbrash, and acid eructations, but was able to continue at his usual employment till about six months ago. Since then, he has been gradually losing his appetite, and his strength has become much prostrated. * Reported by Mr. "William Calder, Clinical Clerk. 4:36 DISEASES OF THE DIGESTIVE SYSTEM. He has never vomited blood or any dark-coloured matter, and has never passed any such by stool. Symptoms on Admission. — On admission tongue clean ; no difficult}- in deglu- tition ; appetite capricious, but always best in the morning and earlj^ part of the day. Shortly after taking food, he begins to have uneasy sensations in the epigastrium, sickness, and a sense of weight at the stomach. When these symptoms appear, the abdomen generally begins to swell, and in about an hour to an hour and a half, the food is vomited. The rejected matters consist generally of the half-digested food, ■with a thick, dirty, frothy scum on the surface, resembling yeast. He has also fre- quent pyrosis, acid eructations, and flatulence, the latter sometimes so great as to occasion a sensation of choking, especially after vomiting. These symptoms are worse after some kinds of food than others : oatmeal, especially in the form of por- ridge, produces them in the severest form ; broths, vegetables, or any kind of slops, disagree with him ; animal food suits him best, but w'hen even this is taken for any length of time, the symptoms soon reappear. The abdomen at present is much swollen, very tense, and tympanitic on percussion, with considerable tenderness over the epigastrium. The bowels are generally constipated ; the stools usuallj' of a dark colour and hard consistence. He has occasionally slight pain and difficulty in void- ing his urine, W'hicli is slightly phosphatic. Other functions are normal. Progress of the Case. — On taking charge of this patient on the 1st of Novem- ber, I found him vomiting from time to time large quantities of fluid mixed with undi- gested matters, on which there gatliered, after a shoi't time, a thick brownish scum, exactly resembling yeast. On examining this scum with the microscope, it was ascer- tained to contain a large number of sarcinse ventriculi (see p. 83, Fig. 61), mingled with starch corpuscles, more or less broken down, and granular matter. Erom the ward books, I learnt that his treatment had consisted in the successive administra- tion of, — 1. The local application of leeches ,• 2. Of the sulj^hite of soda, in scruple doses, with two grains of aromatic powder three times a day ; 3. Of half a grain of protochloride of mercury at night ; 4. Of a scruple of the sulphite of soda every three hours, which was subsequently increased to half a drachm ; 5. Of creasote mixture ; 6. Of a naphtha mixture ; 7. Of bismuth and aromatic powders ; and 8. Of pills of calomel and opium. These different kinds of treatment, some of which, especially that of the sulphite of soda, had been continued for several weeks without intermis- sion, seemed to have produced no good effect. November llth. — During the last four days, he has vomited every night, four hours after dinner, that is, about six p.m. The ejected matter presents the same yeast-like character formerly described ; but the sarcinas, though still abundant, are not so numerous. He complains of a great sense of distension, and a feeling of " working " or " bubbling " in the stomach shortly before vomiting. 5 -^cid. Bydrocyan. dil. m. xviij ; Syrup. Aurant. § j ; Aquce § v. M., half an oz. three times a day. Nov. 20ih. — The hydrocyanic acid checked the vomiting till last night, when it returned with more violence than ever. Nov. 24t/i. — Vomiting stiU continues regularly every day. Omittatur Mist. Acid. Hydrocyan. '^, Liquor. Pota^ss. 3 ss; Aquce § vss. Two taUe-spoonfids to be taken every four hours. Dec. 2d. — Alkaline mixture again checked the vomiting, which, however, returned last night to a slight degree. Applicet Vesical. 4X5 Ejngastrio. Dec. 8ih. — Vomit- ing has once more returned daily smce last report. ]J Ti7ict. Ferri Muriat. § i. Sumat 3 ss ter in die ex aqua. Dec. I6th. — The vomiting has been again checked, but once more returned in a slight degree at one a.m. this morning. The matter ejected exhibits very little of the usual frothy scum, but consists of a brown liquid like coffee, with a few slu'eds of undigested food. It is of intensely acid re-action, and contains only a few sarcinte. The dose of the Acid Tincture has been reduced to M. XV. The diet during this period has been principally animal, porridge and vege- rUNCTIOXAL DISORDEES OF THE STOMACH. 437 tables invariably increasing his complaint. To-day he left the hospital to visit his friends in the countr\', expressing himself as greatly relieved. Commentary. — Tlie kind of chronic vomiting and dyspepsia here spoken of has been long known in Scotland, and was described by Cul- len as a form of pvrosis. It was supposed to be associated with the habit of largelv consuming oatmeal as a principal part of the diet ; but its real pathologv was unknown. In 1843 Mr. Goodsir discovered in the ejected matter from the stomach, in a case of this kind, organized forms, which, from their resembling a wool pack, he denominated sarchue. He considered that they were of a vegetable nature, and by multiplying fissiparously, give to the contents of the stomach the appearance of yeast, which ts also known to be dependent on the development and growth of vegetable structures. The occurrence of these sarcinse in the stomach of course explains their frequent presence in the foeces, although whether thev are ever developed in the intestines is unknown. In two cases I have seen them in the urine, when they were uniformly smaller in size than the sarcince ventriculi. They have also been discovered by Virchow in an abscess of the lung; and I have recently seen them in the juice squeezed from an oedematous lung. The origin and exact mode of development of these structures are unknown ; but their pre- sence is no doubt the real cause of the chronic vomiting and other symptoms of the individuals affected ; and the cure of the disease will depend on the use of such means as are capable of insuring their de- struction and preventing their return. It is obvious, however, that the means which destroy or check vegetable growths on the external surface of the bodv (see Favus), are not applicable to the mucous lining of the stomach. "Besides, we do not know whether these parasites grow in an exudation poured out on the mucous membrane, or are developed onlv in a fluid. Ao-ain, it it- very possible that, on being introduced from without, the conditions necessary for their development may be depen- dent on particular kinds of ingesta — a view which derives support from the facts observed in the case before ns, namely, that the sarcinaj were alwavs increased by farinaceous kinds of food. On all these points, however, we are as yet ignorant, and our efforts at cure hitherto have not so much been directed to cutting off the sources of growth, as to destrovins: the sarcinse after it has proceeded to a certain extent. With this viewit has been imagined, that the sulphite of soda would destroy them, bv causing, on its union with the gastric juice, the extrication of sulphurous acid, which is so destructive to vegetable life. This remedy has consequentlv been given, and, not unfrequently, with success ; but in the present case it was of no benefit. Subsequently a variety of medi- cines Avere administered, several of which succeeded in checking the vomiting for a time. Indeed, it was remarked that the mere circumstance of chano-ing the medicine was sufficient to stop the vomiting for several davs, when it returned and continued as before. Of all the numerous remedies tried, the Tr. Ferri Muriatis seems to have done most good. The following case offers a remarkable contrast to the one just given, for, although of some standing, it was rapidly cured by the sulphite of soda. 438 DISEASES OF THE DIGESTIVE SYSTEM. Case LY.* — Dys2)epsia — Vomiting of fermented matter containing SarcincB. History. — Christina Torrence, vet. 18, servant — admitted July 11, 1853. For the last three j^ears has been suftering from more or less pain in tlie stomach, loss of appetite, and occasional vomiting, generally soon after meals. The ejected matters have always been very acid, and have varied in appearance with that of the food taken, which, for the most part, consisted of tea and porridge, with ver}' little animal food. She is thin, and her general strength has been much reduced. She has taken all kinds of medicines, and has been treated homoeopathically for some time without the slightest relief Progress of the Case. — On admission she was ordered bismuth and aromatic powders, which slightly alleviated some of the sj^mptoms. On the 14th, however^ there was vomiting of a brown frothy fluid, to the extent of § iv, which, on micro- scopic examination, was demonstrated to contain numerous sarcinaj. A scruple of Sulphite of Soda was ordered to he taken three times a-da]]. On tlie 2 2d vomiting again returned, but the rejected fluid contained no sarcinaj. From this time all pains ceased, other symptoms disappeared, and she was dismissed quite well July 28th. ORGANIC DISEASES OF THE STOMACH. Case LYI.f — Chronic Ulcer of the Stomach — Recovery. History. — Janet Grant, sii. 30, married — admitted 14th November, 1852. She stated that she enjoyed tolerably good health till twelve months ago, when she had an attack of hsematemesis, which returned on three successive days early in the morning. The vomiting was preceded by a sense of weight and uneasiness in the epigastrium, nausea, dimness of sight, and feeling of syncope, which actually occurred on one or two occasions. After vomiting took place, she generally suS'ered from severe griping pains in the bowels until they were opened. The stools were often of a dark brown colour. The quantity of matters ejected from the stomach varied from one to two pints, and contained coagula of blood. She has been twice received into the Infirmary, and on both occasions dismissed much relieved. After January 1852, she continued in good health, and was able to follow her usual occupation till the 3d of November, 1852, when the hsematemesis returned, having been preceded by the symptoms already enumerated. On this occasion there was less blood than formerly ; but the vomited matter still contained numerous bloody coagula. She had no recurrence of vomiting for eight days, but remained very weak, and was confined to bed. On the 11th November she passed by stool some matters like slimy tar. Since then she has frequently vomited, sometimes as often as three or four times a-day, a quantity of matter consisting principally of dark-coloured blood. Tlie pain in the head, epigastrium, and between the scapulse, has increased since that time. Symptoms on Admission. — On admission, tongue moist, slightly loaded ; appetite bad ; food is rejected from the stomach almost immediately after being taken ; pain and tenderness in the epigastrium on pressure; slight tenderness over the whole abdomen, which becomes much distended after taking food. Bowels rather costive ; no blood in the stools at present, and no blood corpuscles in the vomited matters when examined by the microscope. Urine normal. Other functions normal. * Reported by Mr. Joseph Johnston, Clinical Clerk. •)• Reported by Mr. F. M. Russell, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 439 B Sulph. Magnes. ^ss; Acid. Sulph.dil. I'l; Infus. Eosarum § viij. Sumant. §ij, et repehint. eras jnane. 5 Acid. GaUic. 5 i; Fidv. Opii gr. iij. M. et divide inpulv. xij. Sumai unum tei- in die. Progress of the Case. — November \^th. — Had some vomiting to-day, but no blood. Still considerable pain in epigastrium. Bowels freelj' moved by medicine ; stools very dark in colour. Xov. 17th. — Omitt Acid. Gallic. 5 Bismuthi albi 3 ss. Fidv. Opii gr. iss. M. et div. in pulv. vj. Sumat unum ter in die. Farinace&u-s diet. Nov. ISih. — Complains of burning pain at lower part of the sternum; former pain in epio'astrium somewhat easier; no vomiting since the 16th; bowels open; stools still of a dark colour ; great thirst ; tongue loaded and coated with brown fur in centre : with bad taste in the mouth. Nov. 20th. — StiU considerable pain and tenderness in epigastrium, which is now referred to one spot about the size of a crown piece ; bowels confined; pulse 75, natural. Applicentur hirudines iv epigastric. Kep)etat. mist, cathartic, si opus sit. Nov. 23d. — Complains still of pain m epigastrium, which was slightly relieved by the leeches; has had no return of vomiting; bowels open. Applicet. Vesical (3 x 2) epigastric. Nov. 2(ith.—Fa.m in epigastrium considerably relieved since the application of the blister. Still bad appetite and sour taste ui mouth. IJ Carb. Potass. 3 i- ^'v. in pulv. xij ; sumat unum ter in die. Dec. 9th. — Pain in epigastrium much reUeved, and only returns at intervals, and in much less degree than formerly. She now takes her food weU; bad taste in mouth gone; bowels still costive; pulse 80, of good strength. Dec. Uth. — Her former stomach symptoms have entirely disappeared. Dismissed. Commentary. — The vomiting excited on taking food, tlie lia?niatemesis, and the local pain increased af the epigastrium on pressure, indicated the presence of an idcer in the stomach, which, by opening blood-vessels, had several times catised extravasations of blood. Before I saw her, an astringent mixture, with gallic acid, had been ordered to check the ten- dencv to hemorrhage. For this I substituted quietude, a farinaceous diet, "to be taken insraall quantities at a time, fi-equently repeated, and powdeis of white bismuth and opium, to check acidity and relieve pain. The pain not subsiding, six leeches were ordered to the epigastrium, fol- lowed bv warm fomentations, and subsequently a blister was applied there, the result of which treatment was gradual abatement, and at length complete disappearance of all her symptoms. Case LYII.* — Chronic Ulcer of the Stomach — Cure. History. — Mary Reed, set. 38, married — admitted December 20th, 1852. She states that about four years ago, having been exposed to cold and wet, she was seized with shivering, followed by severe pains in the epigastrium, with uneasy sensations in the lower part of the abdomen, resembling labour pains ; these were accompanied by thirst, loss of appetite, sickness, and vomiting. These symptoms disappeared, but re-occurred at intervals up to December, 1851, when she had a more severe attack than before, and since then she has always been complaining more or less of the same thing. About three months ago, she felt as if something gave way in the left hypochondrium, and nearly fainted. She immediately afterwards vomited about a tea-cupful of blood; this took place four or five times during the night; but the last time the ejected matters were paler and more watery, having somewhat the appearance of finely grated carrots. The loss of appetite, thirst, pain in epigastrium * Reported by Mr. F. S. B. F. de Chaumoat, Clinical Clerk. 440 DISEASES OF THE DIGESTIVE SYSTEM. and bowels, with frequent severe headache, have continued up to the present time. She has had no return of the hrematemesis, but generally vomits her food about half an hour after it has been taken. Symptoms on Admission. — On admission, she has a pale anasmic appearance. The tongue is furred, appetite bad, pain in epigastrium and distension, with a sense of load at the stomach after meals, which continues till relief is aftbrded by vomiting, which comes on generally in about half an hour. She complains also of pain in the left hypochondrium ; has no uneasy sensations in the bowels, but habitual costive- ness, for which she has been in the habit of taking laxative medicine. She has been much troubled with laalpitation, but the heart sounds and impulse are normal ; pulse 96, small, and rather soft; micturition normal; urine of a pale colour, sp. gr. 1022, with slight deposit, showing phosphates under the microscope. Catamenia now present. She does not sleep well, has slight headache and occasional vertigo, with muscss volitantes, pain in lumbar region, but no tenderness over spine. Other func- tions normal. To re^nain quiet in bed. Farinaceous diet in small quantities. To have the hoivels gently opened. Progress op the Case. — December 23d — Bowels moved since last report ; complains of much pain in the epigastrium ; has had no vomiting of blood since admission. Applicent. hirudines iv part, dolent. et postea foveatur. Omitt. alia. IJ Lactis Recent. § xii. ; Aq. Calais § vj M. To be taken as a drink when thirsty. Dec. SOth. — Continues somewhat easier; complains still of occasional pain in stomach ; appetite rather improved ; less thirst. Bowels very costive. Jan. Uh. — Complains still of severe pain in epigastrium, with nausea, but no vomiting. Tongue rather furred. It has been found that the patient has been getting up and walking about after the visit, and has taken some beefsteak, contrary to orders. 5 Pulv. Scammon. et Pulv. Jalap, a a gr. x. M. Ft. pulv. hora somni sumend. Jan. Gih. — Bowels well opened, tongue much cleaner, feels better, and slept well during the night. To have rice diet. Has been complaining again of pain in stomach ; tongue furred, but moist ; appetite rather better ; slept well during the night ; bowels open. Jan. 9th. — Has been rather sick to-day, and vomited a little during the night for the first time since admission She still complains of pain in epigastrium. AppUcet. Vesical. (3 x 2) part, dolent. Jan. 12th. — Has been much relieved since the application of the blister, and exjjresses herself as feeling a great deal better. Tongue moist, and cleaner than before ; less thirst ; appetite improved ; bowels still costive. Jan. 20th. — Dismissed cured. Coynmentary. — This case in all its essential features is very similar to the former one, with the exception that vomiting, instead of occurring immediately after taking food, came on half an hour later. TIjc same treatment was pursued, but was not so carefully followed out, for it was ascertained that she was continually getting out of bed, and committing indiscretions, which caused returns of the symptoms. Case LYIII.* — Chronic Ulceration and Perforation of the Stomach — Peritonitis — Limited Pneumonia with Gangrene — Abdominal Abscess, simulating Pleurisy — Death. History. — Evina Clark, set. 29, single, housemaid — admitted December T, 1852. Froju the age of fifteen, she has had more or less derangement of the functions of the stomach, as exiiibited by frequent vomiting of greenish matters, not pre- * Reported by Mr. F. S. B. F. de Chaumont, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 441 ceded by am^ nausea. She attributes her complaint to a severe stomach disease at the age of fifteen, which confined her to bed for some months. Two months ago the vomitings became more frequent, and have continued worse than usual ever since. She has been in the habit of taking very large quantities of bi-carbonate of soda, sometimes even as much as 1 oz per day. On the day before admission, she took a dose of castor-oil, and this morning (Dec. 7) she rose at five o'clock to stool, then returned to bed. At half-past five, she again rose to see what o'clock it was, and again returned to bed and fell asleep without having experienced any pain. About six o'clock she awoke with severe pain in the epigastrium, and a feeling of faiutness. Her mistress, on being summoned to her bedside, administered to her half a glass of brandy in some hot water. Immediately after this was swal- lowed, the former pain became excruciating; the abdomen was then fomented with hot water, and medical assistance sent for. The medical man ordered warm bran poultices to be applied, which somewhat relieved the symptoms ; three hours afterwards the pain again becoming violent, one drachm of tincture of opimn was admbiistered, and she was sent to the Infirmary. The catamenia have always been regular. Symptoms ox Admission'. — On admission she was in a state of extreme depres- sion, the surface cold, face livid, pulse 108, almost imperceptible ; and the house- clerk administered a draught which was at hand, composed of S}). Ammon. Arornat. rain, x ; Sp. ^ther. Sulph. min. xv ; Sol. Mur. Mmph. min. xx ; Aqv.ce § ss. Warm fomeaiations to the epigastrium were also ordered. "When first seen at the hour of visit, she complained of intense pain in the abdomen, especially in the epigastrium and left hj-pochondrium, which was increased by pressure. The tongue was slightly furred in the centre, but moist. She had great thirst, no nausea ; bowels had been freely opened at five o'clock that morning. Heart sounds normal ; pulse 136, the strength having much improved since the draught, which caused no in- crease of the pain. Is evidently under the influence of opium. All the other func- tions are normally performed. To have immediately an enema of beef-tea with an ounce of brandy. The warm fomentations to be continued. Progress of the Case. — In the evening the pain was dimiaished to a feeling of soreness; pulse 129, small; lividity efface and depression continued; surface cold ; no rigors. Has had, at intervals of three hours, four enemata of beef-tea, T\-ith an eg%, two containing an ounce of brandy, and two with one drachm of laudanum. She has also been sucking ice to relieve her thirst. December 8th. — There has been profuse sweating during the night; face is still pale; pulse 126, weak and thread}-; acute pain continues on pressure below ensiform cartilage. The abdomen is tense and tympanitic, but the tenderness is slight ; considerable flatulence in stomach ; febrile symptoms well pronounced. IJ Bismuthi albi, gr. xviii ; Pulv. Opii gr. iii. M. fiantpiil. vi. One to be taken every six hours. The nutritive and anodyne enemata to be continued. Dec. 9th — She vomited yesterday afternoon, 3 p.m., about a pint of green fluid, and at the same time passed a fluid foeculent stool. Slept a little during the night. To-day she is somewhat refreshed, but the symptoms are the same as yesterday. Dec. lOth. — Yesterday evening, the epigastric pain having increased, and extended into left hj-pochondrium, six leeches were applied, followed by warm fomentations. To-day pain and tenderness continue; pulse 120, improved in strength. Six more leeches to be applied. The anodyne and nutritive enemata to be continued. To svxk ice to relieve the thirst. Dec. Wth. — Bowels were open shortly before the visit ; pulse 128, full ; tongue dry; thirst continues ; but appetite is returning. Tenderness of epigastrium and abdomen has nearly disappeared. To have beef-tea, by the mouth, in table-spoonfuls at a time, and occasionally toastand- water to relieve the thii'st, Dec. IWi. — The beef-tea produced a disagreeable but 442 DISEASES OF THE DIGESTIVE STSTEil. not painful sensation in tiie stomach, but there has been no vomiting. Pulse to-daj 128, of good strength ; feels much easier, and can turn herself more freely in bed. There have been two foecal evacuations since yesterday. Dec. \%lh — She has no pain ; pulse 1 28, of moderate strength. To have a little toasted bread soaked in beef-tea. Dec. \4th. — The toast and beef tea occasioned uneasiness and tightness in the epigastrium and both hypochondria, foUowed by dyspnoea and general restless- ness, but no pain. The bowels were opened twice during the afternoon and evening. To-day there is tenderness over the right hypochondrium ; febrile symptoms have again returned; pulse 132, rather feeble. Six leeches to be applied over the tender part. To have enemata of brandy and beef-tea every iivo hours. To suspend the administration of food by the mouth. Dec. loth. — At the evening visit yesterday the febrile symptoms had greatly increased; thirst excessive; tongue dry and cracked ; abdominal tenderness much relieved by the application of the leeches. To-day the febrile symptoms continue ; face is flushed ; and, on being interro- gated, she states that she had a rigor and feeling of cold yesterday afternoon. On percussing the chest posteriorly, there is dulness over lower third of right lung, with double friction murmur and cegophonic vocal resonance; on the left side also slight dulness inferior! y, wnth crepitation during inspmation ; pulse 132, feeble. The enemata, which have been continued at intervals, are no longer retained. Inter- Tnittantur enemata. To have a Utile calf ^s-foot jelly by the mouth, alternated tvith a table-spoonful of clear broivn soup every tvjo hours. ^ Solutionis tartratis anti- inonii, Z iij ; Potassce aceiatis, 3 ij ; Sp. aetheris nitrici, 3 v ; aquce, 3 V. M. Fiat onistura. A table-spoonful every four hours in tioo or three iabk-spoonfuls of ivaier. Dec. IGth. — Yesterday evening there was great exhaustion and feebleness; the mixture tvas suspended; and a table-spoonful of vnne was ordered every tivo hours. To-day no tenderness over abdomen, but the dyspnoea and the physical thoracic signs continue ; febrile symptoms still strongly marked ; pulse 140, soft and vibrat- ing; there is much flatulence. At her own request, she was aWovced fifteen grains of the bi-carbonaie of soda. To continue the jelly and broivn soup, vnth half an ounce of sherry every hour. Dec. 11th. — Feels better to-daj' ; urine loaded with lithates ; flatulence has been relieved by the bi-carbonate of soda. Dec. 18th. — Xo change. To have milk and lime-vjater to drink. Dec. I9th. — Complains of increased paiia in inferior portion of right side of chest, where there is stQl dulness and loud friction. Some dyspnoea. Si.v leechct to be applied. Dec. 20th. — Pain was relieved by the leeches, but the dyspnoea and physical signs on both sides of chest continue. Blister, 4 by 3, to be applied over lower portion of right lung poster iot'ly. Dec. 21st — Has had copious sweating during the niglit ; otherwise the same. Dec. 22d. — Much weaker ; pulse 136, small and weak ; lithates have disappeared from the urine ; great dyspnoea. 5 ^P- -^th. Kit. § ss ; Tinct. Colchici, 3 ij ; Aquce, § v ; a table- spoonful every four hours. To have an enema of beef-tea and egg ; and rice, with beef-tea, by the mouth. Dec 23d — Is free from pain ; general symptoms unchanged ; pulse 124, weak ; slight subsultus tendinum ; appetite capricious ; prefers arrow- root to rice. Dec. 2oth — Complains now of diarrhoea. Haheat Enema, c. Tr. Opii min. ±1. Dec. 26fh. — Diarrhoea continues; early this morning took the following draught: — 5 Sol. Mur. Morph.m.'s.v; Tinct. Catechu, 3ss; Syrup). Limonum., Zj-^- No change in the febrile symptoms, dyspnoea, or the pulmonarj'- physical signs ; has no pain; pulse 124, weak; skin clammy; states that she felt very cold during the night. Dec. 27th. — Diarrhoea continues. To have an enema of starch and opium. Dec. 28/7i.— Diarrhoea has ceased; dyspnoea and febrile symptoms increased; no pain; face pale and anxious. Dec. 29th. — Evidently weaker ; breathing laboured ; pulse 140, weak and thready ; countenance of a yellow waxy tinge. There was profuse sweating this morning; other symptoms unchanged. Dec. SOth. — She ORGANIC DISEASES OF THE STOMACH. 443 continued to sink, and died tliis morning at 3 a.m., death having been preceded by repeated vomiting of dirty brownish-green matter. Sectio Cadaveris. — Thlviy-thrce hours after death. Head not examined. Thorax. — Two drachms of clear serum in the pericardium ; heart healtliy ; the right kmg healtliy, but its lower lobe and the diaphragm on that side were con- siderably pushed upwards by an abscess containing nearly a pint of pus, situated above the liver and below the diaphragm : the left lung also healthy, with the exception of a gangrenous ulcer, the size of a shilling, in the centre of the lower lobe inferiorly, where it rested on the diaphragm. This ulcer presented a brownish, broken up, sloughing surface, and was surrounded by red hepatization, occupying the pulmonary substance to about the extent of a hen's egg. Abdomen.— On reflecting the integuments, a considerable quantity of pus escaped from the abscess above alluded to on the right side, immediately below the diaphragm and above the liver. This abscess contained nearly a pint of pus, and was situated in a circumscribed pouch formed by the diaphragm above, the liver below, the peritoneum anteriorly and externally, and false lymph of considerable tenacity internally. Lymph also glued these parts and the small curvature of the stomach together. On reflecting the integuments, the anterior wall of the abscess was removed, and so the pus escaped. The stomach, transverse colon, and coils of intestine in the superior third of the abdomen, were all glued together by bands and flakes of lymph, which, though of tolerable tenacity, were gelatinous in con- sistence, and could readily be torn through by the fingers. In the left hypochondrium there was a layer of this lymph half an inch in thickness, softened, purulent, and gangrenous in the centre, situated above the spleen, and communicating, by a sloughened opening, with the ulcer and hepatization in the lung formerly described. On cutting open the stomach, in the line of its large curvature, there flowed out a dirty, greenish-brown, grumous liquid, containing coagulated masses, apparently of milk, tinged of a dark-red colour by port wine. In the posterior part of the stomach, about its centre, was observed an oval ulcer, the size of a flve-shilling piece, with smooth, thickened edges, and surrounded by puckered folds of the mucous mem- brane, which was otherwise healthy. The ulcer was adherent to the pancreas behind, which constituted its base ; but the adhesions round its superior half were composed of the same gelatinous lymph as has been previously alluded to. On dis- secting the ulcer from its attachments, it was seen to have completely perforated the coats of the stomach, although the opening behind, viewed on the serous surface, was not above the size of a shilling. On removing the intestines from the pelvis, flakes of purulent lymph were observed between several of the coils and on the serous membrane of the pelvic cavity. AU the other organs healthy. Commentary. — All tlie facts connected with this case were obtained witli great accuracy, and left us in little doubt, from the commencement, that we had to treat a chronic ulcer of the stomach, which, on the morning of the day she was admitted, had perforated the organ, and induced the violent pain she complained of. The peritonitis, which may have been induced by the perforation alone, was undoubtedly auo-mented by the brandy and water administered to rally her from the state of collapse into which she was thrown by the immediate effects of the accident. On entering the house also about five hours after slie became ill, a stimulating and anodyne draught was adminis- 444 DISEASES OF THE DIGESTIVE SYSTEM. tered by tlie clerk to rouse lier from her depressed condition. As this was followed by no increase of local pain, but bv improvement of the vital powers, we may fairly conclude that the practice, though highly questionable, ft'as not productive of injurv. Nothing, indeed, is more natural on the sudden occurrence of violent pain in the epigastric region with a feeling of syncope, than to have recourse to stimulants, for perforations of the stomach are rare occurrences, and it is not every one who at such a moment, even among the profession, has sufficient coolness and discrimination to detect the real nature of the disease. Hence, why so frequently these perforations are fatal, not so much from their own natural results as from the stimulating reme- dies administei-ed, which pass through the aperture into the abdominal cavity. Indeed, had not brandy and water been given in this instance, there is every reason to suppose that the perforation might not have occasioned much mischief, for it occurred early in the morning, before breakfast, and long after her evening meal, and consequently when the organ was empty ; and, besides, it is to be observed that such perforations have a great tendency to become re-closed by the rapid formation of fibrous lymph round their edges. In this case, however, extensive peritonitis was alreadv occasioned when I first saw her, and the subsequent treatment was directed — 1st, To prevent the intro- duction of fuTther matters into the stomach ; 2d, To rally her from collapse by stimulating and nutritive enemata; and 3d, To conduct the inflammation to a favourable termination by local fomentations and opiates largely administered in the form of enemata, and subsequently in pills by the month. This treatment was attended with apparent success, so that on the fifth day nourishment was cautiously adminis- tered by the mouth, and also with tolerable benefit. On the eighth day, however, rigors appeared, followed bv fever, which was atti'ibuted to a pleurisy on the right side, where increased thoracic dulness was discovered inferiorly, with loud friction and oegophony. Circumscribed pneumonia evidently also existed on the left side, as indicated by crepitation. This formidable complication was attempted to be relieved by gentle salines, and topical bleeding bv leeches. It was soon appa- rent, however, from the appearance of dyspncea and other symptoms, that there was now little hope of recoverv, and notwithstanding the liberal administration of stimulants, the patient sank on the twenty- third day. Dissection exhibited exactly what was anticipated with regard to the stomach and peritoneum, but showed that the signs of the presumed pleurisy were occasioned by an abscess, which, by pushing up the diaphragm and occupying the lower portion of the thoracic space on the right side, had given rise to all the physical signs of pleuritis. On the left side there was limited pneumonia, as was expected, the lung communicating by a gangrenous idcer in the diaphragm, with the lymph exuded above and around the spleen. The edges of the ulcer of the stomach were firmly united to the pancreas, so that the patient undoubtedly died from tlie extensive peritonitis. ORGANIC DISEASES OF THE STOMACH. 445 Case LIX.* — Clironic Ulceration in the Stomach — Perforation occasioned by a Fall{?) — Jiecovei'y. History. — Barbara Ferguson, servant, aged 51 — admitted Januar}- 6, 1853. States that she enjoyed excellent health till about eight years ago, when she first began to complain of her stomach — suffering from pain of a cutting or grinding cha- racter, always worse after taking food. Her appetite has all along continued good, but she often experienced considerable thirst ; has never had nausea or vomiting. She believes that she has been getting worse lately, but has had no distinct exacer- bation. On January the 4th instant, stepping upon a chair, her foot slipped, and she fell with the stomach across the back of it. She was immediately seized with intense pain in the epigastrium, rapidly extending over the whole abdomen. She did not faint, and was still able to speak, but had to be carried to bed. The accident occurred about 9 P. M , three hours after she had taken any food, which had consisted of some coffee, with a few mouthfuls only of bread. She was immediately ordered a one-grain pill of opium, which was to be repeated every four hours. On the next day, as the acute pain still continued, four leeches were applied to the epigastrium, followed by warm fomentations. She has had nothing by the mouth except the opium pills, up to date of admission. Symptoms ox Admissiox. — On admission she appears very weak and nervous, and in a state of partial collapse; the countenance is sallow; pulse 100; weak: heart sounds normal ; no headache, but a feeling of vertigo on attempting to rise or change her position ; tongue clean, moist ; no nausea or vomiting ; appetite gone ; considerable thirst ; pain in epigastrium, which, with the whole abdomen, is exces- sively tender on pressure ; she has had great dysuria and pain on micturition ever since the accident. All the other functions are normal ; ordered to have no food by the mouth, hut an enema of beef-tea, with the yolk of an egg, immediately, to befolloived in two hours by an opiate enema, with 40 minims of tincture of opium ; to be kept quiet, and not to get out of bed. Progress of the Case. — January 1th. — TTas almost free from pain yesterday evening, and felt altogether much better, having slept a good deal during the after- noon. The beef-tea enema, with yolk of egg, has been repeated at intervals of four hours, and she had another opiate at 4 a.ji., after which she slept well. To-day she feels easier ; pain, or rather tenderness in epigastrium somewhat diminished ; and consi- derable pressure may now be exerted without causing uneasiness. She has stUl thirst; tongue dry; very httle inclination for food ; pulse 1 00, soft. Jan. Sth. — Was considerably easier last night, and expressed a desire for some food; the pulse was of better strength, 90. To-day is still improving ; complains of no pain when lying quiet, but still pain on pressure in epigastrium ; she expresses fear and pain when other parts are touched, but not to the same extent; pulse 95, of moderate strength. She has had the beef-tea, etc., enemata as before, with an opiate enema every 10 or 12 hours — to have beef-tea, and milk by the mouth, in table-spoonfuls at a time, repeated every five minutes if the 2'>atient desires it. Jan. 9th. — Felt rather uneasy after taking the beef-tea and milk, which occasioned a sense of '"working " in the stomach. An opiate enema was ordered in about two hours, and in the evening she expressed herself as free from uneasiness, and rather refreshed from the beef-tea. To-day she feels not quite so well, and her general appearance is more depressed. She has con- tinued the beef-tea, but has had an egg and beef-tea enema t^\ace a day in addition ; pulse 88, of good strength ; bowels have not been open since admission ; to have a warm icater enema, with an ounce of castor oil, followed, if necessai-y, by an opiate one. * Reported by Mr. F. S. B. F. de Chaumout, Clinical Clerk. 4-i6 DISEASES OF THE DIGESTIVE SYSTEM. Jan. 10th. — Felt rather weak and exhausted after bowels were opened; the opiate enema was administered two hours afterwards, and she has felt better since ; had some tea, with a little toast, by the mouth this morning ; takes beef tea for dinner, but cannot eat rice or any farinaceous food ; no bad effects have followed tak- ing food by the mouth ; pulse 88, of good strength ; little pain complained ofj and she can now sustain considerable pressure on epigastrium without suffering. Slept less last night than before; urine clear, sp. gr. 1020, contains phosphates. Omit the enemata. Jan. 2iih. — Since the last report she has been doing well, and gradually gaining strength. Dismissed. Commentary. — Many cases are on record of evident perforations of the stomach, which have been cured by judicious treatment, and the one just narrated seems to me to be an instructive example of this favourable termination of tlie lesion. The symptoms at the commencement were very lilie those of Case LVIIL, but were induced by a blow on the epigastrium instead of coming on after straining at stool. Violent pain, tenderness on pressure, and collapse were the immediate effects. For- tunately, I saw the patient immediately after the accident, and took care not to administer brandy, or stimulating draughts. A grain of opium in the form of pill was administered every four hours, quietude enjoined, and complete abstinence insisted on. Xext day the local pain continued, and on the following morning I sent her to the Intirmary. Xourisliment was administered by enemata, and on the fourth day was cautiously given by the mouth, and no untoward symptom ensued. From this time she slowly recovered. Of course we have no positive evidence that there was a perforation in this case. For eight years, however, she had been sub- ject to severe attacks of pain in the stomach, increased on taking food, but there had been no vomiting. It is possible, that the blow may have been sufficiently strong in itself to induce the pain and subsequent symptoms, although, from all the inquiries I could make, it did not appear to be so. One of her fellow-servants indeed maintained that it must have been trifling. Wherever anatomical evidence fails, there must be more or less uncertainty hanging over the history of those cases which recover; but, taking all the circumstances into consideration, I cannot help thinking that had brandy and water been given in this as in the former instance, there is every chance that here also fatal peritonitis would have been occasioned. From wliat I have observed of post-mortem examinations in the Royal Infirmary of Edinburgh, it does not appear to me that chronic ulcer of the stomach is a common disease here. Without having made any exact calculation, nothing positive can be said, but I do not think that the disease exists in more than 3 per cent, of those examined ; whereas in the Copenhagen and some German hospitals, it is said to vary from 6 to 13 per cent.* This frequency of it has been thought to be dependent on habits of intemperance and particular diet ; and, if so, we might have anticipated that the habit of drinking raw whisky would have rendered it more common in Scotland than it appears to be. Its morbid anatomy was first admirably described and figured by Cruveilhier.f The ulcer is * See an able Memoir on the subject by Dr. Brinton. London, 18.57. \ Anat. Pathologique. Liv's x. et xx. ORGANIC DISEASES OF THE STOMACH. 447 chronic, of circular or oval tbni), generally varying in size from afourpenny to that of a crown piece, having an abrupt, slightly thickened margin as if it had been punched out, and an indurated smooth base. It may be shallow or deep, and frequently perforates all the coats of tbe stomach, in which case the external is larger than the internal aperture. It has a great tendency to contract adhesions by its external borders to neigh- bouring viscera, more especially the pancreas, immediately over which, in the posterior wall of the stoniach, the ulcer is most commonly situjited. When it occurs in the anterior wall, it less readily contracts adhesions, and therefore is more likely to induce perforation. The ulcer may heal at any period of its progress, leaving a cicatrix, which varies in appearance according to the amount of tissue previously lost. Sometimes there is a mere scar, at others a stellate puckering. Occasionally there is a dense thickening, with rigid folds, causing contractions in one place, and pouches in another, "and this contraction may even be circular, causing a stricture of the organ. Mmeral deposits are now and then found adherent to the cicatrix. The three leading symptoms of chronic ulcer of the stomach are pain, increased on pressure, vomiting after taking food, and haimatemesis. Of these, the last is the most important in a diagnostic point of view, because its presence renders certain, what would otherwise only be conjectural. The disease, however, may exist without as yet having so injured a blood- vessel as to occasion hemorrhage. Hence the symptoms of chronic ' dyspepsia, with vomiting after food and fixed pain, if long continued, should invariably give rise to the suspicion of an ulcer, and lead to an appropi'iate treatment. The remedies I have found most efficacious, in simple chronic ulcer of the stomach, are quietude, careful regulation of the diet, bismuth and opium pills or powders, and sometimes warmth, at others cold applied locally. It may frequently be observed that the mere coming into a hospital and remaining quietly in bed has a favourable eftect in modify- ing the distressing symptoms. I have also remarked that those patients who are always getting up and walking about sutfer much more than those who remain in bed, especially at the commencement of the disease. Hence, repose in an easy position should be enjoined. The diet should consist of farinaceous pulpy substances, occasionally mixed with beef-tea, or milk, given in small quantities, frequently repeated. If the stomach will not tolerate the food warm, it should be given cold. When, despite this treatment, vomiting continues, it is best to suspend all nourishment for a day or two, and give nutritive enemata. As the patient gets better, the amount of solid food should be very cautiously increased. Thirst is a distressing symptom in such cases, and is best allayed by allowing ice to dissolve in the mouth slowly, or sipping, at intervals, milk and lime- water, mingled in equal proportions. The pain is alleviated best by bis- muth and opium, combined in the form of pill or powder. Sometimes local warmth, but more frequently pounded ice, mixed with salt in a bladder, applied over the part, will give relief. Two or three leeches, or a counter-irritant, may succeed when evei'ything else fails, and should be tried. Quietude and^ suspending all ingesta for a time, I believe to be the best remedies for hemorrhage, and where exhaustion from want of food exists, nutrient enemata, with wine, must be administered. ^^ hen a 448 DISEASES OF THE DIGESTIVE SYSTEM. perforation occurs, I have already pointed out tlie great importance of avoiding the giving of stimuli by the mouth (Cases LVIII. LIX.), and have stated the practice which should be perseveringly followed, namely, the administering of opium in the form of pill, quietude, avoidance of purgatives, and nourishing at first by enemata, and then cautiously by unirritating substances, given in small quantities by the mouth. Case LX.* — Cancer of Stomach, Pancreas, and Mesenteric Glands — Cijstic Atrophy of Right Kidney. History. — Thomas Gaffney, get. 50, married, a labourer — admitted November 24, 1856. Stales that up to twelve months ago he was ia good health, but since that time he has been troubled with pyrosis and occasional vomiting, with diminished appetite. Three months ago, feeling much pain in the epigastrium, he noticed that he had a tumour in that region. It was very sore, continued to increase in size, and became more and more painful. At present he is very emaciated, and suffers severe pain in whatever position he places himself Symptoms on Admission. — Teeth and gums dry ; tongue dr}', whh a longitudinal fissure down tlie centre. Thirst only occasionally felt. Has no appetite. Has no diflQculty in swallowing ; but complains of constant pain in the epigastrium. It is not distinctly increased on taking food. The food cannot be retained on bis stomach, coming up in mouthfuls from an hour to an hour and a half after ingestion. The vomited matter is described as resembling in colour coffee grounds. On examining the epigastrium in the mesial line, two inches below the ensiform cartilage, and three inches above the umbilicus, there is felt a small tumour about the size of a walnut of an irregular margin superiorly. The convex surfiice looks outwards and down- wards. It may be moved upwards and to the riglit, but not downwards or to the left. In left half of epigastrium, over a space of two square inches, there is dulness on percussion, and on palpation, a deep-seated strongly-resisting tumour is felt, with a distinct margin to the riglit side. It appears to pass upwards under the superior part of left hypochondrium, where percussion gives forth a comparatively dull resonance. Percussion elsewhere over abdomen, tympanitic. Over the hepatic organ and over the tumour there is great tenderness on percussion. Occasionally the tumour is felt more distinctly, and is then rough and nodulated. The chest is barrel-shaped. Percussion is unusually resonant. Respiration is feeble anteriorly and is harsh posteriorly, the expiratory murmur being prolonged. No dyspnoea. Sputum scanty. Prsecordial region unusually resonant on percussion. Transverse dulness, two and a quarter inches. Cardiac sounds healthy, but feeble. Apex of heart cannot be felt. Pulse small and weak, 68 per minute. Sleeps but little. Urine normal. The diet is io be carefully regulated ; small quantities of nutritive food and wine to be taken at frequent intervals. A mixture of snotv and salt put into a bladder is to be applied over the tumour. To take two of the folio-wing pills every night : — IJ Morph. Acet. gr. iss. ; Conserv. Rosar. gr. xij. Fiat massa in pilulas sex dividenda. Progress of the Case. — December \st. — The local apphcation of cold has afforded him considerable relief, so much so that he does not like to be without it. He is unable to take a sufficient amount of aliment, and is gradually getting weaker. Dec. ith. — The pills at night continue to lull his pain. His diet consists of strong beef-tea, three half-pints per diem ; bread and milk ; milk and rice pudding ; with six ounces of wine. Patient always vomits after eating, however httle, and conti- nues to sink. Dec. 5th. — Died at 10.30 a.m. * Reported by Mr. "William Guy, Clinical Clerk. OEGAN'IC DISEASES OF THE STOMACH. 449 Sectio Cadaveris.— Twenty-eigld hours after death. Abdomex.— Permission could only be obtained to examine the abdomen. On opening the stomach it was seen to contain a considerable quantit.v of yellow pulta- ceous s°ubstance, being half digested food tinged with bUe. The pyloric orifice was compressed by a mass of cancerous exudation, seated in the smaller curvature, and projecting into the stomach ; this mass was about 5 inches in diameter, rounded at the margins ; nodulated internally with two projecting portions, so situated as to act as valves in front of the pyloric orifice, through which a finger could be easily passed behind them. The thickness of this mass was in one place two inches, gra- dually diminishmg towards the margins to half an inch. The tissue was friable, easily breaking do^vn under the finger, but not yielding cancerous juice. The pan- creas was generally healthy, but an inch of the duodenal extremity was involved in the cancerous tumour. The cardiac orifice, which was half an inch from the margm of the cancerous tumour formerly described, was quite healthy, as was the rest of the stomach not involved. Several mesenteric glands in the neighbourhood of the pancreas were enlarged, nodulated, and filled with cancerous exudation. Ante- rioriy the stomach was strongly adherent to a portion of the liver, which below, over the tumour described, felt hard and nodulated. In the position of the right kid- ney was a cyst, the size of the human head, containing yellow serum. Internally it presented a smooth serous surface, here and there interrupted by circles and frag- ments of circles leading into pouches. Some of these openings were perfectly circu- lar, with smooth abrupt margins, and were about the size of a fourpenny piece ; others were about the size of a half crown or five shilling piece. Here and there, on the surface of the serous membrane, were corrugated indurated lines with black calcareous plates upon them, the result of cicatrizations. Externally the pouch was smooth, covered with shreds of cellular tissue ; at its mferior portion was an indura- tion, measuring two inches in length, and being cut into four, was found to consist of cortical renal substance about one sixth of an inch in thickness. Immediately behind this renal substance was a cyst, communicating with one of the pouches previously described, about the size of half a crown. No trace of tubercular struc- ture could anywhere be seen. A portion of lung was also removed about two inches square ; it was spongy throughout, but presented gelatinous-looking masses, about one-sixth of an inch in diameter, scattered through its substance. They could be squeezed and compressed between the fingers, but had a certain amount of firmness. On section they pre- sented a smooth surface of grey colour. Microscopic Esamixatiox. — The cancerous mass in the stomach presented cancer cells in all stages of formation, with granule cells here and there embedded m masses of molecular substance. The mesenteric and epigastric glands on being cut presented a fragile surface, from which a glutinous substance could readily be scraped. This contained, when examined microscopically, large cancer cells multi- plying endogenously ; here and there granule cells, with a few filjres and numerous molecules. The rounded masses m the lung were of the same structure. Case LXI.* — Colloid Cancer, with Perforating Ulcer of Stomach — Peritonitis. History. — James Douglas, ret. 55, a porter — admitted Sept 15, 1854. About fourteen weeks ago, being previously quite healthy, he began to experience a burn- ing pain in the epigastrium, more severe after taking food, and also a sensation as of * Reported bv Mr. Robert Rhind, Clinical Clerk. 29 450 DISEASES OF THE DIGESTIVE SYSTEM. a ball rising in his throat. For three weeks he continued to work, but gradually grew worse ; eight weeks ago, he vomited, for two daj^s, dark coloured matter like coffee grounds. Has since been troubled with pyrosis, has lost his appetite, and become weaker and thinner. Symptoms on Admission. — Is greatly emaciated. Tongue moist, slightly furred ; appetite bad ; no d3^sphagia ; feels pain in the epigastric region constantly of a burning character, more severe after taking food ; no vomiting, but has eructations of a thin watery fluid. The epigastrium feels hard on palpation ; in the region of the umbilicus there is a distinct tumour stretching across the abdomen; movable under the integument; not very tender to the touch. Bowels habitually costive. Has no cough. Pulse 56, weak. Urine not coagulable, of sp. gr. 1019. Other systems normal. Progress of the Case. — September IbiJi to October 9ih. — The patient has been treated by the administration of antacids, bismuth and magnesia ; by the injection of nutritive enemata ; b}^ occasional opiates at night ; by suitable aperients, and careful regulation of the diet. He has gained no strength ; is indeed much weaker ; at present he has a burning sensation along whole course of the oesophagus. Oct 13th. — This morning experienced acute pain in the abdomen, which is now dis- tended, and generally painful on pressure and deep inspiration. Pulse 84, pretty firm. Eight leeches were applied to the abdomen, followed by warm fomentations, and opium in grain doses. Oct. lith. — Has had much vomiting, this morning, of dark cotfee-coloured fluid ; pulse is feeble, and extremities are cold. While eating his dinner to day, he fell forward, and immediately expired. Scctio Cadaveris. — Twenty-two hows after death. Body very much emaciated. Thorax. — Thoracic organs normal. Abdomen. — On opening the abdomen a large quantity of dark coloured fluid was found, in which were suspended flakes of white lymph. To the inner surface of the peritoneum pieces of soft recent lymph were attached, but it was quite free of small round nodules. The stomach and the intestines were loosely glued to each other, and to the parietal peritoneum, by soft lymph. The fingers alone were sufficient to separate the bowels. On examining attentively the anterior surface of the stomach two or three small perforations could be detected. The largest was nearly an inch long on the outer surface of the stomach, and corresponded to an ulceration about 2-^ inches in extent internally. The pyloric half of the stomach was transformed into a large, intensely hard, glue-like mass, and was about the size of a cocoa-nut, or two closed fists. On opening the stomach, the mucous membrane, towards the car- diac extremity, was perfectl}^ sound, but at the pyloric end it had undergone ulcera- tion at several points, especially near the smaller curvature and the pylorus. The pyloric orifice was of sufficient diameter to admit easily the little finger. The pan- creas, liver, and surrounding organs were healthJ^ The texture of the growth was as hard as cartilage, and creaked under the knife, but on section presented the usual characters of colloid cancer. (See p. 136.) The mucous membrane of the intestines was perfectly healthy. The other abdominal organs were normal. Microscopic Examination. — The colloid cancer presented the characteristic structure described and figured p. 136. Commentary. — An indurated swelling in the epigastric region, pain and vomiting after food, are the usual symptoms of cancer in the stomach ; and they were all present in the two cases just noticed. There was, besides, ha^matemesis, indicating ulceration in Case LX., and, in ORGANIC DISEASES OF THE STOMACH. 451 addition, sudi^n pain, with peritonitis, in Case LXI., pointing out the occurrence of perforation. The vomiting did not appear so soon in the last as in the first case, and it will be noticed that in it the pyloric con- striction was not great. On the other hand, ulceration was more exten sive with pyrosis, and led to perforation with fatal peritonitis. The atrophy of the right kidney, which was converted into a fibrous sac, had not apparently in Gaffney produced any complaint whatever during life. All the symptoms observed in this man, with the exception of hsematemesis, may be produced by a tumour outside the stomach, as well as by disease of the stomach itself, pressing on the organ, and nothing is" more difficult (if indeed it be ever possible) than to diagnose the former condition from the latter, which, however, occurs rarely. (See p. 474.) In manv cases the lesion hitherto described as scirrhus of the pylorus or stomach seems to be a simple hypertrophy of their muscular and fibrous coats, which may or may not be associated with cancer of the neiofhbouring glands. A simple stricture of the pylorus may in this way produce more or less thickening of the stomach, in consequence of the chronic vomiting excited by it ; or by increasing the muscular power Wimi^xM Fis. Fig. 393. Fis. S99. necessary to overcome the obstruction, just as happens in the intestines, bladder, and other hollow viscera, when the parts below them are stric- Fig. 397. Appearance of the gastric glands in recent catarrh of the stomach. Their external outline is irregular, and they are filled with enlarged secreting cells. — {Wilson Fox.) Fig. 398. Commencing cystic formation in a gastric follicle, which is constricted in some places {b, c,) and swollen at others, a. Shows the thickening of the limitary membrane, and d, slight fatty degeneration of the epitheUum. — {Wilso/i Fox.) Fig. 399. A cyst in the pyloric portion of the stomach, composed of a fibrous envefope, and contents wholly composed of cylindrical epithelium. At a, the limitary membrane of the gastric glands commences to be thickened ; and at b, their contents have undergone the fatty degeneration, so common in chronic catarrh. — ( Wilson lox.) 340 diam. 452 DISEASES OF THE DIGESTIVE SYSTEM. turcd. (See Figs. 146 to 148, p. 153.) I have recorde(4, four cases of this kind in my work on "Cancerous and Cancroid Growths." (Edin- burgh, 1848, p. 46, et seq.) In all such cases it is observable, that the same emaciation and cachectic appearances are present as in instances of undoubted cancer — a circumstance which is attributable to the impeded nutrition of the body rather than to a supposed cancerous diathesis. On this account I have long ceased to place any confidence in the so-called "cachectic appearance" as diagnostic of cancer, attribut- inp- it either to imperfect nutrition, or to wearing down of the body from excessive pain. This cachexia is often present in many other forms of morbid growth, and frequently absent when the disease has been proved to be cancerous by a microscopic examination. Of all forms of cancerous disease, that of the stomach is perhaps the most distressing; it cuts off the supply of nourishment which should enter the system, and induces (in addition to the wearing-down pain) loss of sleep, loss of blood, and more or less constant vomiting. Our duty in such cases is to relieve and support the system ; and to this end opiates in large doses, nutritive enemata, careful regulation of the diet, and ice allowed to dissolve in the mouth, are the best remedies. A local frio-orific mixture, as recommended by Dr. J. Arnott, and the application of a few leeches to the epigastrium, are also occasionally beneficial. In Case LX. the cold application was of marked service. The histological changes which occur in various disorders of the ft w v~Z i^vg [ i ]^^^^4^^y d Fig. 400. Fig. 402. stomach were first investigated by Dr. Handfield Jones, who lias described and figured the appearances presented by the follicles, their contained cells, and other minute structures under a variety of circum- Fig. 400. The gastric glands in chronic catarrh of the stomach, the breaking down of tlie upper portion being proljably due to post mortem change, a, A mass of pig- ment ; 5, h, free fat drops ; c, tliickened limitary membrane ; d, d, d, complete fatty degeneration of the epithelium. — {Wilson Fox.) 240 diam. Fig. 401. Chronic catarrh of the stomach, with hypertrophy of the fibrous tissue between the glands. The section has been treated with acetic acid, which exhibits more distinctly the nuclei of the nervous tissue, and gives a cloudy appearance to the follicular epithelium. — ( Wilsoyi Fox.) Fig. 402. Fatty degeneration affecting the upper layer of the follicular epithelium, c, and fibrous connective tissue, a, a, producing erosion of the surface ; h, fatty degeneration of the epithelium and sub-mucous fibrous tissue. — ( Wilson Fox.) 340 diam. DISEASES OF THE LIVER. *i53 stances.* There may be hypertrophy and atrophy of the sohtary glands; atrophy of the glandular tubes; fatty degeneration; wasting and black discoloration o"f their epithelial contents ; fibroid thickening, etc. His researches have been for the most part confirmed by Dr. F. Schlapferf and Dr. Wilson Fox.J The latter observer has added some important facts connected with chronic catarrh of the stomach, thicken- ing of the limitary membrane, and cystic degeneration of the glands. Dr. Habershon,§ as well as Dr. Fox, points out the rapid changes which take place in the glands of tlie stomach after death, and the great cau- tion therefore required in forming conclusions, when examination of the minute structure is too long delayed. As a guide to the clinical student and practitioner, I give the more important morbid changes which have been observed in the gastric glands, from the excellent representations of Dr. Fox. Dr. Jones has the great merit of having laid the founda- tion for a clinical history of these lesions, although the observations are as yet far too few to enable us to connect them with diagnosis and treatment at the bed-side. From what is known on this subject, I must refer to the works I have named, hoping that before long these researches may be extended by clinical histologists, and uUimately lead to a more exact knowledge of the dyspeptic and organic diseases of this important organ. DISEASES OF THE LIVER. Notwithstanding the obscurity which still rests upon the functions of the liver, the progress of histological pathology has tended to make ns better acquainted with the minute changes which occur in many dis- eases of the organ. The nature of fatty enlargement, of cirrhosis, and of the disintegration of cell-texture following obstruction of the bile- ducts, is now understood, but much reseai'ch is still necessary. A care- ful comparison of the structural changes observed in the liver after death, with the clinical history and symptoms observed during life, is what is o-reatly desired to advance our knowledge of hepatic diseases. This knowledore, however, can scarcely be hoped for, until medical men, and especially such as practise in the East, become efficient histologists. It is the application of therapeutics to these diseases, however, and a correct appreciation of the class of remedies called cholagogues, which, in the present state of medicine, requires most to be determined. Such an investigation necessitates physiological, histological, and chemical knowledge, added to good powers of clinical observation. But of all the subjects of research now open to the young investigator, I know of none in which patience and exactitude, based on a scientific rather than an empirical svstem of inquiry, is likely to yield more useful results. * Pathological and Clinical Observations respecting Morbid Coaditions of the Stomach. London, 1845. \ Yirchow's Archiv. B. 7, p. 158. 185-1. X Medico-Chir. Trans, of London. Vol. XLI. 1858. § On Diseases ol the Alimentary Canal, p. 52. 8vo, bound. 1857. 45-i DISEASES OF THE DIGESTIVE SYSTEM. Case LXII.* — Acute Congestion of the Liver — Hepatitis ? — Eecovery. History. — Thomas Eussell, ffit. 38, labourer at a gas work — admitted January 26th, 1855. States that about three weeks ago, after indulging freely in the use of ardent spirits, he experienced general shivering and pain in the right hypochon- drium, with tinnitus and a sense of faintness. Subsequently he lelt pain in the right shoulder, and at length was obliged to leave off work. His comrades, who went home with him, told him that he looked yellow in the face. At night he became very hot. He returned to his work on the following day, and continued at his employment for a fortnight, but was very weak, and suffered much from tlie pain in his side, and in the shoulder. Since then he has been confined to bed, under medical care, applying counter-irritants locally, and taking pills which have made his mouth sore. Symptoms ox Admission. — On admission, he complains of pain in the right hypo- chondrium and right shoulder, in the former of which situations it is permanent and increased by pressure, while in the latter it is only occasional. The tongue is covered with a moist, white fur; the breath has a mercurial foetor; the gums are painful; appetite good. Bowels open. Pressure and percussion over the liver painful. Yer- tical hepatic dulness 4i inches. Pulse 72, soft. Sleeps little in consequence of the pain. Urine normal ; no jaundice. Other functions well performed. To apply six leeches to the 7-ight hypochondrium, and the parts afterwards to he fomented. To take two com- pound rhubarb jiills every night. Progress of the Case. — February 1st. — The leeches and fomentations have in no way benefited the pain, which to-day is as severe as on admission. Bowels still open. Stools darker than formerly, but healthy. Feb. 3d. — Since last report all pain has left him ; he declares himself to be well, and at his own request was discharged. Case LXIII.f — Acute Jaundice — Albuminuria — Recovery. History. — "Walter HaUiday, set. 51, tailor — admitted July 6th, 1857. States that he has generally been a temperate man, although, occasionally, he has taken spirits moderately. On the first of this month, when working below an open window, he was suddenly seized with rigors, followed by great thirst, heat of skin, and headache. Next morning he went to work as usual, but was obliged to desist in the middle of the day, and go home. The rigors have returned occasionally ever since, and he has experienced obscure pain in the lumbar region. The skin became jaundiced on the second day of his illness, and the yellow tint has been increasing in intensity since. He has also occasionally vomited. Sy'mptoms on Admission. — The tongue is moist and covered with a whitish fur. No difiQcult}^ in taking food nor pain afterwards. No tenderness or pain in abdomen ; but feels a pain in the lumbar region, which sometimes darts round the right side towards the umbilicus. Appetite impaired. Bowels costive. Yertical dulness of liver, on percussion 4 inches. The skin over the whole body is of a deep yellow tint, dotted with spots of purpura the size of pin heads : but is cool and moist. The urine is deep coloured, hke Madeira wine. It is very albuminous on the addition of heat, and contains a large quantity of bile. Pulse 88, small and weak. Other organs healthy. 5 Potass. Acet. 3 ij ; Sp. jFther. Nit. f ss ; Aquce, § vi. M. One ounce to be taken every three hours. July Sth. — Bowels were freely opened yesterday in con- * Reported by Mr. W. J. Marshall, Clinical Clerk. \ Reported by Mr. W. H. Davies, Clinical Clerk. DISEASES OF THE LIVER, 455 sequence of a Calomel and Jalap powder which was given. Stools were fluid and of a dark brown color. Progress of the Case. — July 9(h. — On microscopic examination of the urine, it was seen to contain numerous casts, with delicate walls, having in their interior large epithelial cells. Passes more urine than formerly. To Imve pidv. Doveri gr. x. at bed time, folloiued hy a diaphoretic draught. Tioo compound rhubarb pills to be taken every night Julyl2th. — The urine and skin are now of a healthy colour. The pulse, how- ever, remains low, and the patient weak and languid. Nutrients, tonics, and wine, with gentle exercise, were now given, under which he became thoroughly well, and was discharged August 3d. Commentary/. — These two cases are examples of the slighter forms of hepatic disease, although what that disease is it becomes no easy matter to determine. In the first case we have pain, increased on pressure in the right hypochondrium, and in the right shoulder, ushered in by rigor and febrile symptoms. On percussion the liver is found to be slightly enlarged. After coming into the house the disease subsides in a few- days. The leeches and fomentations did not seem to alleviate the pain, but the purgative produced a more healthy intestinal discharge. In the second case there was little local pain, but evidently something had caused interference with the secretion of bile. The skin was deeply jaundiced, the stools of a dark clay or leaden colour, and the urine loaded. This condition was also ushered in with rigors and febrile symptoms. Ptyalism was produced before he entered the house, without occasioning the slightest benefit. On the contrarv, the disease increased. But under the action of diuretics and diaphoretics, to fa\'our secretion of the bile already absorbed, as well as of mercurial purgatives to rouse the duode- num and upper parts of the alimentary canal to a more healthy action, he rapidly recovered. Whether the disorder in these cases was congestive or inflammatory, or both, cannot be determined. ^Yhatever the lesion, it so operated in the one case as to induce great pain, and in the other to obstruct the gall ducts and occasion jaundice. In jaundice the diminished excretion of bile by the intestines is at- tempted to be compensated for by its entering more or less largely into the secretions of the kidney and skin — especially the former. In intense forms of the disease, casts of the renal tubes are frequently seen in the urine, their contained cells deeply tinged with bile pigment. Frerichs has carefully described and figured the histological changes which occur in the kidneys and skin under such circumstances. These consist in the accumulation of yellow, brown, and green pigment, in the cells of the ttibuli uriiiiferi, and not unfrequently the pigment is infiltrated through the parenchymatous tissue of the kidney. He has even seen it assume the form of hard coal-like masses, which must have greatly inteifered with the functions of the organ. In the skin the deeper layer of round epidermic cells contains a yellowish or deeply brown granular pigment, and the secreting cells of the sudoriferous glands are similarly affected, but never to the extent which may be observed in the kidney.* Such observations indicate the importance of diuretics and sudorifics in the treatment of jaundice, in addition to the means usually adopted for stimulating the upper part of the ahmentary canal. * Frerichs, Klinik der Leber Krankheiten, 185S, pp. lOT-8, and plate I. 456 DISEASES OF THE DIGESTIVE SYSTEM. Case LXIV.-)- — Impaction of a Gail-Stone in the Common Bik-Dud — Jaundice — Death. HiSTOET. — Mary Duncan, jet. 36, married — admitted November 24, 1851. She has lived in India some time, and returned only a few months since. Three weeks ago, when recovering from a severe attack of lumbago, she experienced great pain in the epigastric and right hj'pochondiiac regions. This Avas ushered in by rigors and feverishness, and lasted three or four days. Its severitj- then dimuiislied ; but jaun- dice appeared, and has since become more intense. Symptoms on Admission. — On admission, the whole integumentary surface pre- sents a deep yellow colour. Pulse 100, full. The tongue is dry, with a dark-brown coat. There is a disagreeable taste in the mouth, impairment of appetite, but no nausea or sickness. The liver ou percussion presents the normal dulness of four inches on the right side. Pressure in the neighbourhood of the gall bladder elicits pain, and there is permanent soreness diffused over the anterior portion of the liver and epigastric region. The pain is not spasmodic in its character, nor more severe at one time than at another. The bowels are generally costive ; skin hot and dry, urine like porter, staining linen yellow, and becoming green, and then red on the addition of nitric acid. The abdomen is enlarged. She has had a child pre- viously, and saj's she is now six or seven months pregnant. The treatment consisted of purgatives {Pil. Rhei comp.); leeches and fomentations to the tender spot over the liver, and diuretics of acetate of potass and sp. oither. nit. Progress of the Case. — December M. — The bowels have been kept open by purgatives, and the stools have been well coloured with bile. Leeches have been applied tmoe, and the hepatic pain has been much relieved. She has also been taking small doses of tartrate of antimony, and muriate of morphia. The skin, however, continues dry, and is now more deeply tinged yellow than on her admis- sion. The urine also is still loaded with bile. To-day vomiting came on, and she rejects her food and medicine. Tlie lips and teeth are covered with sordes, and she complains of great languor and depression. Diuretics to be continued; a blister to the right hypochondriac region ; and a powder, containing four grains of calomel and one- third of a grain of opium^ to he taken every hour for six doses. The mercury produced no physiological action, although continued in smaller doses and at longer intervals for several days, assisted by mercurial frictions over the right hypochondrium. Dec. \lth. — ^There was slight diarrhoea, which was checked by an aromatic cretaceous mixture. Mercurials were suspended. On the 13i/i she was evidently worse ; the skin assumed a greenish hue ; she is very feeble, and passes her stools in bed ; pulse 120, small. On the 15!l/i, the skin assumed a tawny colour; the stools are passed in bed, are green, of a dark colour, and of a very offensive cadaveric smell ; great prostration of strength , urine still loaded with bile ; low delirium at night. Died on tlie 18^/i. Sectio Cadaveris. — Thirty hours after death. Thorax. — Thoracic organs healthy. Abdomen. — On opening the abdomen, bands of recently-exuded lymph are found firmly uniting together, the peritoneal surfaces of the gall-bladder, the anterior mar- gin of the liver, and a portion of the omentum, over an extent the size of the palm of the hand. On separating these adliesions, the gall-bladder and omentum were found so firmly united, that an aperture was formed in the former the size of a pea; * Reported by Mr. J. L. Brown, Clinical Clerk. DISEASES OF THE LIVEK. 457 through which a quantitj- of dark-green bile escaped. The hver was of its normal size, and presented externally a dark olive-green colour. On cutting into its sub- stance, the gall ducts were everywhere dilated and thickened. Some were distended into elongated cavities above half an inch in calibre, and they were all filled with thick dark-green bile. The tissue of the liver throughout was unusually soft, readOy breaking down under the fingers, and uniformly of the same olive-green colour as the external surface. In the common bile-duct, about half an inch from its duodenal extremity, a hard light-yellow gall-stone, the size of a small hazel-nut, was firmly impacted, the duct both above and below being somewhat thickened and dilated. No other gall-stones could be anywhere discovered. The uterus and rectum were adherent, and in separating them about a teaspoonful of yellow pus escaped. The vagina was shortened and constricted about two inches from the vulva, so as scarcely to admit a common quill. About an inch width in the vagina, on its inferior wall, was a round aperture, the size of a shilling-piece, with ragged edges, and com- municating with the rectum. On the superior wall of the vagina, about half an inch from the clitoris, was another rounded opening, about the size of a sixpenny-piece, into which the point of the little '"^ "^ " " ^oo finger could be pushed and passed into the bladder. The !. /^a natural meatus urinarius was occluded. „ ~' " Microscopic Examination. — On crushing a small o piece of the liver between glasses, and examining it under ~' ° O ° ° a power of 250 diameters linear, it was found to consist ^'" '*'^*'- of a multitude of iatty molecules and granules, with larger globules of loose oil. Many of the cells seemed to be broken down and disintegrated, but such as were entire were more or less distended with bile pigment. — Fig. 403. Commentary/. — The symptoms present in this case on admission, viz., the jaundice, local pain, the rigors, and fever, were indicative of obstruc- tion in the common bile-duct connected with some inflammatory action going on in the liver or its neighbourhood. Hence the topical applica- tion of leeches, and afterwards wai'm fomentations, were ordered. As the blood and urine were evidently loaded with bile, diuretics and purgatives were also given to assist the excretion of that product. These remedies proving of no avail, and the constitutional symptoms increasing, mercury, conjoined with opium, was actively administered, but failed to produce its physiological or any useful therapeutical result. After death, perito- nitis surrounding the gall-bladder and common duct was discovered ; but death evidently resulted from the poisoning of the system through the absorption of bile, the excretion of which was prevented by the firm impaction of a calculus in the common bile duct. The benefit of mer- cury in such cases, though sti'ongly recommended as a means of altering the constitution of the bile, appeals to me very doubtful ; for, supposing it to possess the eff"ect ascribed to it, and to act as an alterative and * cholagogue, its action in obstruction of the gall-ducts must be to distend them still furthei', and thus increase the pressure on the hepatic cells, and consequently the disintegration of the hepatic texture. Most of the examining class were in favour of the trial of mercury in this case ; and considering how uniformly it has hitherto been recommended by experienced practitioners, I did not think it right to deprive the patient Fig. 403. Disintegration of the hepatic structure following obstruction of the biliary ducts. 250 diani. 458 DISEASES OF THE DIGESTIVE SYSTEM. of any chance wliich miglit arise from its use. At the time, I expressed my want of confidence in its virtues, an opinion which the progress of the case fully justified. In the present state of science and art of medi- cine, there is no one point in therapeutics which so urgently requires thoi'ough re-investigation as the real value of the medical properties attributed to mercury. ' The effect of the long-continued over-distension of the gall-ducts on the liver was a partial disintegration of its cell elements, and an accu- mulation of bile in such of the cells as remained perfect. This lesion is remarkablv well described by Dr. Budd, in the third chapter of his work on the liver, where he treats of fatal jaundice. It admits of question how far this destruction of the hepatic cells may not, by impeding the secreting power of the organ, at length induce that condition described by Dr. Al- lison, where the biliary principles are not eliminated. It must, I think, be certain that jaundice, produced primarily, as in the present case, by a mechanical obstruction, must be kept up by the altered condition of the cell-structure afterwards induced. This case was instructive to all who observed it, with regard to a sup- posed pregnancv she laboured under. The abdomen was certainly some- what prominent ; but the investigation of the existence of this state was never gone into, for the simple reason, that it no way aft'ected the diag- nosis or treatment. When the woman was dying, however, the husband applied to me, with a view of ascertaining whether it might not be pos- sible to save the child. On this point I requested the opinion of Dr. Simpson, who, on examining the woman, declared her not to be pregnant. This circumstance then is an illustration of how women who have pre- viouslv had children may be deceived as to the existence of a subsequent pregnancy, and how important it is for the practitioner, as a general rule, to satisfy himself of the reality or falsity of such a state in all cases. When formerly delivered in India, she said instruments were employed, and that she sustained some injury. This account is rendered highly probable by the existence of the recto-vaginal and urethro-vaginal fistulse, and the remarkable vaginal stricture, found after death. Case LXY.* — Jaundice — Compression of the Ductus Communis Choledochus from a Cancerous Tumour, composed of Epigastric and Lumbar Glands — Occlusion of Cystic Duct — Enlargement of Gall Bladder — Cancer of the Pancrecbs — Biliary Congestion of the Liver — Cancej-ous Exudation into various organs — Slight Leu- cocythemia. History. — William Dodds, set. 23, ploughman — admitted December Stli, 1854. He states that four weeks ago he was seized with pain in tlie lower part of the abdo- men, accompanied by unusual eostiveness. Some days afterwards he commenced to vomit his food a few hours after taking it. The vomiting continued for a fortnight, and then suddenly ceased. But it returned about four days ago as before, and has continued up to the time of admission. Si'MPTOMs ON Admission. — The tongue is loaded with a thick white coat, but moist. Appetite bad. After taking food he has feeling of a great load and dis- tension m his stomach. No flatulence, but has frequent eructations of a watery * Reported by Mr. Robert Rhind, Clinical Clerk. DISEASES OF THE LIVEK. 459 fluid, which is neither acid nor of disagreeable taste. Usually vomits it about 4 o'clock, A.ir., and for some time afterwards experiences considerable relief; has con- stant severe pain and considerable tenderness over the epigastrium. A tumour can be felt towards the pjioric end of the stomach, of a rounded form. It measures two and a half inches vertically, its upper and lower margins being distinctly tangible, its lateral margins, however, cannot be determined. The hepatic duluess in the right hypochondrium was normal. All the other functions are healthy. Diet to be carefully regulated. Progress of the Case. — December 10th. — Has been much better since admis- sion, not having vomited till this morning at five o'clock. He then brought np a large quantity of brownish pultaceous matter, which, on microscopic observation, was found to consist of half-digested muscular fibres, starch and oil globules, and epithelial cells. Has considerable pain and tenderness in the epigastrium. Eight leeches to be applied, followed by tvarm fomentations. Dec. IStli. — There have been remissions in the epigastric pain, which, however, still continues. The vomiting also has not been permanent, having been suspended for two days by eating ice, and again on the 16th, by a morphia draught. The constipation has been relieved by domestic enemata. It was observed to-day for the first time, that the skin has a decided though very slight yellow tinge. I>ec. 23d— Since last report has expe- rienced great pain at times in the abdomen generally, for which he was ordered a draught at night with Tr. Cannabis Ind. 3ss. Six more leeches were also applied on the 20th, but without lessening his sufferings. There has been considerable fever, with thirst and loss of appetite. Iced Lemonade for drink, and tvarm fomentations to the abdomen, give most relief! Yesterday the jaundice was decidedly more pro- nounced, and has increased still more to-day. There has latterly been constant vomiting, shortly after taking food." He is more emaciated, and the tumour formerly alluded to can now be felt hard and nodulated through the integuments. The stools are of a clay colour, and the urine loaded with bile so as to resemble porter. Pulse 120, very weak. Vf. Pil. Opii vj. One to be taken immediately, and repeated in four hours if there be no alleviation of the pain. To have wine § iv daily, and ice to dissolve in the mouth. Continue the tuarm fomentations to the abdomen, and to inject slowly 5 iv of strong beef tea into the rectum. From this time he continued sinking. The skin assumed a greenish tinge. On the 2J:th he vomited blood, and passed black tarry matter by stool. Brandy and stimulants were freely administered, but he died Dec. 26th. Sectio Cadaveris. — Fifty -one hours after death. The body considerably emaciated. The whole surface, and all the tissues, includ- ing the cartilages, were stained of a greenish-yellow colour. Thorax. — Both lungs were emphysematous anteriorly, especially the left. Pos- teriorly they were engorged, and on section were cedematous, with scattered nodules of cancerous matter in their substance, of cheesy consistence, but occasion- ally very soft, and varying in size from a pepper-corn to that of a small hazel-nut. A continuous layer of cancerous matter also here and there surrounded the bronchial tubes From the universal predominance of bile-pigment, these cancerous masses closely resembled to the eye tubercular matter. Immediately under the upper part of the sternum, and over the ascending aorta, was a mass of lymphatic glands, about three inches long and two inches thick, of a fleshy colour and pulpy consist- ence, easily breaking down under the finger, and infiltrated here and there with a yellowish-white cheesy deposit, exactly resembling tubercle. The bronchial glands at the root of the lungs were greatly enlarged, and presented a similar 460 DISEASES OF THE DIGESTIVE SYSTEil. appearance. The heart was healthy. The ventricles contained semi-coagulated blood, the veins black fluid blood. ABDOifEX. — In the cavity of the peritoneum there was about 8 oz. of dark brown clear serum. The liver weighed .3 ll3s. 12 oz., was of a light olive-green colour, approaching to brown, soft in texture, and on section was seen to contain a few whitish yellow masses, varying in size from a millet-seed to that of a small pea, of tolerably firm consistence. The gall-bladder projected about an inch and a half below the lower margin of the liver. It was considerably enlarged, and was dis- tended with thick black bile. Tlie cystic duct was completely closed a little above its junction with the hepatic, which was quite free. The calibre of the common duct was much diminished; and although a probe could be pushed through it, it was evidently compressed by the tumour to be described immediately. The spleen weighed 5 oz , and was healthy, with the exception of a cancerous mass in its centre, about the size of a coftee-bean, similar to those in the lung. Surrounding the pyloric end of the stomach, and projecting from below the liver towards the left side, was an agglomerated, indurated, and nodulated mass of enlarged and can- cerous lymphatic glands, of the size and form of a cocoa-nut. This was the tumour which, during the life of the individual, was felt in the epigastrium. It pressed upon and completely occluded the ductus communis choledochus. The aorta passed through the left third of this mass, and was so compressed as scarcely to admit the little finger. On section, this mass presented very much the appearance of some specimens of pudding stone, consisting of rounded or oval yeUo wish- white masses, varying in diameter from J to 1^ inches, and united together by highly congested areolar tissue, of a deep purple colour, with here and there extravasations of blood in its substance. The affected glands were friable and easily crushed between the fingers, but yielded no juice on pressure. The mesenteric, mesocolic, and lumbar glands generally were similarly diseased. The right extremity of the pancreas was converted into a firm mass by cancerous exudation, and closely connected to the tumour just described, of which it formed an integral part. On opening the stomach, it was seen to contain a quantity of tenacious, brown, glairy mucus, closely coherent to the mucous membrane. Its walls at the pylorus were found thick- ened ; and from this point the thickening gradually diminished, until it ceased at a convex margin, somewhat irregularly nodulated, and elevated above the rest of the mucous surface. The diseased portion occupied about one-third of the area of the organ. The mucous surface covering it was of a dirty-white colour, and was ulcer- ated at one point with softened ragged edges over a space the size of a shilling- piece. The healthy two-thirds of the mucous surface was of bright rose-pink colour, from vascular congestion. The cut edge of the pylorus was a quarter of an inch thick, dependent on hypertrophy of the muscular coat to the extent of one- sixth of an inch, and of an infiltration of firm whitish exudation, in the submucous areolar tissue. The intestines, kidneys, and other organs, were healthy. Microscopic Examination. — The whitish-yellow masses in the lungs were prin- cipally composed of molecular matter, but with numerous delicate nucleated cells apparently forming. In the bronchial glands, the whitish-yellow matter was com- posed of a few cancer cells only, evidently in a state of disintegration, associated with multitudes of fatty molecules and granules. The fluid squeezed from the fleshy and pulpy matter from the same glands, contained, 1st, numerous round and oval nucleated cells, about one-thousandth of an inch in diameter ; 2d, many gra- nule cells of varying size; 3d, multitudes of gland nuclei; 4th, blood corpuscles; 5th, a large quantity of molecular matter. The pulp of the epigastric glands contained, 1st, large cancer cells, some containing three included cells ; 2d, a very few granule cells ; 3d, numerous molecules. The blood contained a decided increase of colour- DISEASES OF THE LIVER. 461 less corpuscles. The cells of the liver contained a quantity of biliary matter, giving them, under the microscope, a bright yellow colour. Commentari/. — The nature of this case was tolerably evident from the first ; the epioastric tumour, pain, and vomiting after taking food, indi- cated obstruction of the pylorus produced by a cancerous growth. Later, when jaundice appeared, it became clear that the common duct was obstructed. Treatment could, of course, only be palliative. On dissection, it was singular to observe the resemblance which the can- cerous masses in the lungs and in the glands bore to tubercle. Some persons who were present, indeed, judging from the youth of the patient, their friable consistence and yellow colour, maintained that the glands were scrofulous ; and it would have been difficult to undeceive them •without the assistance of the microscope. All the tissues were tinged of a deep yellow, and the hepatic cells were goi'ged with bile, so that the absorption of this excretion into the blood must have been very great. The insensible manner in which so much cancerous matter developed itself is worthy of observation, as it was only four weeks before admission that he experienced any inconvenience. Then came on the effects of obstruction — first, of the pylorus, and, secondly, of the common duct — from the combined effects of which lie died. Case LXVl.*— Jaundice— Cancerous Tumour of the Pancreas, comprising the Ductus Communis Choledochus— Dilatation of the Gall-bladder, and passage of Gall-stones into the Gall-bladder— Cancer of the Liver and Kidneys. History.— John M'Donald, ait. 50, tailor— admitted November 29, 1853. Four weeks ago he was seized with a gnawing pain in the epigastrium. On the 1.3th he was over- worked, and went liome mucli exliausted. On the following day, there was drowsiness, loss of appetite, and anorexia. On the 27th, the skin was slightly tinged yellow. He applied at one of the dispensaries, and was then suffering from intense grinding pain in the right hypochondrium. One of the clinical students who saw him there advised him to come into the Infirmary. Symptoms on Admission. — He has no pain, no difficulty in taking food, though it excites nausea. Tongue slightly furred; moist. No appetite. Considerable thirst. Vertical dulness of liver is 3f niches. No abdominal tenderness. No tumour to be felt in epigastrium. Bowels constipated. Stools of a dark green colour ; but he says they were white when tlie attack came on. Urine is of a dark brown colour, like weak porter, from the presence of bile ; unaffected by heat. Pulse 60, regular. Skin of a deep yellow colour. Other organs and functions normal. '^ Pit. Hydrarg. ; Pil. Hhcei Co. aa 3 ss. M. et divide in pil. xii. Two to be taken every night. Progress of the Case. — December 3d.— The stools are now of a lead colour. To have gr. v. of Pil. Hydrarg., and of Ext. Taraxaci every night Dec. lOth — Com- plains of acute grinding pain in the region of the liver. Bowels have not been open for some days. Skin of a deeper yellow. To have gr. v. of Pil. Bhcei Co. in addi- tion to the others. Dec. Uih—Had an asafcetida enema yesterday. The bowels have been well opened ; pain much relieved. Stools still of a lead colour. Omitiant. Pil. IJ Pil. Phcei Co. 3j; Calomel, 3j; Olei Cinnamomi, gutias iv. 31. et divide * Reported by Mr. Almeric Seymour, Clinical Clerk. 462 DISEASES OF THE DIGESTIVE SYSTE;M. in pil. xij. Two to be taken every night. Dec. lith. — Is now free from pain, but feels very weak. Stools of a dark green colour. Otherwise the same. Cannot take food. 5 Liq. Potasses 3 ij ; Sp. JSther. Kit. § ss ; Infus. Gentian. Co. § v. M. Two table spoonfuls to be taken three times a day. Dec. 11 th. — Much weaker. Takes no nou- rishment. Skin of a dark green tint. Tongue dry, and covered with a dark brown crust. Bowels open. Stools of a dark leaden tint. Pulse 120, very weak. To have I vj of wine. Dec. I9th. — Whisky has been hberally administered ; but he continued to sink, and died at two o'clock a.m. Sectio Cadaveris. — Thirty-four hours after death. Extreme jaundiced appearance of the whole body, and yellowness of all the tissues. Thorax. — With the exception of shght emphysema of the lungs, all the thoracic organs were healthy. ABDOiiEX. — On opening the duodenum, there was seen at the point where the common duct enters it, a tumour bulging inwards, and compressing the duct. The growth was the size of a walnut, and presented aU the characters of scirrhus. It was formed in the right extremity of the pancreas ; and the rest of the organ was indurated, and contained several small cysts filled with a gelatinous fluid. The por- tion of the common duct which passed through the tumour was an inch and a half long, and barely admitted a small probe. Behind the constriction, the common, cystic, and hepatic ducts were greatly enlarged, the common duct having a cahbre nearly equal to the size of the tliumb. The gaU-bladder was much enlarged, and distended with dark-coloured bile. It contained two small gaU-stones of bile pig- ment, but none could be found in the ducts. The hver weighed 3 lbs. 9 oz., was of a green colour, with the centres of the lobules congested. The bile-ducts were everywhere dilated throughout its substance. Scattered throughout the liver were white cancerous masses, varying in size from a pea to that of a hazel-nut. Similar small cancerous masses existed in the cortical substance of the kidneys. On open- ing the intestmes, a considerable quantity of black blood was found mingled with the foeculent matter, both in the smaU and large intestines. Other organs healthy. Microscopic Examination. — The cancerous masses in the pancreas, and hver, and kidneys, contained numerous characteristic cells. The hepatic cells were loaded with yellow bile, which became of a cherry-red colour on the application of Petten- kofer's test. They contained no fat. Commentary. — It appeared, fi-om careful examination of this man's case, that he had suffered from two attacks of grinding pain in the right hypochondrium, such as are commonly felt during the passage of gall- stones. After death, two biliary calculi were found in the gall-bladder, having all the appearance of those which are usually formed in the liver. It is almost certain, therefore, that the painful attacks were coin- cident with the passage of these calculi from the liver to the gall-blad- der, as their escape into the intestines was prevented by the constriction of the common duct, by the cancerous mass in the pancreas. Since tlie researches of Bernard as to the functions of the pancreas were made known, I have carefully sought, in a great number of cases, for the passage of fatty matter in the alvine evacuations, but in vain. In several instances of jaundice, such as the present, I have found the head of the pancreas diseased ; but in none of them did the stools pre- sent the characters described in the cases of Bright, Lloyd, Elliotson, and others. It is true that in this case the common duct Avas not abso- DISEASES OF THE LIVEK. 463 lutely obliterated, but it appeared to me that the pancreatic duct was so involved in the tumour, that its fluid secretion was incapable of passing. But as no special anatomical investigation was made in reference to this point, we are not entitled to suppose that the supply of pancreatic juice was entirely cut off". In other cases, however, where the common duct has been obstructed (Case LXIV.), or where, from disease of the head of the pancreas, the pancreatic duct has been obliterated (Cases LX. and LXV.), there has been no proof whatever that the fatty elements of the food have not been emnlsionized. Such fiicts indicate that the function attributed by Bernard to the pancreas must also be performed, under certain circumstances, by the alimentary canal alone, independent of that organ. Case LXY 11.*— Enlargement of the Liver— Ascites— Albicmmuria— Recovery. History.— David Harper, a3t. 30, painter— admitted into tlie clinical ward Feb- ruary 18th, 1852. Four months ago, was seized with diarrhoea and vomiting, whicli have continued more or less ever since. The hver was first observed to be enlarged in the beginning of December last, and it has gradually increased in size up to the present time. He has taken numerous remedies to check the diarrhcea and vomiting, but with little efl'ect. Symptoms ox Admission.— On admission, the liver is found to extend from one inch below the right nipple above to within an inch and a half of the anterior supe- rior spine of the ilium below— a depth of nine inches. From this point its margin could be felt ascending obliquely upwards to the most depending portion of the ninth rib on the left side, crossing about an inch above the umbihcus. There is distinct fluctuation to be felt throughout the rest of the abdomen, indicating ascites. In the right lumbar region the enlarged liver is tender on pressure. The abdomen measures 32^ inches in circumference at its widest part. Spleen of normal size. Tongue moist, slightly loaded. There has been no vomiting for some days, but the diarrlioea is very severe. Says he has frequently passed blood by stool. Skin not jaundiced, but rather dry. Kespiratory, circulatory, and other systems normal. IJ Pit. Plumb, et Opii xij. Sumat unam ter indies. Progress op the Case. — March ith. — Has had occasionally vomiting and diar- rhoea since last report, for which he has been taking at times the naphtha mixture, morphia draughts, and gallic acid. To-day the urine is somewhat scanty, and slightly coagulable on the addition of heat and nitric acid : spec. grav. 1024. $ Acetatis Potassce, 3 j ; »S/j. ^th. Nit. 3 ij ; Syr. Aurantii, § j ; Aquce, | v. M. Sumat 3 j ter indies. March I2th. — To-day the urine was ascertained with the microscope to contain numerous casts of the tubes and isolated epithelial cells loaded with fatty granules. The vomiting and diarrhoea continue. Habeat suppositorium opiatum octavo, qucique hord. April 6th. — The diarrlioea was for a few days somewhat checked by the suppositories, but gradually returned, and is now very severe ; the bowels having been opened twelve times yesterday. The urine has continued albuminous, and loaded with desquamative casts and fatty tubes. To-day its spec. grav. is 1007. There is now great debihty, and occasional stupor and drowsi- ness. May 11th. — The drowsiness has disappeared. For the last few days has been taking 3 j of the potass, bitart. with the mixture of acetate of potash and nitric aether, and he now passes a larger amount of urine, which is free of tubular casts The abdomen is less tense. About the middle of May the vomiting and diarrhcea * Reported by Mr. J. A. Douglas, Clinical Clerk. 464 DISEASES OF THE DIGESTIVE SYSTEM. first abated, and was soon after checked. In August his health was so much improved that lie was allowed to go out of the house for the benefit of air and exer- cise. He was re-admitted September I3(h, having enjoyed tolerable health in the interval, although the hepatic swelling is about the same size. He was now ordered, ^. Hydrarg. Proto-iodidi, gr. vj; Pulv. Opii gr ij; Ext. 2'araxaci, 3ss; Coiiserv. Rosarum, gr .v. fiant. pil xx. Sumat unam ter indies. These pills on the 20th produced salivation, when they were discontinued, and an astringent gargle was ordered. The abdomen now measures thirtj'-six inches in its broadest circum- ference. Oct. 25th. — Complains of oppression on walking, of shooting pains through the chest and abdomen. Ascites seems once more to be increasing. Tr. lodini to be painted over the abdominal surface. Nov. 2\st. — Since last report the liver has greatly diminished in size, and his complaints have ceased. The urine presents a slight hazy albuminous appearance on the addition of heat and nitric acid, but is voided in natural quantity. Dec. 13<7i.— The liver is now so reduced in size that its lower margin is only two inches below the false ribs in front, and one inch on the rio-ht side. All his functions are apparently healtliy, the urine healthy, and his strength appears perfectly re-established. Dismissed. \ Commentary. — The enlargement of the liver which existed in this man was probably simple hypertrophy, which, by pressing npon the large abdominal veins, caused ascites. It is worthy of remark, that it underwent a sensible diminution after the local application of Tr. of Iodine, having resisted mercurial action and various other remedies. The occurrence of Bright's disease, and the presence of numerous desqua- mative casts of the tubuli uriniferi, more or less loaded with fat, and of albumen in, with diminished density of, the urine, were considered for- midable complications. But here also, under the use of strong diuretics, the renal symptoms subsided, the casts disappeared, and the urine became perfectly healthy. He has since been seen by the clerks walk- ino- about the town, and has informed them that he is quite well, and carries on his occupation without any inconvenience. Case LXVIII.* — Fatty Enlargement of the Liver. History. — James Grant, ast. 29, blacksmith — admitted October 14th, 1851. His occupation consists of watching an apparatus worked by steam, in a room of elevated temperature ; he has no heavy labour, though constantly standing on his feet ; he drinks whisky to a large amount. Since September 1849, he has been three times in the house for various periods, from which he has been as often dismissed relieved. The liver began to enlarge two j^ears ago, and has been very slowly increasing ever since. Symptoms on Admission. — On admission, he labours under slight diarrhoea, having had two or tliree stools daily for several weeks past. He has, moreover, a dull heavy pain in the abdomen, extending to the lumbar region. The belly is evidently enlarged at its upper part, where a firm tumour exists, forming a protu- berance in the epigastric region. The girth of the abdomen at this place during expiration, is 34 inches. The hepatic dulness extends from two inches below the right nipple, down to a transverse line drawn one inch above the superior spine of the ilium. The whole of the right and part of the left hypochondriac regions are * Reported by Mr. W. M. Calder, Clinical Clerk. DISEASES OF THE LIVER. 465 dull on percussion. The tympanitic sound of the stomach is audible in front, the organ being evidently pushed forward by the enlarged liver behind it. The whole surface of the tumour feels smooth, and presents no tenderness. The splenic dulness measures 5^ inches vertically; skin dry; no oedema of the legs; general appear- ance pale and cachectic ; occasionally he has frequent desire to micturate, but the urine has alwaj^s presented its normal cliaracters; considerable breathlessness on exertion, but the lungs and heart, on examination, were apparently quite healthy; other functions well peribrmed. He was ordered a mixture containing the Iodide of Putimium, six grains of which were to be taken three times a day. Frictions with the Unguent. lodinii were also to be employed daily. Progress of the Case. — Towards the end of October, the bowels became reg-ular, and his general health was somewhat improved. Frequent micturition, with dis- charge of pus in the urine, now came on, which subsided in a few days. From this time, altliough the size of the liver underwent no diminution, his bodily strength gradually improved. He occasionally had slight return of looseness in the bowels, which was checked by appropriate remedies. The difficulty of breathing after exer- tion also slowly left him; and lie was dismissed greatly relieved, January 26th, 1852. Commentary. — Fatty liver was first shown by Mr. Bowman to depend on the secretion of a large quantity of oil, which is stored up in the hepatic cells. These cells are, under such circumstances, frequently enlarged, and contain oil varying in amount from a few granules to a large mass, which occupies the whole of their cavities. Not unfrequently livers, which to the naked eye appear healthy enough, may still be demon- strated under the microscope to con- Fig. 404. tain an unusual number of tat granules, and there can be little doubt that considerable variations may exist in this respect quite compatible with a state of health. Almost* all stall-fed animals that do not labour, possess a large amount of fat in their hepatic cells. It is only where the organ is much enlarged, altered in colour, and pressing upon neigh- bouring viscera, that its fatty degeneration can be said to interfere with the vital processes. Fatty degeneratiou of the liver has been observed to be very common in drunkards who are continually taking alcoholic liquids. Of 13 indi- viduals who died from DeliriuraTremens, 6 had very fatty liver, in 3 the organ contained little, in 2 none at all, atid in 2 there was cirrhosis (Frerichs). In such cases, the quantity of carbon taken in the form of spirits being too great in amount to be excreted from the lungs as car- bonic acid, and fi-om the liver as bile, is stored up in the liver as fat. In tropical climates, the same pathological condition comes on under differ- ent cii-cumstances. A high temperature, and a rarified atmosphere, indispose persons to take bodily exercise; and Europeans, instead of living according to the simple manner of the natives, too often continue Fig. 404. Hepatic cells in various stages of fatty degeneration. On the right of tlie tigure, yellow granular pigment is also contained in the cells, which were taken from a cirrhosed liver. -50 diam. 30 466 DISEASES OF THE DIGESTIVE SYSTEM. to consume the food habitual to them in their native country. But the excretory power of the lungs being, at the sante time, diminished, the excess of carbon in the tissues and food is thrown upon the liver, and there converted into fat. Dr. Macnamara* found that, among the first regiment of European Bengal Fusileers, during seven years, tlie morta- lity among the officers was 11 per cent., and among the men 80 per cent., so that the whole of the fighting men in the regiment were changed about once in every ten years. From the circumstance that the great majorit}^ of these men were young, healthy, and vigorous, when they left home, and other circumstances, he attributes the deaths to high feeding, indulgence in spirits, and to slothful habits, causing fatty degene- ration of the textures. The manner in which the livers of geese are made fatty at Strasburg is as follows : — The geese are confined in close cages, in a heated atmo- sphere, and largely supplied with food. Want of exercise and lieat diminish the respiratory functions, and cause that of the liver to be dis- ordered, and the result is an enlargement of the organ from accumula- tion of fat. In the case before us, the cause of the disease seems to have been exactly the same. A man is kept stationarv watching a steam- engine, in an elevated temperature, consuming his usual food, and indulg- ing in alcoholic drinks. Fatty liver is also common in cases of phthisis pulmonalis. Here the excreting function of the lungs is more or less interfered with, and the carbonaceous matters, not separated as usual by this channel, are stored up in the liver in the form of fat. The hepatic disease is especially observed in those consumptive patients who, while they are capable of assimilating a certain amount of food, are prevented by languor, breathlessness, or other causes, from taking exercise. According to Frerichs, of 117 cases of pulmonary tuberculosis, examined after death, there were 17 which presented fatty liver in the highest degree, whilst there were 62 others with the hepatic cells loaded with oil globules. On the contrary, in other diseases of the pulmonary organs, he found fatty liver to occur very seldom. This view of tlie pathology of fatty liver has been objected to on the following grounds: — 1st, That the connection between fatty liver and disease of the lungs is not general ; 2d, That there is no evidence that a fatty liver does not excrete bile as usual ; and 3d, That as a considerable portion of bile is absorbed into the blood to be excreted from the lungs, the liver must be considered as preparing material for these organs. Hence it is argued, that it would be a strange compensation if the func- tions of the liver were to be increased, while that of the lung is dimi- nished by disease (Budd). But if fatty liver be not always conjoined with diseased lung, it will be found associated with some circumstance which diminishes the function of that organ, in relation to the Avork it is called upon to perform ; for instance, the diminished exercise and great heat of tropical climates. Further, although it be granted that the liver may in health prepare carbonaceous matters for pulmonary excre- tion, it must be cleai', that if the lungs cannot accomplish this function, such matters must be thrown back or retained in the liver, and consti- tute a powerful cause of fatty degeneration of that organ. On the * Indian Annals of Medical Science, 1855, p. 170. DISEASES OF THE LIVER. 467 whole, therefore, we must regard excess of carbonaceous matters in the system, and the diminution of pulmonary action, as the chief causes of fatty degeneration of the liver; a view which has the merit of pointing out to us as remedies a diminished diet, a temperate climate, appropriat-e exercise, and an endeavour to promote the functions of the lungs and of the skin. There is another structural alteration of the liver, which, from its colour and general resemblance to bees'- wax, has been called " waxy,'' and sometimes " brawny " liver. This disease has been confounded with fatty liver, but an examination of their minute structure shows that the hepatic cells present a verv different character in this condition. Instead of being enlarged and filled more or less with oil globules, they are colourless, shrunken, and for the most part destitute of contents, and the nucleus disappears. (See Fig. 295.) I have previously described this lesion as one of the forms of albuminous degeneration. (See p. 214.) Its clinical history will be given under the head of Phthisis. (See case of Margaret Clark.) Case LXIX.* — Cirrhosis with Atrophy of the Liver — Ascites. History. — John Harper, xt. 28, farmer, from Caithness — admitted June 24th, 1852. Six years ago, after recovering from measles, his health was greatly deranged. He was weak, and perspired profusely at night, or when performing any unusual exertion. A short time afterwards, he was exposed to cold and wet, and he observed that the abdomen gradually enlarged, and dyspnoea supervened. On two occasions paracentesis abdominis was performed ; at the first operation a quart, and at the second a pint, of fluid was removed, without producing much relief He has had considerable pain in the epigastric region at times, and latterly the appetite has been diminished, and the bowels costiva SviiPTOMS ON* Admission'. — On admission, the abdomen is shghtly swollen, and evidently contains fluid. Round the umbilicus it measures 39 inches. Xo anasarca. The hepatic dulness extends three inches downwards on the right side, commencing two inches under the nipple. Tongue is furred ; appetite diminished ; no epigastric pain or uneasiness ; bowels irregular, but at present costive. There is slight dulness on percussion under the right clavicle, with harsh inspiration, prolonged expiration, and increased vocal resonance : urine scanty, depositing lithates. The other func- tions are well performed, and he appears to be a strong, well-nourished person. Progress of the Case. — The treatment consisted of diuretics {Sjx ^ther. Nit. and Tr. Digitalis) and sudorifics {Pulv. JDoveri) ; but feehug the confinement of the Hospital to disagree witli him after his usual active occupations, he insisted on going out, which he did July 6th. Commentary, — The diminished extent of the hepatic dulness, the ascites, and the chronic nature of the disease, point out this case to be one of cirrhosis. This morbid change in the liver consists of the forma- tion of fibrous tissue between the lobules of the organ, wherebv its secreting cells are compressed and atrophied. As a further result, the large venous trunks are also compressed, and their commencing ramifi- * Reported by Mr. John Matthews, Clinical Clerk. 468 DISEASES OF THE DIGESTIVE SYSTEM. cations so congested that effusion into, or dropsy of, tLe peritoneal cavity is induced. Notwithstanding the extensive organic changes which are frequently observed in this disease, danger is not so much to be appre- hended from them as from the ascites, which, by distending the abdomen and compressing the lungs and liver, so interferes with those important oro;ans as to destroy life. Case LXX.* — Cirrhosis with Enlargement of Liver — Hypertrophy of Spleen — Slight Leucocythemia — Jaundice — Constriction of Arch and descending Aorta. History.— James Kerr, ret. 28, a labourer — admitted July 22, 1852. This man first had jaundice, with swelling of the abdomen, between four and five years ago : and since then he has been several times in the Infirmary. The treatment has con- sisted of various alteratives internally, with the occasional application of the Tr. lodinii, bUsters, and leeches externally. The swelling, however, has continued to increase verj-^ slowly, and for the last two years he has been incapacitated from work- ing. The blood for some time has contained an excess of fibrin, and a slight increase of the colourless corpuscles; and he has been troubled at intervals with attacks of epistaxis and occasional diarrhoea. For two years past there has been an increased impulse, with a rough blowing murmur, loudest with the first sound under the manu- brium of the sternum. SYMPTOiis ON Anjiissiox. — On admission the hepatic duLness commences an inch below the right nipple, and extends down to the umbilicus, measuring twelve inches vertically. The splenic dulness reaches from the lower margin of the fifth rib to a transverse line drawn an inch below the umbilicus, and measures eight inches verti- cally. The liver presents a protuberance anteriorly, which extends in the form of a ridge, four inches broad, from the epigastrium backwards towards the false ribs. The girth of the abdomen over this ridge is 42 inches. The inferior border of the spleen and liver can be distinctly felt through the parietes of the abdomen. The heart's action and sounds are normal. An increased pulsation is distinctly visible at the root of the neck, and can be felt above the clavicles and under the top of the sternum. Here there is a loud rough murmur synchronous with the systole of the heart, and accompanied by a distmct impulse. There is a slight cough, with a little mucous expectoration, but auscultation and percussion of the lungs reveal nothing abnormal Urine rather scanty, high coloured, spec. grav. 1026, contains some biliary matter, and deposits on cooling a pretty copious pinkish sediment of lithates. The integuments and conjunctivae are still tinged of a light bile yellow colour. There is considerable tenderness over the Hver in the right hypochondi'ium. He says slight epistaxis returns about once a week. The bowels are open daily; no diarrhoea. After walking or unusual exercise oedema of the legs comes on. On examining the blood microscopically, the colourless corpuscles are not so numerous as when he was last in the house. Four leeches to be applied to the right hypochondrium. Progress of the Case — This man left the house in August. He was re- admitted November 9th, having in the interval suffered from an attack of pleurisy on the right side. Latterly he has been in the Dundee Hospital, and says that five weeks ago he passed considerable quantities of dark grumous matter from the bowels. In other respects his condition is the same as formerly reported. Xoiemier Wth. — Vomited about nine or ten ounces of blood. 29^/i. — Hematemesis returned yesterday afternoon with great violence, and at intervals he brought up in all 132 ounces of blood. His strength is now greatly diminished; pulse 104, full. The abdominal * Eeported by Messrs. Douglas and Dewar. Clinical Clerks. DISEASES OF THE LIVER. 469 swelling and aortic signs as formerly reported ; but the breathing is laboured, with dyspnoea at night, considerable cough, and muco-purulent expectoration. No dul- ness on percussion over lungs ; but sibilant and sonorous rales are heard at the base of the right lung on auscultation. From this period his general health evidently began to fail. Ascites first came on, followed by oedema of the legs and general anasarca. The dyspnoea became more urgent, with a sense of oppression in the chest, and there was occasional vomiting of blood. On the 21st of December there was considerable hematemesis, and discharge of blood by stool, which was followed by exliausting diarrhoea. lie died December 25th. Secfio Cadaveris. — Fifty-three hours after death. Body generally anasarcous. Thorax.— Extensive chronic adhesions between the pleura on the right side. On the left side about four ounces of serum in the pleural cavit.y. Lungs oedematous. Slight emphysema of the left lung anteriorly. Posteriorly both lungs congested, and here and there compressed. The ascending portion of the aortic arch was of normal size, but its transverse and descending portions, as well as the descending aorta generally, were unusually small in calibre, so that the little finger could with diffi- culty be introduced. In structure the vessel was healthy, but in consequence of this formation a pouch was formed immediately above the sigmoid valves. About two ounces of serum in the pericardium. The heart healthy. Abdomen. — About twenty ounces of serum in the peritoneal cavity. The stomach was about half full of brownisli-black blood, containing soft coagula. Mucous coat healthy. Brunner's glands much enlarged, about the size of millet seeds. The intestines everywhere healthy. Mesenteric glands slightly enlarged. Liver weighed nine pounds one ounce, was of a pale gamboge colour throughout, speckled here and there with rounded masses, the size of a pea, liaving a darker ochrey tint. On section, it offered considerable resistance to the knife, and the fresh cut surftice presented a dense, whitish-yellow fibrous structure, with the lobules of the organ atrophied and embedded in it, and of various tints of yellow, varying towards white. In short, the last stage of cirrliosis. Spleen weighed 3 lb. 6 oz., and is enlarged from simple hypertrophy. Kidneys, larynx, oisophagus, and other organs healthy. FiK. 405. Fig. 405. Structure of a thiu section of liver in the last stage of cirrhosis. 250 diam. 470 DISEASES OF THE DIGESTIVE SYSTEM. Microscopic Examixatiox. — On making a thin section of the liver with a Valen- tin's knife, and examining it with a power of 250 diameters, the appearance was seen represented in the woodcut. (Fig. 405.) The stroma of the organ was com- posed of fibrous substance, surrounding and compressing the hepatic lobules, many of which presented pale cells, more or less filled with yellowish pigment ; in some the cells were more or less fatty, and in others waxy. Here and there the spaces were empty, the contents having apparently lost their cohesion, or having been dragged out by the knife. Co7nmentary. — The lesion which I presumed to exist in the liver of this man during his life was that of a simple hj-pertrophy, a disease fre- quently associated with enlarged spleen and excess of colourless cor- puscles in the blood. But on dissection, the liver presented all the structural characters of the last stage of cirrhosis, associated with great increase of size in the organ. The fibrous structure especially Avas very large in amount, the lobules much compressed, and so altered, that, while the cells in many of them were loaded with pigment, some had undergone the fatty, and others the waxy, degeneration. The cirrhosis must have occasioned some obstruction to the perfect excretion of bile, as the jaundice, though slight, was uniform for more than four years. There had also been epistaxis, haematemesis, and frequent diarrhoea, symptoms very common in connection with enlarged liver and spleen, and probably dependent on the congested condition of the gastro-intes- tinal mucous membrane, produced by pressure on the portal veins. For a long time he suffered no inconvenience from the abdominal swelling, except from its bulk and occasional tenderness, unless indeed dyspnaa be taken into consideration, which was attributed partly to an aneuris- mal dilatation of the aortic arch. A dilatation in point of fact did exist, and a certain obstruction was occasioned from the state of the parts described, sufficient to produce all the physical signs and functional symptoms of aneurism of the aorta. The origin of the excessive hemor- rhages is involved in mystery, the most careful examination of the body having failed to detect lesion of any vessel, or of any part of the mucous membrane. Some years ago I opened the body of a man whose stomach was found filled with a firm coagulum of blood, so that, when the organ was opened, it could be turned out, presenting a cast of its interior, weighing between two and three pounds. Yet the most minute inspec- tion did not enable me to discover the slightest lesion to which such extensive hemorrhage could be attributed. Such lesion, however, must have existed ; for no one can now conceive the possibility of blood cor- puscles passing through the vascular walls by transudation, as was for- merly imagined. AVe may, I think, theoretically ascribe them to the excessive congestions occasioned, and to the rupture of capillaries which escape detection after death. Another fact worth}" of observation in the case of Kerr was, that the excess of colourless corpuscles in the blood (leucocythemia), which existed when he first came under my notice, had entirely disappeared during the last few months of his life. The treatment in cirrhosis must be purely palliative, and directed to diminish the ascites by means of diuretics and diaphoretics. The ques- tion of drawing ofi" the fluid by paracentesis is one which may arise, in case the swelling is very great, and the embarrassment to the pulmonary DISEASES OF THE LIVER. 471 and renal organs extreme. Even then, althongh temporary relief may be obtained by the operation, there is every reason to believe that, in the majority of cases, life is in no way prolonged. A condition of the liver is frequently seen, and which has been call- ed the nutmeg liver, from the resemblance it pre- sents to the fresh-cnt sur- face of a nutmeg. That is to say, it exhibits bright red or brown points, sur- rounded by a whitish or slightly yellow^ substance. On making thin sections of such a liver, it will be seen, that whilst the ves- sels of the lobules, and especially their central parts, are distended with blood, the cells at the mar- gins of the lobules have undergone the fatty degeneration. It has been supposed by some that this condition is an incipient cirrhosis, by others an incipient fatty degeneration of the organ. Certain it is, that in such cases the fatty cells are form- ed at the circumference of the lobule, in im- mediate relation to + the portal capillaries, which are loaded with blood. It has been called interlobular fat- ty degeneration, but is in fact fatty degenera- tion of the cells at the circumference of the lobule. Wedl has pointed out that in some rare forms of this lesion there is a deposit of pigment in the cells nearest the hepatic ca- pillaries, and occupy- ing the centre of the lobule, without any fatty degeneration whatever. Pigment may also Fiir. 407. Pig 406. Peri-lobular fsitty or nutmeg liver. «, Fatty degeneration around the lobules; h and c, Centres of the lobules with tlie vessels congested — {Wedl.) Fig. 407. Pigmented nutmeg liver, a, Lobule with the central vein divided at -f- , containing amorphous pigment; 6, Lobule with the central vein healthy; c, The central vein filled with pigment. The radiated central pigment is owing to its being deposited in that portion of the hepatic cells nearest the capillaries. — ( Wedl.) 90 diam. 472 DISEASES OF THE DIGESTIVE SYSTEM, occur in tlie veins themselves. At otlier times the fatty and pigmentary degenerations of the liver may be more or less combined, the former existing at the periphery, and the latter at the centre of the lobule. We have no clinical history of these forms of nutmeg liver, nor, so far as is yet known, do they occasion any symptoms, susceptible of being recoonised in the livino- bodv. Case LXXI.* — Cancerous Exudation into the Livtr — Cancerous Ulceration of (Esopha- gus — Simple Stricture of Pylorus — Profuse Hematemesis — Aneurism of Ihoracic Am ta, bursting into the left Pleura. History. — Thomas Stewart, xt. 54, bookseller — admitted Xovember 28, 1849. States that about six years ago he had an attack of hemoptysis, but, with this ex- ception, he always enjoyed good health, tUl about four months ago. At that time his appetite began to fail, and he felt sick after eating, occasionally vomiting his food. Since then the sickness has been increasing, and about three or four weeks ago, be began to vomit blood. He has also been affected with paiu in the throat on attempt- ing to swallow, and a sense of constriction in the oesophagus, opposite the superior border of the sternum. He states, that he can very seldom take food without excit- ing vomiting ; but occasionally, when he succeeds in retaining it for half an hour, the sense of sickness passes off. He further states that he vomits blood mixed with clots of dark -brown masses. This does not occur after eating, but generally between three and five in the morning ; occasionally, however, it occurs during the day, and is then preceded by a fit of coughing. He has been losing flesh lately to a great ex- tent, and is now very thin, having formerly been of a stout and robust habit of body. Symptoms ox Admission. — On admission he appears pale and emaciated. Com- plains of great general weakness. Tongue much furred, and the superior surface fissured. He has pain and constriction on attempting to swallow. Is sick, and generally vomits after every meal, and this whether his diet be solid or fluid. Vo- mits a great deal of florid blood, mixed with dark grumous masses, and clots of a black colour. Ou examining this fluid under a microscope, it is seen to consist chiefly of blood corpuscles and epithelial scales ; no cancer cells can be detected. He states that on Friday last (Nov. 23), he vomited about half a gallon of blood, and on the following day even a larger quantity. There is great tenderness over the region of the stomach ; and on examination, a hard lobulated oval tumour is discovered on the right side of the epigastric region, measuring four inches transversely, and two inches from above downwards. The appetite is bad. and has been getting worse of late. Bowels usually regular. He complains of cough, which has existed for about four months ; no dyspnoea. On percussion, the chest sounds well, except that there is dulness over the lower third of the left lung posteriorly. On auscultation, the expiration is prolonged anteriorly, and crepitation is heard over the part where dulness is elicited on percussion. Pulse 90, of tolerable strength. Complains of occasional palpitation, and the impulse of the heart is somewhat increased ; but on auscultation, the heart's sounds are normal. Urine, sp.gr. 1020, natural in quantity, not coagulable; deposits, on cooling, an abundant lateritious sediment of lithate of ammonia. Complains of giddiness, and is unable to walk well, owing to weakness. Four leecJies to be applied over the tumour in epigastrium. IJ. Pulv. Opii gr. ij ; Extract. Hyoscyam. gr. xii. M. et divide in jnl. iv. One to be taken morning and evening. 5- ^aphthce Medicin. 3i; Mist. Camphxyra, § iij. M. Half an ounce to be taken every three hours. * Reported by Mr. Hugh Balfour, Clinical Clerk. DISEASES OF THE LIVEE. 473 Progress of the C>.se.— December Is/.— Pain and tenderness are somewhat relieved by the leeches. Still vomits, but not to so great an extent as formerly. From this" time he went on with occasional exacerbations and remissions, but on the whole became manifestly weaker. Every now and then he vomited large quan- tities of florid blood, and on one occasion the quantity amounted to thirty-six ounces. Gallic acid and acetate of kad and opium were given at these times. After each attack of hematemesis, for some hours small quantities of blood came welling up into his moulh, and were expectorated. On December liih, it is noted that the weakness is increasing, and appetite diminishing. He was then ordered eight ounces of wine and beef-tea enemaia. IT^/i.— Extremely weak, and quite unable to take food, evi- dently sinking. IQth. — Died, this morning at four a.m. Sectio Cadaveris. — Twenty-one hours after death. The body was Hvid and greatly emaciated. On reflecting tlie integuments from tlie thorax and abdomen, a nodulated portion of the liver, nearly separated from the rest, very movable, containing a large mass of cancerous exudation, and measuring four by two inches across, projected as a distinct tumour into the epigastrium, and was evidently the same swelling as had been felt during hfe, through the iu- tegumenls. Thorax. — The cavity of the left pleura contained about a pound and a half of recently coagulated blood. The pericardium contained about six ounces of clear straw-coloured serum. Heart much contracted. The whole of the thoracic viscera, together with the trachea, and great vessels, were removed en masse. The blood in the pleura was then seen to have issued from between the lobes of the left lung, through a laceration of the pleura, at the external and back part of that organ. The aorta "being sUt up, was found to be somewhat rough internally. At the outer part of the arch, where it joins the descending aorta, the left side of the vessel was perfo- rated by a nearly circular aperture, two inches in diameter, with smooth edges, which led into an aneurismal sac, the size of a large cocoa-nut, filled with a soft coagulum. The aneurismal sac pressed and encroached on the left lung inferiorly, and communicated with the pleural cavity through a recent ragged laceration in the pleura costalis, three inches in length. Here and there, immediately round the sac, the lung was infiltrated with blood, and greatly softened. In these places it was very thin, and presented several perforations, through which hemorrhage into the luno- must have taken place. Xo communication could be discovered between the aneurismal sac and the stomach or oesophagus. The whole arch of aorta was shghtly dilated; the valves healthy. Between the thoracic aorta and the oesophagus there were two masses of glands, greatly enlarged from cancerous infiltration. The oesophagus itself was ulcerated about its middle, and the enlarged glands before mentioned projected into its cavity. This ulceration surrounded the tube internally, and extended about three inches from above do\\Tiwards, presenting a soft pulta- ceous surface, the result of disintegrated cancerous exudation. The lung presented throughout a number of small irregularly-shaped masses of exudation, not langer, in most instances, than four or five lines in diameter, and resembling masses of crude tubercle, but somewhat softer, and slightly redder in colour. There were also one or two larger masses, nearly globular in form, from one-fourth to three-fourths of an inch in diameter, of soft consistence, yielding a cream-coloured juice, and marked with one or two red vessels and reddish points. The bronchial glands were infil- trated with black matter, and mostly contained masses of cancerous exudation similar to, but smaller tlian, those in the lung. Abdomex. — The peritoneum covering the diaphragm, as weU as that in the pelvis and several other places, showed fungus-Uke projections and nodules of irregular 474 DISEASES OF THE DIGESTIVE SYSTEM. form — the largest two inches in diameter, flattened on their surface, of a yellowisli- white-colour, mottled with numerous red vessels externally. Internally they were of a similar colour and appearance — crossed by fibres, which included matter of the consistence and general appearance of boiled ground rice. In the pelvic cavity, at its most depending parts, there were about two ounces of bloody pus and lymph, infil- trated with blood, and here and there these existed in small patches on the surface of the intestines and parietal peritoneum. The liver was much enlarged, and weighed six pounds ten ounces. It contained numerous nodular masses, which on the surfoce were cup-shaped. The largest were nearly four inches across, and were usually softened in their centre. On section, they presented the ordinary appearance of encephaloma of the liver, with the exception, that in many places their substance was partly diffluent, and on section excavations or cavities were left in the ma.ss. Some of them contained a creamy yellowish fluid, mixed with red, and others olive- coloured serum, with a large amount of flocculent and granular pinkish debris. Here and there, also, masses of reticulum were infiltrated among the whitish and greyish cancerous exudation. The liver itself was pale fawn coloured and very fatty. The stomach was perfectly healthy ; but there was a simple stricture at the pylorus, which with difficulty admitted the introduction of the little finger, and which depended on hypertroph}' of tlie areolar tissue between the muscular and mucous coats. The intestines were extremely contracted ; the colon not being above one-half inch in diameter. Kidneys pale, containing numerous small cysts. The epithelium, however, was nearly healthy, exhibiting under the microscope only a small quantity of granular matter. The mesenteric and lumbar glands were healthy. Microscopic Examixatiox. — A small portion of the white and tolerably con- sistent cancerous exudation in the liver presented numerous cancer cells, varying greatly in size and shape, but none exceeding the l-50th of a millimetre in its longest diameter. Many were nucleated, and several were evidently breaking up and disintegrating. They were associated with some free nuclei, and a multitude of molecules and granules — (Fig 323). The reticulum was wholly composed of fatty molecules and granules — (Fig. 324). The broken-down matter on the surface of the oesophagus, where it was ulcerated, closely resembled that represented in Fig. 322, but was even more disintegrated. The milky juice squeezed from the glands between the thoracic aorta and the oesophagus, presented large cancer cells, which presented the various appearances characteristic of their undergoing the fatty dege- neration. — (Fig. 323). Commentary. — During life, the pain in the stomach, the vomitino- after food, the black bloody coagula rendered, and the distinct nodulated and somewhat movable tumour in the epigastrium, left little doubt in the minds of all those who examined the case, that we had to do with cancer of the pylorus. On examination after death, however, the tumour which had previously been felt, was found to be a nodule of cancerous exudation developing itself in the liver, a part of which had been pushed forward so as to occasion the swelling. As the rest of the liver was entirely hid under the ribs, it was not possible to have suspected this occurrence during life. The simple structure, however, that really existed in the pylorus, conjoined with the pressure exercised bv the tumour on the valve, caused the vomiting that formed the principal fea- ture of the disease. The appearance of the matters rendered by the mouth proved that they must have come from the stomach ; because, although a con- DISEASES OF THE LIVER. 475 siderable quantity of red blood was evacuated, this was commonly mino-led with rusty brown, and even perfectly black, coagula. Besides, on one occasion, he was actually seen by the clerk to render the blood by the act of vomiting ; and the same thing was repeatedly observed by the nurse. At first, ■then, I considered that the cancer of the stomach liad ulcerated internally, and poured out the blood evacuated ; but latterly, from the large quantities discharged, my suspicions were fixed on the presence of an aneurism pressing on the lung, and communicating witli the trachea, in which case he must have swallowed the blood. This supposition seemed to be confirmed by the existence of limited dul- ness on the left side, and by crepitation — an almost invariable concomi- tant of aneurism so situated. On attempting, after death, to ascertain by Avhat means the blood entered the stomach, I could not find any direct communication between the aneurism and that viscus, or the oesophagus. It may have resulted from the blood, in the first instance, having been infiltrated into the sub- stance of the lung, then passed through the bronchi, trachea, and larynx, into the pharynx, and so been swallowed. More probably, however, it was caused by intense portal congestion, producing hemorrhage from the capillaries. This man presented in a very marked degree the so-called peculiar Tis. 40S. cachectic aspect of malignant disease. I have alwavs noticed that this aspect is best marked in individuals labouring under cancer of the Fig. 40S. Remarkable carcinomatous cyst in the liver ; a, part of diaphragm. — (Ogh.) Half the real size. 476 DISEASES OF THE DIGESTIVE SYSTEM. stomach, so situated as to interfere Avith tbe process of nutrition. It is stated in the report that he had previously been stout and fat — a condition I have pointed out in another place* to be favourable to the development of cancer generally. I am inclined to think that this maliornant aspect, so much dwelt on bv practitioners, is the mere result of emaciation from interference with the nutritive processes, or from pain and want of sleep, and is in no way distincti\e of cancer in organs where such effects are not occasioned. Cancer of the liver may occur in two forms — 1st, That of distinct nodules, which have been so well described by Baillie and Farre ; 2d, More or less infiltrated in minute grains throughout the hepatic tissue. The former is by far the most common, and when it presents projections from the surface of the organ, these constitute the only positive proof during life of its being affected with cancer. In some rare cases I have seen these two forms run into one another. Softening of the cancerous masses was well observed in the case just recorded, as well as its transformation into the fatty substance wliich forms the so-called reti- culum. Dr. Oglef has recorded a case in which a cancerous mass in the liver presented on section the remarkable form of a cvst with thick walls, closely resembling a small cocoa-nut full of fluid. The walls exhibited the usual appearance and structure of encephaloma, and the fluid which occupied the centre was slightly turbid and con- tained shreddy particles of cancer and some fatty matter. In the majority of cases of cancerous liver, other organs of the body are similarly affected, rendering the disease more or less complicated. (See Cases LXV, and LXXVI.) The treatment must be entirely palliative. DISEASES OF THE INTESTINES. Case LXXII. J — Diarrhaa — Recovery. History.— Mary Gordon, £et. 21, a thin weak-looking woman, lately employed as a herring-curer — admitted in the afternoon of July 25th, 1855. She has for the last two days been much exposed to cold and wet, and early this morning was seized with violent pain in the epigastric and lumbar regions, accompanied by shivering, sickness, and vomiting. At nine o'clock the bowels were freely opened, and since then she has had several fluid stools, with griping pain in the abdomen, and violent tenesmus. The matters discharged from the bowels she describes as watery, mingled with slime. She has taken some brandy, which caused slight relief. Symptoms ox Admission'. — On admission the tongue is white, appetite impaired, great thirst, no nausea nor vomiting at present, no tenderness over stomach or abdomen. Bowels still loose ; the matter discharged consists of a dirty yellow fluid, in which masses of mucus are floating. Xo blood nor pus. Pulse 84, fuU. Says she has occasional palpitations. Countenance slightly flushed. Considerable lumbar pain. Urine healthy. Other functions well performed. ^ Tr. Opii 3 j ; Conf. Aroinat. 3j ; Mist. Creke comp. ? iij ; M. Half an ounce to be taken every three hours. * On Cancerous and Cancroid Growths. Edinburgh, 1849. f Trans, of Patholog. Society. Yol. ix.. p. 238. \. Reported by Mr. Simon Mutakisna, CUuical Clerk. DISEASES OF THE INTESTINES. 477 Progress of the Case.— July 26seated to be felt. Pungent heat, and drj-ness of skin over its surface. Tongue white, with prominent papillje, pale, smooth, and glossy at tip and edges. Complains of constant bad taste in mouth ; has a burning pain at epigastrium, and most intense thirst, but cannot take cold water, as it causes immediate vomiting, though she does not otherwise feel sick. Appetite entirely gone; bowels have not been moved since her admission. Urine diminished in quantity, high-coloured, with a deposit of lithates; the chlorides are present; sp, gr. 1014; she has a sense of heat in passing it, Catamenia last appeared about a month ago. Pulse 108, small and weak. Apex of heart beats between fifth and sixth ribs ; transverse dulness normal. Sounds normal. Breathing mostly thoracic ; respi- rations, 32 per minute ; cannot take a full breath without pain ; has a short hacking cough. Chest expands equally, but imperfectly. Percussion good, both anteriorly and posteriorly ; respiratory murmurs natural. Has headache, tinnitus aurium, and niuscse volitantes. Feels sick and giddy on sitting up. There is oedema of the feet, ankles, and legs To have wine 4 oz^ and in the evening a Turpentine and Asafoetida enema. Progress of the Case. — December Isi. — The enema was followed by two fcecu- lent and hard stools. Pain in the abdomen considerable — most felt below the margin of the right false ribs. Complete anorexia. Great thirst ; pulse 104, small and hard- Dec. 2d. — State much the same; bowels not again opened. Pain in the abdomen being increased, she was ordered six tnore leeches to the right hypo- chondrium, and the following diuretic mixture — 5 Potassce Acetatis 3ij; ulse 108, weak, Dec. 23d, — Yomiting more frequent : is much troubled with flatulence ; tongue pale, smooth, and glossy ; bowels regular, Dec. 2oth. — Tr. lodinii to be painted over the abdomen. Dec. 21ih. — 606 DISEASES OF THE DIGESTIVE SYSTEM. The iodine caused lier great pain, wliicli was, however, relieved by warm fomenta- tions. The swelling of the abdomen and tympanitis, the cough, and the expectora- tion, have increased ; breatliing slightly laborious. 5 »^. ^tli. Sulpli. 3 iij ; ^ol. Mur. 3fo7-ph. 3j ; Mist. Scilke 1 iiss. To be taken in half ounce doses token the cough is troublesome. Dec. 30th. — Abdomen measures 34 inches in circumference. Bowels regular; percussion normal over chest; mucous and sibilant rales heard on auscul- tation. Coughs much ; expectoration abundant, purulent, and tenacious ; pulse small and weak; legs and feet very oedematons; urine as before. Jan. 2d. — Jaundiced tint of slvin is growing deeper; distension of abdomen from tympanitis increased; pulse rapid and thready; vomits all her food immediately after taking it, together with a quantity of black matter ; thirst great ; stools pale-coloured but consistent. To omit the Squill and Digitalis Pill, and to take Potass. Bitart. 3j ier indies. Jan. 4dh — Jaundice increases ; urine very small in quantity, and contains bile. Swelling of abdomen augmented ; great protrusion of lower ribs, but breath- ing is not much affected. Yomiting continues. There is oedema of feet, legs, and hands; she is getting decidedly weaker. Pulse 96, steady and weak. Jan. 5th. — Died this morning at 2 a.m. Sectio Cadaveris. — Fiftij-eight hours after death. The body emaciated ; tlie surface of a moderately yellow tinge ; abdomen much distended and fluctuating. Thorax. — Tlie pericardium and heart were healthy ; there were a few slight old adhesions on the left side of the chest; the left lung, when removed, had an irregular feeling from the presence of a number of masses, some immediately under the pleura, others embedded in the pulmonary tissue ; the masses visible externally had a circumference equal to about that of a fourpenny piece ; their margnis were slightly prominent, while they were depressed or flattened in the centre ; they appeared of a greyish- white colour, and felt firm and hard; on cutting into the lung, pretty numerous masses similar in size could be seen scattered through it; they were generally of a white or greyish- white colour, while some were 3^ellowish, as if stained by biliary matter; most of these masses felt tolerably firm, but j'ielded on pressure a small quantity of a glairy juice ; others, however (which were more opaque-looking than the rest), crumbled down easily under the fingers. The right lung was very densely adherent throughout externally ; it presented masses similar to those found in the left lung, and others could be felt in its substance ; it was not cut into, but was sent entire to the university museum ; the pulmonary tissue intervening between the masses was quite healthy. A few of tlie bronchial glands at the root of each lung were a little enlarged, and when bisected were found to contain a substance like that met with in the tumours of the lungs. The bronchi were unaffected. One gland in the anterior mediastinum immediately under the upper part of the sternum was of the size of a walnut, and on being divided, was found converted into a mass of almost cheesy consistence, of a yellow colour, mottled by the pre- sence of a good deal of black pigmentary matter. Abdomen. — The cavity of the abdomen contained about a gallon and a half of a clear yellowish fluid. Peritoneal membrane everywhere healthy. The liver, which was much enlarged, presented a very irregular appearance, in consequence of the projection from its surface of numerous masses of a whitish-yellow colour, varying from the size of a pea to that of the fist ; some were rounded, others of a very irre- gular form Only a very few of these masses presented any central depression. When cut into, tlie substance of the liver was found, to a great extent, occupied by a similar matter; at some places it occurred in small isolated masses, but in general it was found infiltrated in large patches. It was of a yellowish colour; some PEEITOXITIS. 507 parts of it, however, were opaque, while intervening portions were clear and semi- transparent; other parts, again, were intermediate between these conditions; the matter was generally tolerably firm, but the more opaque parts had a tendency to crumble down. The liepatic tissue itself was of a yellowish colour, and moderately firm. The weight of the entire liver was 7 lbs. ; behind the liver a mass of enlarged glands surrounded and compressed the vena cava, the gall-bladder, and common duct ; the vena cava was somewhat diminished in size ; the gallbladder was much contracted, being little larger than an almond, and contained scarcely any bile ; on passing a probe from the gall-bladder along the cystic duct, the latter was found quite occluded, a little before its point of junction with the common duct; a probe was passed from the duodenum along the common duct, but both it and the hepatic duct were compressed and contracted ; the enlarged glands, when cut into, were found converted into firm yellowish masses, quite similar to those met with elsewhere. The pancreas was healthy; the stomach felt indurated towards its pyloric end, and on being cut into, a large ulcer was found near the pyloric orifice ; it was of an oval form, about 3^ by 2^ inches, its longest diameter being from above downwards; its right margin was about an inch from the pylorus. The ulcer had a hard thickened base, and a very irregular surface from the presence of numerous fungating excrescences of a greyish-white colour. The margins of the ulcer were elevated above the surrounding mucous membrane, but were irregular looking, as if they had been gnawed bj' some animal. There was no perforation. The rest of the stomach and the duodenum were healthy. Some of the gastric lymjyhatic glands, particularly some of those connected with the lesser curvature, were enlarged and cancerous. The spleen was natural. Tlie kidneys, when cut into, were of a yellowish colour ; their surface was a little irregular, appa- rently resulting from old cysts; a few cysts were seen in the surface, and also in the cortical portion ; several of the lumbar glands, lower down than the mass found behind the liver, were enlarged and similarly aSected. The uterus and ovaries were healthy. Microscopic Ex.oiixatiox. — On examining a little of the juice squeezed out of any of the masses above described, tolerably large nucleated cells were found. Many of them presented the usual appearance of cancer cells^ others, however, were small, and many nuclei were seen free. In the opaque portions, the cells were less distinct, and there was a large quantity of fattj' matter. The cells of the liver con- tained a good deal of bOiary matter, but they were otherwise quite healthy. The kidneys, when examined microscopically, also appeared healthy. Commentary. — This subject of cancer of the lungs, liver, stomach, and other org-ans, when she entered the clinical ward, presented all the symptoms of acute peritonitis, including great tenderness, with disten- sion of the abdomen, fever, and increase of urates in the urine. There was, however, no evidence, on palpation, of the nodular swellino-s found after death ; these were masked by the accumulation of fluid and tym- panitis. Neither did physical signs indicate the cancerous deposition in the lung, it being so diffused as not to occasion any marked abnormal respiratory symptoms ; such as did exist were explicable bv the abdo- minal disease. The facts presented in these three cases indicate the uncertainty of our diagnosis in abdominal diseases. In the first, jt is true, the symp- toms corresponded with the acute peritonitis of authors; but in the second there were no such symptoms, though there was abundance of 508 DISEASES OF THE DIGESTIVE SYSTEM. exudation ', while tlie third case presented all of them in a marked and chai'acteristic degree, in connection with cancer of the abdominal organs, and effusion of serum. I never saw a case which better satisfied me of the insufficiency of mere symptoms, for the purpose of arriving at an exact knowledge of a patient's real disease. The history of this case, it is true, indicated the existence of some chronic disease, but all the positive symptoms, after her admission, including extreme tenderness of the abdomen, its distension, tympanitis, constipation, high fever, vomit- ing, etc., pointed out that the chronic disease of the stomach and other organs had terminated in acute peritonitis. Yet, on examination, peri- tonitis there was none, but only serous effusion, or ascites evidently resulting from the organic disease of the liver obstructing the abdominal circulation. When contrasted with the last case, in which the perito- neal membrane was covered with lymph, the present one, wdiere it was healthy, exhibits a remarkable discordance with systematic descriptions of disease. The true exudation had not one of the so-called symptoms of that lesion, whereas, in the last case, there was every symptom, with a perfectly sound peritoneum. I have recorded therefore this case at great length, because the acute symptoms will speak for themselves, and because, when compared with some remarkable cases afterwards to be given of pleuritis without the usual symptoms, it serves, in my opinion, to convince us that many of our existing notions as to the pathology of acute diseases require to be modified. For other examples of perito- nitis, see Cases LVIII. and LXXVIII. Case LXXXA'I.* — Cancero^is PeriionitU — Ascites and Hydrofhorax — Paracentesis Abdominis — Arrested Pldhisis Pulmonalis. History. — Margaret Purdou, xt. G3, a widow, has had two children — admitted December 15th, 1856. Three years ago she had profuse hematemesis, accompanied by loss of blood j^er anum, which caused faiiitness. lu a few days, however, she quite recovered, and remained perfectly well until three months ago, when she first observed that the lower part of the abdomen was swollen, but not painful. About a fortnight afterwards she experienced severe pain iu the left lumbar region, together with a sensation as of cold water trickling down her left thigh as far as the knee. Two months after the first sjaiiptoms had shown themselves, the abdomen had become gradually much distended, and she experienced a "dead pain" in the epigastric region, which, she saj^s, was constant, but not aggravated by pres- sure, and caused great shortness of breath. Simultaneously with this epigastric pain a scantiness and turbidity of the urine appeared, and a day or two subsequently both feet and legs became very much swollen, the right one especially so. During the last fortnight she has taken several doses of rhubarb and magnesia, the purga- tive action of which has been followed by considerable alleviation of her symptoms, and diminution in the size of the abdomen, and of the dropsical swelling of the inferior extremities. Symptoms on Admission. — The abdomen is so distended as to measure at the epigastrium 29J, and at the umbilicus 35 inches round. It fluctuates on palpation, but there is no pain on pressure. In every position the lower portion of the abdo- men is dull, and the upper tympanitic on percussion. Xo tumour can be detected, * Reported by Mr. Alexr. M'Leod Pemberton, Clinical Clerk. PERITONITIS. 509 nor can the amount of the hepatic dulness be accurately determined. The tongue is covered with a -white fur on the right side, and is perfectly clean on the left. She has a good appetite, but cannot eat much on account of the uneasiness it occasions in the epigastrium — a symptom from which she is now seldom free. The bowels are opened naturally every other day. Xo flatulence. There is considerable dyspnoea ; a slight cough, but no sputum. Percussion is resonant over the whole chest. At the apex of the left lung expiration is prolonged and hard, and the vocal resonance increased. Pulse 85, of good strength. Heart's size and sounds normal The face is much emaciated and pale. Both feet and legs somewhat cedematous, the right one most so. Does not sleep well on account of the dyspnoea. Urine sp. gr. 1012 ; contams phosphates in solution, but no albumen. Progress of the Case. — January bth. — Since coming into the house she has had an occasional dose of castor oil, and her symptoms have on the whole been much alleviated. There is, however, great orthopnoea at night, and she says it is easier to lie on the left side. A careM examination to-day has determined that there is great dulness on percussion over the lower half of right lung, and that the respira- tory murmurs there are inaudible. The abdomen now measures at the epigastrium 31+, and at the umbilicus 37 inches. Pulse 92, feeble. Passes urme, loaded with phosphates, freely. To have eocira radrknis, and fmir ounces of wine daily. Ja- nuary I2ih. — In consequence of the great dyspnoea, which is daily increasing, para- centesis of the abdomen was performed, and 190 ounces of a pale, greenish yellow- fluid were drawn off. This fluid was of the sp. gr. 1012, and formed a sohd, gela- tinous m;;ss on the addition of heat. On standing it became slightly turbid, but exhibited nothing but a few scattered blood corpuscles under the microscope. The operation was followed by a tendency to syncope, which was removed by the free use of port wine and brandy. Jan. IStt.— Feels greatly relieved by the operation. Several nodulated swellings can now be felt under the flaccid abdominal mtegu- ments, especially on the left side. Ja7i. 14Wi.— Though greatly reUeved, complains of great weakness. Jan. loth.— Though liberally supplied with stimulants, died this morning at half-past two, apparently from exliaustion. Secfio Cudaveris. — Thirty-five hours after death. External Appearaxces. — Great emaciation. Abdomen flaccid, she having been tapped a short time before her death, and 190 ounce,? of serum removed. Thorax. — The external surface of the pericardium contained a number of cancerous nodules, varying in size from a pepper-corn to that of a small bean, of a white and pinkish-white colour. The internal layer of the pericardium and the heart were healthy. The right pleura contained about four pints of serum. The lung was compressed and pushed up against the spine. Its upper fomth was spongy, but most of the three inferior fourths were carnified, and contained httle air. Scattered over the pulmonary pleura were numerous cancerous masses, of a rounded or oval form, varying from the size of a pin's head to that of a split pea- They were of a clear white colour, rose abruptly from the pleura, and were gene- rally half a line or a line deep. Some of them had a slight central depression, and in many, blood-vessels could be seen. The costal pleura had sunilar nodules, and flat patches covering it, some of the latter being the diameter of a shilling. The apex of right lung was strongly puckered, and contained several concretions surrounded by dense pigment ; the rest of its tissue was healthy. The left lung was more volu- minous than the right. The pleurse at the apex were adherent and thickened. On section this was found to correspond to an old tubercular cavity of the size of a small filbert, also surrounded by dense tissue loaded with pigment. The substance of the lung was otherwise healthy, and the pleura? generally presented only a few 510 DISEASES OF THE DIGESTIVE SYSTEM. small cancerous masses scattered over them, similar to those on the opposite side. The bronchial and mediastinal glands were healtlw. Abdomex. — There were two or three pints of clear fluid in the abdominal cavity- The whole of the peritoneum (parietal and visceral), was studded over with can- cerous masses. The great omentum was shrivelled, drawn up, and converted into a thick mass of opaque, moderately firm, cancerous matter, the substance of which contained numerous yellow opaque pouits. The transverse colon was dragged up towards the stomach, and much compressed by this mass. All the adjoinmg veins were greatly congested. The peritoneum covering the lower surface of the dia- phragm was lined by a thick layer of cancerous matter, which appeared to have been deposited in nodules, which were so thickly placed as to have run into one another, forming a layer about two lines thick. At other parts of the peritoneum, nodules and small patches of cancerous matter were scattered about. The whole of the mesentery was studded with little masses from the size of a grain of sand to that of a pepper-corn. Similar masses were found in the serous coat of the small intestines. The meso-colon and meso-rectum were thickened and covered with cancerous masses. The uterus, urinary bladder, and ovaries were matted together by cancerous exuda- tion. None of the abdominal viscera or glands were involved in the cancerous dis- ease, which was exclusively confined to the serous membrane. Microscopic Examination-.— The difiierent nodules of cancer presented all stages of development and disintegration of the cancer cell ; in some places numerous naked nuclei ; in others, large compound cells ; la others, debris and fatty degeneration, forming yellow masses of the reticulum. Commentary. — The insidious approach and development of so large an amount of cancerous exudation on the peritoneum is worthy of observation. It is very possible that the disease existed three years pre- vious to her admission into the house, when the hemorrhage occurred from the mucous membrane of the stomach and bowels. But she rapidly recovered, and remained well until dropsical symptoms super- vened' in consequence of the pressure of the indurated cancerous masses on the abdominal veins, inducing etfasion. At no time was there any general fever, pain, nor tenderness on pressure. In this respect the case strongly contrasts with the last. Here, with extensive disease of the peritoneum, there were no symptoms of peritonitis; there, with the peritoneum perfectly healthy, violent symptoms of peritonitis were mani- fested. Indeed, the only symptoms 'occasioned were those resulting from pressure on the lungs, by the accumulation of serum in the perito- neal and right pleural cavities. The orthopnoea thus occasioned was so distressing as to induce me to have the abdomen tapped ; and it is worthy of remark that, although thereby the greatest relief was expe- rienced, she rapidly sank. Indeed, it seldom happens when, in ascites, resulting from organic disease, this operation is had recourse to, that death is'long delayed — a remarkable proof of the fallacy of that system which is based on the treatment of symptoms. Hence, as with the large bleedings formerly practised for the cure of inflammations, it is, true we give relief, but we also increase the mortality. In a case very similar to the above, occurring in a young man, i3et. 20, admitted under my care during the winter 1858, there was the same universal cancerous peritonitis, and the same distension of^ the abdomen from fluid without local tenderness. Instead of " nutmeg liver" — that is, incipient cirrhosis — however, the organ presented the disease in a more PEEITONITIS. ■ 511 advanced condition. Difficulty of breathing, notwithstanding, was never so nro-ent, the plenrte being healthy, and three weeks before death, the abdominal tension spontaneously disappeared, so as to enable me to feel the nodulated omentum through the abdominal walls, and thus deter- mine the nature of the case. He was a groom, and the first symptom of the disease appeared in the form of varicose veins in the lower extre- mities. These on admission were enormonsly swollen and tortuous, especially in the popliteal and inguinal regions, where they formed tumours the size of pigeons' eggs. After death the swellings were found to consist of distended veins tilled witli firmly clotted blood of a red brick colour. The cause of the varicosities in the extremities was the pressure occasioned by the tight and thickened omentum over the external iliac veins, just before they passed mider Poupart's ligament. It results that the cancer must have existed in the abdomen, when he was actively pursuing his employment, for the varicosities appeared a year before his admission. In both cases the ascites may have been mainly owing to the hepatic disease. (See also Case LXXVII.) SECTION VL DISEASES OP THE CIRCULATORY SYSTEM. Before proceeding to narrate and comment on lesions of tlie heart and large vessels, allow me to remind you of some of the rules which the laborious researches of many able men have established for your guidance in the diagnosis of cardiac diseases. They are as follows : — 1. In health, the cardiac dulness, on percussion, measures, immediately below the nipple, two inches across, and the extent of dulness beyond this measurement commonly indicates either the increased size of the organ or undue distension of the pericardium. "2. In health, the apex of the heart may be felt and seen to strike the chest between the fifth and sixth ribs, immediately below and a little to the inside of the left nipple. Any variations that may exist in the posi- tion of the apex are indications of disease either of the lieart itself or of the parts around it. 3. A friction murmur, synchronous with the heart's movements, indi- cates pericardial or exo-pericardial exudation. 4. A bellows murmur with the first sound, heard loudest over the apex, indicates mitral insufficiency. 5. A bellows murmur with the second sound, heard loudest at the base, indicates aortic insufticiency. G. A murmur with the second sound, loudest at the apex, is very rare, but when present it indicates — 1st, Aortic disease, the murmur being propagated downwards to the apex ; or, 2d, Roughened auricular surface of the mitral valves ; or, 3d, Mitral obstruction, which is almost always associated with insufficiency, when the murmur is double, or occupies the period of both cardiac sounds. 1. A murmur with the firet sound, loudest at the base, and propagated in the direction of the large arteries, is more common. It may depend, — 1st, On an altered condition of the blood, as in anaemia; or, 2d, On dilatation or disease of the aorta itself; or, 3dly, On stricture of the aortic orifice, or disease of the aortic valves, — in which case there is almost always insufficiency also, and then the murmur is double, or occupies the'period of both sounds. I have also seen cases which satisfy DISEASES OF THE CIRCULATORY SYSTEil. 513 rae that it may occasionally depend on roughness of the ventricular sur- face of the mitral valves, and on coagulated exudation attached to the internal surface of the heart. 8. Ilvpertrophy of the heart may exist independently of valvular dis- ease, but this is very rare. In the vast majority of cases it is the left ventricle which is affected, and in connexion with mitral or aortic dis- ease. In the former case the hypertrophy is uniform with rounding of the apex ; in the latter, there is dilated hypertrophy, with elongation of the apex. Attention to these rules alone will, in the great majority of cases, enable you to arrive with precision at the nature of the lesion present. In cases in which there may be any doubt, you will derive further assistance from an observation of the concomitant symptoms, such as, — 1st, The nature of the pulse at the wrist; 2d, The nature of the pul- monary or cerebral derangements. Thus, as a general rule, but one on which 'you must not place too much confidence, the pulse is soft or irre- gular in mitral disease, but hard, jerking, or regular in aortic disease. Again it has been observed that cerebral symptoms are more common ami urgent in aortic disease, and pulmonary symptoms more common and urgent in mitral disease. 1 have purposely said nothing now of diseases of the right side of the heart, and of a few other rare disordered conditions of the organ, because I am convinced that an appreciation of the rules above given is the best method of enabling you to comprehend and easily detect any exceptional cases which may arise. In truth, however, I have remarked in our examinations at the bedside that your difficulty is, not how to arrive at correct conclusions from such and such data, but hoiv to arrive at the data themseloes. You have to determine,— 1st, By percussion, whether the heart be of its normal size or not ; 2d, Whether an abnormal murmur does or does not exist ; 3d, If it be present, whether it accompanies the first or second sound of the heart; and 4thly, At what place and in what direction the murmur is heard loudest, these points ascertained, the conclusion flows from the rules previously given. But no instruction on my part, no reading or reflection on yours, will enable you to ascertain these facts for yourselves. In short, nothing but percussing the cardiac region with your ow.u hands, and carefully listening to the sounds with your own ears, can be of the slightest service, and the sooner you feel convinced of this truth the sooner are you likely to overcome these pre- liminarv difiiculties. This is the reason why a series of cases assembled in the ward of an hospital is so valuable. By careful examination of them, you can at once convince yourselves of the accuracy of the facts affirmed by others to exist, — reflect on the probable correctness of the diagnosis formed at the bedside, watch the various complications, and the efl"ects of treatment, and finally, observe how, in the fatal cases, by following the rules given, the accuracy of the diagnosis has or has not been con- firmed by post-mortem examination. After you have made yourselves familiar with the ordinary forms of heart disease, you will find 'that occasionally very puzzling instances occur where the above rules do not apply, these' exceptional cases should always be carefully studied. Indeed, this is what is now being done by the cultivators of physical diagnosis throughout Europe, with a view, if 33 514 DISEASES OF THE CIECULATORT SYSTEM. possible, of determining the characters wliich distinguish disease of the right from disease of the left side of the heart ; those indicative of lesions of the pulmonary artery, of chronic forms of pericarditis, of open foramen ovale, of clots in the ventricles or auricles, etc. etc. Well observed cases of these rarer diseases, however, are still too few to enable us to generalize confidently regarding them. I have frequently examined exceptional combinations of signs with the utmost care, and then been denied a post- mortem examination, or again have stumbled on rare forms of lesions after death in cases, where during life sufficiently careful and repeated examination of the physical signs had not been made to secure accuracy. I would strongly advise you to attach little importance to the record of such exceptional cases, and never to record such yourselves, unless equal care have been shown in the examination of physical signs and functional svmptoms during life on the one hand, and in anatomical investigation after death on the other. PERICARDITIS. Case LXXXTII.* — Acute Pericarditis — Recovery. History. — Jane Stambroke, aet. 25, servant — admitted January 7tli, 1857. Six months ago she entered another ward in the Infirmary, on account of rheumatic pains in the ankle joints. These pains were unaccompanied by general fever, and there is no evidence that the heart was then affected. During the last six weeks, however, she has experienced considerable dyspnoea, palpitation, and uneasiness over the central part of the sternum, increased by active exertion, or on ascending stairs. Five days ago, after exposure to sudden changes of temperature, she experienced towards evening a distinct rigor and increased pain in the prKCordia, which com- pelled her to desist from working, and retire to bed at an earlier hour than usual. The next day she felt somewhat easier, but on the following one the symptoms increased in intensity, and have continued up to the present time. Yesterday evening six leeches were applied, and caused reliefj which, however, was not permanent. SviiPTOiis ox Acinssiox. — Cardiac impulse is faintly felt between the fourth and fifth ribs. Dulness on percussion, at the level of nipple, extends transversely four inches from the right edge of the sternum, which is its internal boundary. On auscul- tation a loud double friction murmur is audible, over and limited to the cardiac organ, loudest over the sternum and base. The systolic and diastolic sounds are inaudi- ble in consequence of the loud friction murmurs. Pulse 108, regular and of moderate strength. She cannot lie on either side, and prefers the sitting to the recumbent posture. Says she has a slight cough but no expectoration. Percussion elicits com- parative dulness over the two lower thirds of left back, and there is audible over the same space increased vocal resonance and cegophony, without rales. Inspiratory murmur on right side is somewhat harsh, but otherwise normal ; is sleepless in con- bequence of cardiac uneasiness and dyspnoea, which is considerable. Has not men- struated for the last two months, but the other fimctions are well performed. Warm fumentatiom to ie constantly applied to the prcecordial region. Progress of the Case. — January 9th. — The pains and dyspnoea have been * Reported by Mr. M'Leod Pemberton, Clinical Clerk. PERICARDITIS. 515 greatly relieved by the fomentations. Xo friction murmur audible. The urine densely loaded with urates. Pulse 80, soft. Nutrients ivith zvine. § ij. Jan. lOth — No pain or dyspnoea. Friction sound slight, and only audible over right side of cardiac organ towards the base. Transverse dulness there is diminished by a quar- ter of an inch. Physical signs of left lung the same. No crepitation. Chlorides in the urine abundant. Jan. Uih — Xo friction audible over heart, but cardiac sounds are distant. From this time she rapidly became well. On the 13th, marked dul- ness, increased vocal resonance, and oegophony much diminished over left back. On the 18th, the transverse cardiac dulness measured two and a half inches, and there remained only increased sense of resistance on percussion over left back, with slight oegophony. On the 23d, complained of loss of appetite and slight dyspeptic symptoms, which disappeared the following day. On the 27th she walked out and did not experience so much palpitation or dyspnoea as before the present attack. Was dismissed Jan. 31st. Commeiitari/. — This was a pure case of pericarditis in a rheumatic girl, in which all the symptoms aud physical signs were very carefully examined. The disease went through its natural stages with great rapiditv. On the fifth day, when she was admitted, there was great distension of the pericardium from exudation, with friction sounds. Then for a dav these were absent, probably from the two surfaces being separated" by serum. On the seventh day, distension of the peri- cardium began to' diminish, and there was slight return of the friction. From this time there was rapid decline in the area of dulness, which on the fifteenth day was nearly normal. The local pain she experienced was before admission treated by the application of six leeches, but was still present on her admission. Warm fomentations to the part removed it at once, and constituted the only medical treatment she was subjected to in the house. Nutrients of course were given, and a little wine. The pulmonary physical signs were probably dependent on pressure of the lung backwards by the distended pericardial sac. Case LXXXVIIL* — Pericarditis and Endocarditis — Hydropericardium. History. — Barney Kilpatrick, ajt. 25, a miner — admitted July 8th. 18.50. Xine weeks ago he was suddenly seized with dyspnoea and a feeling of weight or dull pain in the cardiac region. A fortnight since, this became much more acute, and has continued up to the time of admission. For five years he has been much exposed to wet and changes of temperature, but never had rheumatism. Syitptoms ox Adiiissio.v. — Cardiac dulness measures three and a quarter inches transversely-, and is limited above by the margin of the third rib. Apex beats between the fifth and sixth ribs, two inches below, and considerably to the right of the nipple. All over the dull region a double friction sound is heard, resembling a roughened beUows murmur, but superficial. Beyond the region of the dulness these murmurs suddenly cease. Action of the heart regular. Pulse 96, regular, small, and feeble, stronger on the right than on the left side. The slightest movement induces pain, extending from the cardiac region down the left arm to the fingers ; great dyspnoea ; no cough or other pulmonary symptoms ; no fever ; no cerebral symptoms or tendency to syncope. * Reported by Mr. David Christison, Clinical Clerk. 516 DISEASES OF THE CIRCULATORY SYSTEM. Treatment axd Progress of the Case. — Twelve leeclies were ordered to be applied to the cardiac region, and a calomel and opium pill to be taken every six hours. On the 11th, the friction murmurs were much louder at the base than at the apex. The pulse 108 ; feeble at left wrist ; at the right wrist it had a double impulse, — a pretty strong beat being followed by a weaker one. § vj. of hlood to he drawn from the cardiac region by cupping, and a pill to he taken every four hours. On the 13th the breath had a mercurial foetor. Pulse stronger; less dyspnoea; friction murmurs more faint ; pain in arm diminished. On the 1 4th, pulse full ; slight fever; six leeches to be applied to the cardiac region ; morphia draught at night. On the 15th. friction murmurs only heard at the base; anorexia; can take no food; omit calomel and opium pills. \Gth. — Friction murmurs have disappeared, but there is a soft bellows murmur with the second sound, heard at the base. 18//i. — Had an attack of severe dyspnoea and syncope ; pulse 100, regular, but feeble : ^ iv of wme ; cardiac dulness increased. \Wi. — Orthopnoea ; pulse weak and fluttering ; a quiver- ing pulsation felt in the cardiac region ; iaintness ; oedema of feet and legs. Stimu- lants to be freely administered. Died earl}' in the morning of the 20th. Examination of the body was not allowed. Commentary. — This was a well-characterised case of pericarditis. At first the eiidocardial iiiunnur was masked by the friction sounds, but, as these disappeared, its existence became apparent. It was observed that, as the mercury atfected the system, the friction murmur diminished ; but there is every reason to believe that this was not so much owing to absorption of the exudation, as to increase in the amount of serous effu- sion. To the combined eftects of pressure on the heart from liquid with- out, and incapability of performing its function from incompetency of the aortic valve, the fatal event must be atti'ibuted. Since this case occurred, upwards of seven years ago, I have satisfied myself that the treatment pursued was not judicious, and that the local abstraction of blood, with administration of mercury under such circum- stances, is not only useless but injurious. It is true no fair comparison can be drawn between this and the preceding case, inasmuch as here we had undoubted valvular lesion complicating the pericarditis. But this ought to be an additional reason against depletion. I have given it, however, as a fair example of cases that used formerly to be pretty common, but which now, owing to our improved pathological views applied to practice, are somewhat rare. The following case was treated ditlerently. Case LXXXIX.* — Acute Pericarditis followed hy Acute Douhle Pneumonia — Recovery — Aortic Incompetence — Suhsequent Articular Rheumatism — Sudden Death — Adherent Pericardium — Fatty Enlarged Heart — Thickening of Aortic Valves. History. — Jessie Douglas, fet. 22, employed in a paper warehouse — admitted November 19th, 1855. Has never been very healthy ; has had several attacks of rheumatic fever, the last being about seven years ago. On the 9th current, after exposure to cold and damp, she was seized with rigors and pain in the back. These disappearing, were succeeded by pain and slight swelling of the knees, lasting only for a few days. During aU this time, though ill, she had no headache, vomiting, * Reported by Messrs. Geo. Robertson and R. P. Ritchie, Clinical Clerks. PERICARDITIS. 517 nor pain in the chest, but the shortness of breath and palpitation to whicli she is subject became aggravated. She was under medical treatment, and got purgative medicines, but was neither bled nor leeched. Symptoms ox Adjiissiox. — Apex beats distinctly between the fourth and fifth ribs, immediately under and a little to the inside of the nipple ; heart's impulse is heaving, and sensibly moves the whole mamma ; it can be felt but very indistinctly in the normal position ; there is no thrilL Transverse dulness at the level of the nipple 4f inches. Heart sounds are exceedingly indistinct, and muffled at the apex, but no murmur is heard there. At the base the first sound is almost inaudible, but with the second there is heard a soft blowing murmur. Pulse 80, full, regular, incompressible. Breathing is rather laboured ; respirations are 34 per minute, but regular; there is shght cough and no sputum. Percussion is everywhere good; vocal resonance is greater under the left than under the right clavicle ; no rale is audible, but respiration is exaggerated under the right clavicle, and inspiration is blowing under the left. She speaks languidly, does not sleep, and on sitting up feels faint. She is thirsty, and has no appetite ; the bowels are open ; catamenia are regular. Urine is neutral, sp. gr. 1018, not albuminous; deposits copious urates and phosphates; contains no chlorides. Patient lies on her back; cheeks rather flushed ; the skin warm and perspiring ; no pain nor swelling of any joints. Ordered half an ounce every fourth hour of the foUnwing : — IJ LUiuor. Amnion. Acetai. et AqmB aa 3 ij. Progress of tue Case. — Xovember 20(h. — At the apex, the cardiac sounds con- tinue exceedingly indistinct and muffled. At the base, immediately above the nipple, there is heard with each cardiac sound an exceedingly soft blowing noise equal in intensity and duration ; it extends over a considerable space, being heard but very feebly under the right nipple. Immediately under the centre of both clavicles, there is a prolonged blowing noise, occupying the period of both sounds. Pulse 72, full and somewhat jerking; palpitations are occasionally urgent; respi- rations 36, laboured. Ordered ivjelve leeches to be applied over the pnecordia., and subsequently warm fomentations. 21st. — The leech bites bled well. There is great heaving and expansive motion of the whole prjecordia ; at the apex murmurs are indistinct — at the base a double blowing murmur, most clear over the head of the sternum. There is no friction audible — no pain, and the palpitations are not increased. Pulse 80, slightly jerking, but weak. She cannot sit up from tendency to faint ; is depressed and exhausted in her aspect. Urine scanty ; still contains no chlorides. Ordered three ounces of wine iviih beef-tea; to be kept perfectly quiet. 22d. — The skin is covered with moisture ; respirations 46 ; pulse 84 ; still jerking and weak. The apex beats exactly under the fifth rib, a little to the inside of the nipple. At the base there is now a loud creaking which is double, and very loud at the margin of the sternum. Transverse dulness 3^ mches. Ordered to discon- tinue the saline mixture. In the evening loud friction was audible at the apex as well as at the base, and the apex beat had fallen about two lines below and to the inner side. 23d — Pulse 72, of same character; respirations 35. At the base of the cardiac organ, instead of the double friction heard yesterday, there is now a single continuous creaking. The same sound is audible at the apex. 24:th. — Pulse 80, still shghtly jerking, but soft; respirations 36; apex as yesterday. There is a continuous churning friction at base; at the apex it is heard, but less loud and continuous. 5 Sjnr. ^Iher. Nitrici 3 iij ; Tinct. Colchici 3 j ; Aqxus § vss ; M. One ounce thrice a-day. Also ^. Pulv. Opii gr. iij ; Extract. Catechu gr. XV ; Confect. Rosar. q. s. ut fiat massa in pilulas sex dividenda ; one to be taken every sixth liour. 2oth. — The same friction murmur ; pulse 80 : respirations 36 ; m"ine is hyperhthic, and still contauis no chlorides. 2(ith. — Pulse 82, slightly 518 DISEASES OF THE CIRCULATOEY SYSTEM. jerking, more compressible; respirations 32; skin chy andhot; tongue moist ; has no appetite ; urine the same in character ; the friction is less churning and continuous, and occurs more with the fii'st sound. 28<7i. — At the visit to-day, dulness is detected in the left scapular region near the inferior angle, over a space the size of the hand, with crepitation, and pealing vocal resonance. Friction in cardiac region is now diminishing both in intensity and duration. Ordered three additional ounces of wine. (From this day commenced an intercurrent attack of pneumonia, affecting the left lung, terminatuig in seven days. Besides dulness, crepitation, and increased vocal resonance, there were on the fourth and fifth days a friction murmur at the base of the left lung. The chlorides began to reappear in the urine on the fourth day. A blister vjas aijplied (3 by 4) to the right side anterioiiy on the 29quicarb. a.a. 3 ss ; Aqute, § vj ; one ounce every third hour. June 3c?. — Died to-day. Sectio Cadaveris. — Fifty-six hours after death. Bodj- anasarcous. Face swollen and cedematous ; some hemorrhage from the nose. Limbs cedematous ; abdomen protuberant and fluctuating ; great cadaveric livor. Thorax — The right pleura contained nearly two pints of clear serum ; the left one pint. The lower lobe of the right lung was compressed and non-crepitant, and the margin of the other lobes emphysematous; otherwise both lungs natural. The pericardium was found to be firmly adherent over the whole surface. It was much thickened, varying from two lines to two and a half, and it was of fibrous or almost cartilaginous consistence. The heart itself was about the normal size, but its walls, particularly those of the left ventricle, were rather thinner than natural, being less than two lines at the apex. The valves and endocardium were healthy ; the mus- cular tissue was of a pale fawn colour. Abdomen'. — Contained three gallons of clear serum. Liver weighed 3 lb. and 2 oz. Its hepatic vessels were congested, so that the organ presents on section a nutmeg appearance. The spleen soft, weighed 6^ oz. ; but was healthy. The two kidne^-s weighed each 10^ oz. ; and were quite healthy. The whole alimentary canal was carefully examined, but with the exception of congestion of the mucous membrane in the lower two-thirds of the rectum, was found to be quite healthy. The large arteries and veins of the neck, chest, abdomen, and pelvis, were also minutely examined and found healthy. Microscopic ExAJiiXATioy. — The striae in many of the cardiac muscular fibres were indistinct, and numerous minute oU globules were visible within the sarcolemma. The hepatic cells contamed somewhat more bihary and fatty matter than usual But in almost aU of them the nuclei could be seen. The renal structure was normal Comvfientary. — The history and symptoms of this man induced me to consider his disease as essentially hepatic. According to his account it commenced with ascites nine months before admission, and was followed by oedema of the legs and general anasarca. On taking charge of the case in May, however, I could not detect any alteration in the size of the liver, or any uneasiness in the right hypochondrium. The heart was carefully examined and found to be healthy, and at no time had he ever complained of that organ. The lungs presented evidence of slight bron- chitis, which could never be supposed to have occasioned the dropsv. The urine when scanty contained a slight trace of albumen, which after- wards disappeared. At no time did the case resemble one of Bright's disease, and the kidneys after death were quite healthy. The rapidly- advancing dropsy was the source of danger in this case. As diuretics had no effect, hydragogue cathartics were had recourse to, and although these produced temporary relief, the anasarca went on steadily increasing. PERICARDITIS. 525 and he died. On examining the body, the liver was found to be simply cono-ested, while its structure had undergone little alteration; the peri- cardium was universally adherent, and somewhat thickened ; the lungs collapsed posteriorly, with slight emphysema anteriorly. It seems to me that the congested liver and the chief pulmonary lesions were the results rathei' than tlie causes of the anasarca, and that the tnie origin of the disease must be referred to the cardiac lesion. During life, it is true, there were no- symptoms or physical signs to indicate that the heart was diseased. But it became apparent after death that he must have had an extensive pericarditis, and we have previously seen that such may occur without any symptoms at all. This, as in the case of Douglas, led to fatty degeneration of the organ, with atrophy, however, instead of enlarge- ment ; and the result was that, instead of dying suddenly as in her case, such slow languor of the circulation was occasioned, as to produce the venous congestion in the liver and lungs, which in its turn occasioned the anasarca. In most cases where enlargement of the heart follows adhe- rent pericardium, I have noticed the existence of valvular disease. In the present case the valves were healthy, and, instead of hypertrophy, there was atrophy. Case XCII.* — Rheumatic Pericarditis. History. — Jane Beaton, aet. 13, a thin, weak girl — admitted November 30tb, 1853. She states that two years ago she was confined to bed for a month with acute rheu- matism, some time after which, she cannot say precisely when, she observed that her heart was wont to beat very quickly. The impulse also was distinctly seen by her on undressing before going to bed. She had never suffered before from any car- diac uneasiness, pain, or dyspnoea, and asserts tliat she was able to run about as well as the otiier cliildren at school, until the commencement of the present illness. Three weeks ago, after no unusual exposure to cold, so far as she was aware, she felt weak, lost her appetite, and went to bed early. Next day she could not move in conse- quence of pain in both hip joints, and in two days the knees, wrists, elbows, and shoulders were also affected. The knees were much swollen, but not red. In eight days the pains abated, and have not since returned. Since then she has been subject to cough, with a white frothy expectoration, but has had no pain in the chest, dys- pnoea, or palpitation. Symptoms on Admission. — The cardiac impulse is seen and felt in the third, fourth, and fifth intercostal spaces, so low as one and three-fourths of an inch below, and to the outside of the nipple. It is strong, but unaccompanied with fremitus. Per- cussion causes slight pain. Cardiac dulness w^as much increased, extending to the right side of sternum, but its exact limits were not determined. AH over the cardiac region there was a double friction murmur, appearing close to the ear, and of a fine grating character, but very distinct. Over the manubrium of the sternum is a single blowing murmur, apparently wdth the first sound. The second sound cannot be heard. Pulse 136, regular, of good strength and somewhat jerking. The chest expands equally on both sides, percussion normal. Respiration harsh and sibilant over right pulmonary apex, over left apex normal. Posteriorly respiratory sounds healthy. She has slight cough, with trifling mucous expectoration. Does * Reported by Dr. David Cbristisou, Resident Physician, and Mr. James Walker, Clinical Clerk. 526 DISEASES OF THE CIRCULATORY SYSTEM. not complain of dyspnoea, but the breathing is evidently somewhat accelerated. Tongue clean. Appetite somewhat impaired ; shght thirst. Bowels regular. No headache ; does not sleep well, but no startlngs at night. Face flushed ; no anxiety of countenance ; skin hot and dry ; often sweats at night ; no oedema of limbs. Other functions normal. Eight leeches to he applied to the prcecordial region, and a sixth of a grain of Tartrate of Antimony to he given in solution every third Iwur. Progress of the Case. — December \st. — Pulse more soft. To discontinue the antimony. IJ Calomel, gr. xxiv ; Pidv. Jacobi, gr. xxiv ; Pulv. OpU, gr. iii. M, et divide in chartula-s xij. One to he taken every four hours. Dec. 3d. — Friction mur- murs much diminished. Cardiac dulness apparently increased. Urine loaded with lithates. Cough continues. 5 ^P- ^Elher. Nit. 3 iij ; Pot. Acet. 3 ij ; Alist. Scillce, § vss. M. A table-spoonful to be taken every four hours. Dec.iih. — Careful examina- tion determined, that the cardiac dulness measures five inches transversely, com- mencing half an inch outside the left nipple, and extending across the sternum to an inch and a half from the right nipple. Friction is now only audible over the margin of dulness on the right side. A soft blowing murmur is audible, synchronous with the impulse over a space two inches in dianleter below the nipple. At the base a harsher blowing is heard, which alternates with the soft murmur at the apex. It is propagated in the direction of the large vessels, and is very audible under the centre of the right clavicle. Pulse 120, soft, and sliglitly jerking. Ko pain or dyspnoea, Crums not affected by the mercurial powder.s, but complains of tormina and slight diarrhoea. Discontinue the powders, and apply a blister (3 by 4) over the sternum. — Dec. I2th. — Dulness somewhat diminished. Double friction is again very loud over the base of the heart, Dec. \5th. — Dulness much decreased; friction has dis- appeared. Dec. I9th. — Dulness now only measures three inches transversely across. Dec. 2Sth. — Has been doing well, and taking her food regularly. The cough and expectoration have nearly disappeared, and the harshness of breathing on the right side has much diminished. Last night was seized, without apparent cause, with violent palpitation, a sense of suffocation, and coldness of the body, which continued for an hour. Brandy and sulphuric oither ivere given, and hot bottles ajyplied to the feet. To-day she is tranquil as usual. Impulse is undulating between fourth and sixth ribs. The blowing at the apex is more harsh and prolonged. Above the nipple, on a level with the margin of sternum, there is a superficial blowing, occupying the period of both sounds. It is no longer audible under the clavicle. No retraction of the intercostal space over the undulation visible between the fourth and sixth ribs. January lAtJi. — Since last report, the attacks of palpitation and dyspnoea have recurred occasionally at night, apparently excited by any unusual circumstance. Puerile respiration still continues on the right side, but all pul- monary disorder otherwise has ceased. There is now heard, both at the apex and at the base, one loud blowing murmur, synchronous with the impulse, occupying the period of both sounds. That at the base is harder and more clanging in cha- racter than that at the apex, and ceases suddenly on carrying the stethoscope to the articulations of the third and fourth right ribs with the sternum. Pulse 128, soft. She is easily agitated ; otherwise the same, but says she is better. Wine 3 ij daily. March ISth. — Since last report, has been greatlj'- better, and has had comparatively few attacks of dyspnoea and palpitation. To-day the impulse is felt distincth^ between the sixth and seventh ribs, a little to the outside of a line drawn vertically from the nipple. Over this point a double blowing murmur is heard, that with the second sound being longest and somewhat distant. This blowing increases in intensity and loudness as the stethoscope is carried obliquely upwards towards the sternum, and reaches its maximum over the articulation of the third left costal cartilage with the sternum. At this point the murmur is prolonged, occupying the period of both PERICARDITIS. 527 sounds. It suddenly ceases as the stethoscope approaches the clavicles on both sides, and is inaudible over the large vessels. Pulse 120, of good strength, jerking; no venous pulse. April llth. — Has continued the same, but insists on leaving the Infirmary, and is in consequence dismissed. Commentary. — This was an exceedingly interesting case of pericarditis and endocarditis, the former of which apparently terminated in adhesions, while the latter underwent a variety of organic changes, which were in- dicated by physical signs, and were carefully recorded in successive examinations. From these it seems probable that there was gradually developed considerable hypertrophy of the left ventricle, the apex of which descended downwards and outwards, whilst the pulse became more and more jerking. The aortic orifice was apparently constricted ; and it is curious to observe, that whilst the murmur at the base at first was propagated upwards in the course of the large vessels, it subse- quently was propagated downwards towards the apex, and ceased abruptly above the margin of a certain area. The kind of organic lesion which gradually forming ultimately produced this result, it is useless speculating about, although it must be evident that the aorta itself above the valves could not have been implicated. At one time it appeared to me probable that the pulmonary valves were affected, but a careful consideration of all the circumstances obliges me to negative this supposition. Again, tlie pressure of the pericardial exudation might have produced the murnuir at the base. The constant blowing murmur at the apex indicated mitral insufiiciency, a lesion which could not have been so intense as the aortic disease, as the murranr was always more soft, and could easily be distinguished from the one at the base. Indeed it seemed as if this remained almost stationary, whilst the aortic lesion at length became the predominant one. I heard some few weeks after her dismissal that this girl was deaut probably assisted in cansing the heart's sounds to be obscured, which, however, were suf- ficiently masked by the bronchitic rales. The loud double murmur heard on the right of the sternum was n]ost probably owing to the flux and reflux of the blood into the first aneurismal pouch, for although similar sounds might have originated from the diseased aortic orifice, they would be rendered inaudible by the pericarditis and bronchitis. The complications here were formidable, and the man died rather from the heart disorder than from the aneurism. Case CVIII.* — Large Aneurism of the Ascending Arch of the Aorta, causing Ah- sorption of a portion of the Third Rib, and bursting into the Pericardium — Chro- nic Pericarditis — Incompetency of Aortic Valves — Hypertrophy of Left Ventricle. History. — James M'Killoii, set. 24, labourer, of inlemp'jrate habits — admitted January 12th, 1857. He says that two years and a half ago, while engaged in lifting a heavy weight, he suddenly felt something give way in the region of the left chest. From that period he became subject to a beating in that locality, but suffered no other inconvenience, till about four months ago, when he experienced a numbness down the left arm. For the last twelve months he has observed his left chest to be somewhat swollen. Six weeks ago he first felt dyspnoea, which was increased on exertion, and was attended with frequent cough. Two weeks after- wards, he observed his face and neck begin to swell, and this has graduallj^ gone on until now. Continued to work till six weeks ago. Symptoms on Admission. — Apex of heart beats between the fifth and sixth ribs, internal to and below the left nipple. It is feeble and diffused. A heaving pulsation is also felt over the upper part of left chest, synchronous with the cardiac impulse, having also an expansive lateral motion. On percussion, at a level with the nipple, cardiac transverse dulness is three inches. Above this tliere is a dull space, bounded by a curved line, which passes internally to mid-sternum, superiorly to the lower border of the first rib, and externally as far as a line passing vertically through the left nipple. This space measures four inclies from above downwards, and five inches transversely. It bulges forwards visibly more than the correspond- ing part on the opposite side, especially in the second intercostal space, two and a half inches from the sternum. On auscultation at the heart's ajjex, a double blowing murmur is audible, which, however, evidently originates at the base, where it is loudest, the first murmur being rough, and the second comparatively soft. All over the region of the pulsating tumour, there is a double murmur, the first not so loud as the second. They are most distinct towards the outer margin of the dull space formerly described, especially at a point one inch above the left nipple. Over both clavicles there is a single rough blowing murmur. Posteriorly, no comparative dulness can be made out on percussion. On applying the hand at the base of both lungs, fremitus is perceptible with the inspiratory acts, most marked in the left side. On auscultation, a double murmur is audible all over the left back, loudest between vertebra and the edge of scapula. Radial pulse 108, small but strong, without any difference in the two wrists. Both external jugular veins are somewhat distended, so that the position of the valves may be readily perceived. On auscultation over both lungs, harsh sonorous rales are audible, with occasional moist sounds. Expira- tion much prolonged. Has tickling in the larynx ; occasional cough of a hard and * Reported by Mr. H. N. Maclaurin, Clinical Clerk. ANEURISM. 563 somevrhat clanging character; expectoration is mucous, not copious; considerable d}-spnoea, especially on exertion, and pain in the left chest and shoulder, with numb- ness in left arm ; sleep is disturbed ; irides normal; strength diminished; considera- ble oedema of face, neck, and chest only ; eyelids puffy; skin hot : appetite good ; deglutition unaffected. Digestive, urinary, and other functions normal. Eight Leeches to be applied over tumour in left chest, and to take a tablespoonful every two hours of the following mixture :— If. Sp. JSther. Sulph. ; Sp. Animon. Aromat. aa, 3j ; TV. Card. comp. 3iij ; Aquoe ad § iij. M. Progress of the Case. — January llth.—lAtWe benefit followed the application of the leeches. Yesterday, ^ v of blood were removed by cupping, and caused great relief. (Edema of the face lessened. Jan. 22d — Complains of pain passing from tumour to middle of left back. Venesectio ad I x. Jan. 24:th.— 3 xj of blood were taken from the arm, causing instantaneous relief from the pain, and tingling in the arm. The relief continued till to-day, when the pain has returned. Pulse 100, sharp. Other symptoms the same. Morphia and JEther draught. Jan. 29th. — Pain continue.?. Dyspnoea and cough have increased. Face and neck again very oede* matous. To be cupped over the lefl chest, and § vj of blood taken. Feb. 2d. — Was again greatly relieved by the cupping. Complains of tickling in the larynx. The tumour has extended somewhat upwards, and its pulsation is distinctly felt at the right border of the sternum opposite the second rib. ^ Tinct. Lobelice In flake 3j ; Sol. Mur. Morph. 3 j ; Aqua ad I w]. M. One tablespoonful three times in the night. Expired suddenly at 7 p.m. on the 8th, the symptoms having undergone little change. Sectio Cadaveris. — Thirty-two hours after death. Body not emaciated. Left side of thorax rather fuller than right. TiiOR.iX. — There was some oedema of the parietes, greater upon tlie left than the right side. On reflecting the sofl parts, there was an evident prominence in the left mammary region, rounded in form, and about two and a half inches in diameter. The pericardium was much distended, and contained twenty ounces of blood. An aneurism arose from that portion of the ascending aorta contained within the peri- cardium, commencing immediately above the semilunar valves and the origin of the coronary arteries. The aorta below this point was not dilated. The aneurism anteriorly appeared to be divided into two lobes; the left much larger than the right, and of the size of a large cocoa nut, passed upwards and forwards, its long diameter being nearly parallel to the auterior wall of the thorax, to wliich the greater part of its surface was adherent ; the right, larger than a turkey's egg, passed back- wards and a little downwards, its long diameter being nearly parallel to the base of the thorax. The anterior extremity of the right lobe did not approach within two inches of the thoracic wall. Posteriorly no such division into lobes could be seen, but merely a single large aneurismal sac divided into two compartments by the aorta. The left pouch was found adherent to the posterior surface of the sternum, between the junctions of the second and fourth ribs, and to the cartilages and part of the bodies of second, third, and fourth ribs. Over this space, measuring about six inches across, and nearly four vertically, the sac could not be separated from the thoracic parietes; on the contrary, the finger introduced into the sac detected rough exposed bone in various situations, corresponding to the prominence observed. Externally there was a gap in the thoracic wall, formed by the absorption of a considerable por- tion of the third rib, external to its junction with its cartilage. The recurrent nerves were displaced and stretched, especially the left, in consequence of the transverse portion of the arch of the aorta being pushed backwards. A rupture of the aneurism into^he pericardium had taken place at the most dependent part of the larger sac, 564 DISEASES OF THE CIRCULATOEy SYSTEM. at a i^oint corresponding to the right margin of the sternum between the junction of the fifth and sixth right costal cartilages with the sternum, but about two inches behind it. The orifice was of a linear form, hah' an inch in length, and immediately overhanging the right auricle. Tlie sac contained chiefly loose clots, but some imperfect layers of decolorised tough fibrin were in some places adherent to its walls. The heart was displaced downwards and backwards. The larger sac inter- vened between it and the thoracic walls, so that its base was on a level with the lower margin of tlie fourth rib, and five inches behind it. The heart was hypertro- phied, but, as it was kept attached to the preparation, it could not be weighed. The liypertrophy was most marked in the left ventricle. The surface of the heart was roughened by shaggy growths of old plastic lymph, most abundant over the left ven- tricle. Pericardium not adherent. The aortic valves were evidently incompetent, being opaque, tliickened, and shortened There was a small aneurism of this portion of tlie arch, between the origin of the innominate and left carotid arteries, and par- tially involving the commencement of each of these vessels. It was about the size of a large filbert. Tlie huing membrane of the thoracic and abdominal aorta was but slightlj' atheromatous. The larynx was quite natural. The right bronchus was compressed at the point of adhesion between the lung and the smaller sac. The sub- stance of the lungs was quite natural. The right pleura contained a pint and a half of clear serum. Abdomen. — Abdominal organs healthy. Commentary. — In this case, tlie aneurisnial tumour developed itself on the left side, and caused a visible swelling with protrusion in the left chest. It was of larger size, and of older growth than in the previous cases, and by constant pressure forwards on the ribs, had occasioned caries and interstitial absorption of the bones. In consequence of pres- sure posterioi'ly on the bronchus and recurrent nerve, it occasioned harsh cough and tickling of the larynx. Although here also the aortic valves were incompetent, the sounds were marked by a loud double blowing- murmur, evidently connected with the aneurism, because they were audible in the left back. Only one sound, however, could be heard at the root of the neck above the clavicles, owing to a dilatation of the aorta between the innominate and left carotid arteries. In this, as in Case CVIL, a chronic pericarditis existed, which was not indicated by any symptoms. The relief to symptoms by small abstractions of blood was particularly well marked, although it is perhaps almost unnecessary to say that the real disease was in no way altered, and continued its march towards a fatal termination, (For a case of thoracic aneurism bursting into the pleura, see Case LXXIII.) Case CIX.* — Varicose Aneurism of the Ascending Aorta communicaiing with tlie Pulmonary Artery — Jaundice and Nutmeg Liver. History. — Alexander Calder, ajt. 33, a teacher — admitted June 11th, 1855. He had always enjoyed good health until the beginning of last February, when he felt a pain under the ensiform cartilage, which felt like the pricking of a pin, and continued for a week. About a fortnight after this, while walking hastily, he felt as if something had given way below the ensifomi cartilage, which caused him to * Reported by Mr. Robert Byers, Clinical Clerk. ANEURISM. 565 slacken his pace, and produced a sensation of weal^ness. He continued to feel weak for a fortnight, and then resumed his duties, though far from well. During tlie next two months he occasionally expectorated a little blood, and experienced car- diac palpitation. Two months ago he lost blood at stool (6 or 8 ounces passing at time during three days), which was regarded as dysenteric. He has long been subject to hemorrhoids. Last April the feet began to swell, and the abdomen to enlarge, symptoms which have continued more or less since. Latterly the palpita- tion has increased, and tliere has been considerable dyspnoea and cough, with occa- sional vomiting. Symptoms on Admission. — On percussion, the transverse dulne.ss of tlie heart measures three inches. Its impulse is diffused, strong, and irregular. On auscul- tation, a soft blowing murmur is heard over the apex with the first sound, and the second sound is distant but healthy. At the juuction of the third costal cartilage with the sternum, the first sound is loud, prolonged, and blowing, the second is short, abrupt, and rasping. Over the manubrium of the sternum there is a rough, continuous blowing murmur, occupying the period of both sounds. The same murmur is audible under both clavicles and to the right of the manubrium, but is softer and more distant. Pulse 90, irregular, but of natural strength. He lias considerable dyspnoea on going up stairs, and a trifling cough. Over tlie anterior surfece of chest tlie respiratory murmurs are harsh, but otherwise percussion and auscultation furnish no signs of pulmonary disease. Pressure over the stomach is painful. Tongue clean; vomits once or twice a day after coughing. Abdomen rather tumid, but percussion and palpation discover nothing abnoruial. The feet, legs, and thighs are oedematous, pitting strongly on pressure. Urine small in quantity, and high in colour. It contains a superabundance of lithates, but no albumen. Sp. gr. 1025. Tlie other functions are well performed. He has taken a variety of remedies ; at one time drastic purgatives, and at anotlier the strongest diuretics, all of which have only produced temporary relief. I^ Sp. jEther. Nit. 3 ij ; Tind. ffyoscyami 3ij; Liq. Amman. Acetat. '^xy, Aquce § vj. M. Habeat ^j ier die. Progress of the Case. — June 16ih. — The rest and quietude he now enjoys have apparently benefited him, but he sleeps little. ]J -S/j»-. uEtlier. Sulph. min. xv. Sol Mur. Morph. min. xx. Fl. hausius. To he taken at bedtime. Jime IWi. — The breath- ing is more embarrassed, and the oedema of the lower extremities increased. The cough also is more severe, and he has vomited every meal. Pulse 100, weak. 'S^ Sp. Oilier. Nit. 3j; Sol. Mur. Morph. 3j; Mist. Campihorce §jss. M. Half to be taken at 5 p.m. the rest at bedtime. June 2\st. — Since last report the skin has gradually become jaundiced, and the features are now shrunk and anxious, pulse 128, weak. Vomiting was checked by the medicine ordered, but he is unable to take food, or stimulants. 5 Amman. Carb. gr. v; Tind. Garb. Comp. 3ij; Mist. Camph. § iss ; half to be taken immediately, and the other half in an hour. June 22d. — Continues to sink, notwithstanding the liberal administration of stimu- lants and nutrients. Died at half-past two on the morning of June 23d. Secflo Cadaverls. — Thirty-four hours after death. External Appearances.— The general surface and conjunctivae of a yellow tino-e — lower extremities oedematous. and several phlj'ctenaj, filled with sanguinolent serum, existed on the trunk and upper part of the thighs. Thorax. — The pericardium was natural; it contained ^ ss dark coloured serum. On removing the heart a bulging was observed between the aorta and pulmonarj- artery. Seen externally it appeared to rise from the latter vessel. It was of a rounded, rather flattened form, somewhat smaller than a chestnut ; when, how- ever, the finger was passed down the aorta it entered this bulging, which proved to 566 DISEASES OF THE CIRCULATOEY SYSTEM. be an aneurismal sac, rising from the root of the aorta. A stream of water passed down the aorta, escaped rapidly at first ; but the latter portion was retained by the semilunar valves, which proved competent. On laying open the aorta, the aneurism was found to commence immediately above the semOunar valves. Its opening into the vessel was circular, and rather smaller than a florin. The sac itself was of an irregularly rounded form, its greatest diameter (from above do\^Tiwards) being two inches. Its capacity about that of a large walnut. The sac was empty and contained no trace of a clot. At the apex of the tumour was found an opening, which passed into the pulmonary artery. (The sac, as already mentioned, was closely applied to this vessel.) When the pulmonary artery was cut open the com- munication became more distinct. This opening was about four lines in length, and the lips a line and a half apart, so that it was oval in form with its margin slightly rounded off. It was situated transversely to the length of the pulmonary arterv. and was rather more than an inch higher up than the point of union of two of the pulmonary semilunar valves. The whole of the cardiac valves were natural. The left ventricle was rather more capacious than usual ; its walls were of the nor- mal thickness. The right ventricle was also a little dilated; its walls were more decidedly hypertropbied. The heart weighed 15^ ounces. On section of both lunss, they were seen to contain several diiiused patches of extravasated blood, recent and confined to the air ceUs. ABDOiLEX. — In the cavity of the abdomen was about a pint of turbid serum. The liver, when cut into, exliibited congestion of the portal capillaries, causing the so-called nutmeg appearance. The spleen, kidneys, and other abdominal organs were healthy. Commentary. — Cases of aneurism communicating Avith tlie pul- monary arterv are very rare, and the physical signs to which they give rise have, so tar as I can discover, only been recorded in two instances. Of five cases collected by Mr. Thurnam,* there is only one in which the sounds were accurately observed. It Avas published by Dr. Hope,f and was communicated to him by Dr. David Monro of Edinburgh. In that case the size of the aneurism is not given, it is vaguely called " laro-e," but it " communicated by two openings with the pulmonary artery, the larger capable of receiving the point of the little finger, the smaller of transmitting a crow's quill. The edges of both were regular, round, and cartilaginous. Nearer the arch, a third small opening was discovered, with thin rugged edges." All the valves were healthy, excepting the semilunar at the mouth of the aorta, which was thickened." We are not informed to what extent the aortic valves were thickened, and Avhether such thickening produced incompetence in their action. But we are told that " the first sound was accompa- Bied by a loud blowing murmur, most distinct at the middle of the sternum, but audible over the whole fore part of the chest, and over the back on both sides of the spine. The second sound was short, and much obscured by the first." This account rendere it probable that the murmur was synchronous with the ventricular contraction, Avas caused bv the rushing of blood through the laceration of the aneurism into the pulmonary artery, and Avas not OAving to the valvular disease. In * Medico-Chir. Trans., vol. xxiii., p. 349, et seq. f Diseases of the Heart, 3d edit., p. 469. ANEURISM. 567 a case of Professor Smith's of Dublin,* tlie pulmonary artery coimnu- nicateJ with the aorta by a small opening at the origin of the latter vessel. The edges of this opening were thickened and romided off. There was dilatation of the aorta at the point of opening, with distinct signs of arteritis. The auiiculo-ventrienlar openings were healthy. ATloud blowing murmur accompanied the first sound, and an intense purring ti-emor could be felt over the whole cardiac region. AVhere this blowing murmur was heard loudest is not stated, and we are at a loss to determine whether it was owing to the wave of blood rushing througli the dilated and roughened aoita, or its passing through the orifice" into the pulmonary artery. Of the second sound nothing is said. The purring tremor may have been occasioned by the rapid gush of blood through the small opening of the aneurism, and a similar tremor was observed by Mr. Thurnam, Dr. ^Yilliams, and Dr. Hope, in a case where an aortic aneurism communicated with the right ventricle of the heart, by two small rounded apertures. That such tremor should occur where the opening is large, appears to me improbable. In the present uncertain state of our knowledge as to the signs which accompanv an aortic varicose aneurism communicating with the pulmo- nary artery, the case of Calder appears to me to be of great value, as the physical signs w-ere examined with great care, and recorded at my dicta- tion by the clerk at the bed side. At the time they were exceedingly puzzliiiir, because the idea suggested by the double sound heard at the base of "the heart, which, under ordinary circumstances, would have indi- cated aortic disease with stricture, was negatived by the fact that the second sound was distinctly audible at the apex, clear, and healthy. At the same time, the manner in which the disease occurred, the anasarca indicating impeded circulation, the dyspnoea and irregularity of pulse, gave evidence of a profound lesion of the heart, although its nature was verv mysterious, the more so as no thrill or tremor could be detected. The case, however, was at once made clear, and the nature of the sounds explained by the examination of the body after death. All the valves were healthy, and hence the double sound must have been entirely owing to the flux and reflux of blood through the communication between the aneurism and pulmonary artery. The murmurs were heard loudest over the seat of the communication, below the junction of the third left costal cartilage with the sternum ; became continuous as they were propagated upwards ; but interiorly at the apex of the heart, only the systolic blowing was audible, together with the natural sound of the semilunar valves. The size of the laceration or connecting opening explains the absence of whiz and tremor. These facts appear to me very valuable as distinctive of such a lesion when the valves are healthy. If, as frequently happens, they are diseased, there must always exist excessive difliculty, if not an impossibility, of ever distinguishing such a form of aneurism" in the living subject. Mr. Thurnam, in his excellent paper, appears to me rather too sanguine on this point. The other phenomena presented by the case are at once explained, by reflecting on what is likely to happen by a considerable quantity of blood beino; propelled from the aorta through a large opening into the * Dublin Journal of Medical Science, vol. xviii., p. 164, and Stokes on the Diseases of the Heart and Aorta, p. 554. 568 DISEASES OF THE CIRCULATORY SYSTEM. pulmonary artery, and thus sent to the lungs again without liaving passed through the systemic circulation. As stated by Mr. Thurnam, the effects are referable to one or more of three circumstances. 1st, Loss of blood to the systemic circulation, and as a result, feeble, occa- sionally jerking pulse, debility, tendency to syncope, and diminution to animal heat. 2d, Impediment of the return of venous blood from the distant veins, and, as a result, venous congestion of the liver, mucous membrane, and extremities, with engorgement and dilatation of the right side of the heart, and as a result, dropsical effusions and especially anasarca. 3d, Excessive stimulation of the lungs by the reception of arterial instead of purely venous blood, and hence dyspnoea, cough, pul- monary congestion, and extravasations of blood. All these effects wei'e observed in the case we liave had before us. A retrospective view of the f^icts and phenomena of this and similar cases must impress upon us the triitli that drastic purgatives and diuretics, however they may relieve, cannot be expected to produce any permanent benefit. Indeed, when- ever general anasarca is evidently dependent on organic disease, it seems to us that the mildest remedies should be employed, especially taking- care by their use not to lower the general powers of the constitution, so that life may be prolonged as much as possible. Case ex.* — Aneurism of the Arteria Innominata. History. — Catherine Syme, ret. 56, a seamstress — admitted May 2, 1853. She says that her habits have always been temperate and regular. FifTteen years ago she had an attack of acute articular rheumatism, which afterwards became clironic, and rendered her incapable of Avorking for eighteen months. For six j'cars past she has been subject to occasional attacks of giddiness and swimming in the head, accompa- nied by a loud noise like the clanging of machinery. Fourteen months ago, in the night, she was seized mth a fit of intense dyspnoea, threatening suffocation and accompanied with a loud crowing noise on inspiration. The attack lasted about eight minutes. Three months afterwards, she experienced a somewhat similar but milder attack, also in the night, during sleep. She now observed that her voice was becoming rough and hoarse; and a few months later, she felt slight difficulty in swallowing, at a point corresponding to the upper border of the sternum. In the early part of January 1853, after unusual exposure to cold, the dyspnoea returned ever}' morning, gradually became urgent, and generally terminated in the expectora- tion of a small quantit}'^ of mucus. There were also palpitations, and she became subject to sudden startings from sleep. A week ago, all these symptoms became so mucli aggravated, that she was unable to leave her bed. Symptoms on Admission. — The cardiac dulness measures two inches across. The apex beats between the fifth and sixth ribs, a little to the inside of the nipple- Heart's impulse is somewhat diffused, rhythmical, and of good strength. A blowing murmur accompanies both cardiac sounds, that with tlie first sound being loudest at the apex, and that with the second being loudest at the base. Immediate!}' above and towards the outer side of the right sterno-clavicular articulation, a pulsating tumour, about the size of a hen's egg, is visible to the eye. It is felt beneath the sternal and inner portion of the clavicular origins of the sterno-mastoid muscle, pre- sents a distinctly rounded outline, and anteriorly slightly overlaps the trachea imme- * Reported by Mr. Robert Brown, Clinical Clerk. ANEURISM. 569 diately above the upper border of the sternum. The impulse is strong and diffused, and a loud, clear, abrupt murmur is heard over it, synchronous witli the second sound of the heart. The pulse is regular, 106, of good strength, equal at both wrists. There is a paroxysmal cough, harsh, prolonged, and of a clanging metallic character, always worst in the morning, when it is accompanied by urgent dyspnoea, and a loud crowing inspiration. Sputum scanty and gelatinous, containing a few flocculi of pus. Yoice hoarse and weak. Chest everywhere resonant on percussion, but not unusually arched. Respiratory murmurs very faint, but normal in character. Expiration much prolonged. Appetite impaired. When swallowing solid food, she says the bolus seems to meet some obstruction at a point corresponding with the upper border of the manubrium of the sternum. The countenance is anxious, face livid, and the superficial veins of the chest and lower part of the neck are very large and turgid. Sleep restless and easily disturbed. Other functions normal. Progress of the Case. — The .symptoms previously noticed continued, with occa- sional remissions, until the 20ih of June. On that day, it was observed that the blowing murmur synchronous with the second sound at the base of the heart, was much less distinct, and that the murmur with the first sound at the apex was replaced by one with the second. The veins over the upper part of the chest have been gradually enlarging. On the 6th of July, a careful examination elicited the fol- lowing results :— Pulse 88, soft, equal in both wrists. The impulse is very strong over the tumour, and on auscultation there are now heard two sounds, the second being loud, abrupt, and exceedingly clear — no blowing audible. Tliese sounds diminish gradually in intensity as the stethoscope approaches the left edge of the manulirium of the sternum, where the two cardiac sounds are heard quite normal. As the instru- ment descends towards the heart's apex, the second sound gradually assumes a soft blowing character, which at the apex is loud and distinct. The first sound is quite normal. Posteriorly above the right scapula, tlie sounds of the tumour are heard at a distance, but disappear towards the centre of the back, and are inaudible along the vertebral column. July 8ih.—For the last few days the dyspnoea in the morning has been verj^ urgent, and the cough coarser, and of a metallic clanging sound. To-day the paroxysm continued 15 minutes, and even now at the visit, the breathing is noisy, laboured, and hurried, the dyspnoea urgent, and the paroxysm of cough severe and at short intervals. She cannot expectorate easily. The voice is feeble, and the countenance expressive of great anxiety. To relieve these symptoms tracheotomy was attempted by Mr. Syme ; but, having made two incisions, and cut through the integument and subcutaneous fat, such an amount of venous hemorrhage occurred that he desisted, applied a ligature to the large veins, and declined to perform laryngotomy. July 9th. — The loss of blood caused considerable relief, and she passed a tolerable night. A double blowing murmur is now audible both at the apex and base of the heart. That accompanying the second sound is loudest over the apex, while the one accompanying the first is heard loudest over the ensiform cartilage. July I2th. — Last night, about half-past eleven, p.m., a severe paroxysm of dyspnoea, threatening suffocation, came on. The house-surgeon. Dr. Dobie, enlarged the inci- sion made by Mr. Syme, upwards, and inserted a common-sized tube into the trachea and larynx, after dividing the cricoid cartilage. To-day she is again better, the opera- tion having been followed with immediate relief. She still breathes, liowever, with difficulty througli the tube. The countenance is livid and anxious, extremities cold, pulse feeble and fluttering, surface bedewed with a clammy sweat. She now gradually sank, and died at half-past eleven, p.m., on the 14th, the embarrassment of the respiration being apparently increased by the difficulty of expectoration. Imme- diately before expiring, she ejected through the tube about ^j. of dark gre^'-coloured foetid pus, of the consistence of thick cream. 570 DISEASES OF THE CIRCULATORy SYSTEM, The treatment throughout the progress of the case was directed to alleviating tlie cougli and expectoration, by means of anodj'ues and expectorants, and diminishing the paroxysms of dyspnoea by means of diffusible stimuli. Cupping over the sternum, and the occasional application of leeches, were employed, and for some time tliese remedies undoubtedly caused great relief. The surgeons of the Infirmarj- were unanimously of opinion that the aneurism did not admit of relief from any operation. Latterly the propriety of tracheotomy or laryngotomy was discussed as a palliative, and ultimately tried with the eflect already described. Sectio Cadaveris. — Thirteen hours after death. The edges of the wound through which the larynx had been opened were thick- ened, the surrounding muscles discoloured and infiltrated with pus. Thorax. — The heart, aorta, and parts connected with the aneurism, were removed en masse, and carefully dissected, with the following results: — the heart and its valves quite healthy, with the exception of slight thickening of the margin of one aortic valve. The arch of the aorta immediately above the valves considerably dilated, and tlie whole of its internal surface thickly studded with atheromatous and calcareous plates. The whole arteria innominata dilated into an aneurismal swelling of a round and somewhat flattened form, having a diameter of fully three inches. The tracliea is pushed by it towards the left side, as represented in the accompany- ing figure, in consequence of which the incision that was made in the median line during the operation, was witliin one-eighth of an inch of the aneurism. Tlie tumour, by pressing on the right side of the trachea, caused much bulging into and diminu- tion of its calibre. The left innominate vein was nearly obliterated. The remains of its interior contained a softened clot resembling pus, which communicated by a small opening through the aneurismal sac witli a portion of the laminated clot, which occupied about three-fourths of its internal cavity. The opening into tiie sac from the aorta was about the size of lialf-a-cro\vn, and presented a sharp circular margin. Posteriorly the nerves were reddened, and for the most part enlarged, and firmly united to the posterior waU of the tumour. The superior lar^'ugeal nerve was healthy, being above the tumour ; but the inferior was compressed and imbedded in thickened cellular tissue. The posterior half of right lung was partially covered with recent Ij^mph, not adherent, and the pleural sac contained two or three ounces of sero-purulent fluid. The lower lobe of the right lung was hepatized ; and on cut- ting into it, several abscesses up to the size of a cherry were found. The left lung- was oedematous, and its bronchi were filled with muco-purulent matter — otherwise healthy. Abdomen. — The liver presented the incipient waxy appearance. The .spleen was dark in colour and pulpy, almost diffluent in consistence. The kidnej's were crowded with minute cysts, and the cortical substance considerably atrophied. Commentary. — This case terminated in the usual way, by pressure on the nerves of respiration, causing Jyspncea, and at length partial latent pneumonia. The double clear sound over the aneurismal tumour I have been in the habit of attributing to the flux and reflux of the blood over a sharp vibrating opening into the tumour. In few aneurisms were these sounds more decidedly present than in the case under consideration, and few after death presented an opening having the margin in question better formed. In another case of aneurism of the innominate artery (that of John Hunter), examined at the commencement of the winter AXEURIS3I. 571 / session 1856-7, the tumour was very distinct in tlie neck above the claviclr", but -svitliout sound of any kind. It was determined after death that the arteria innominata was dilated to the size of a thumb, and gave origin to the aneurism, which was globular, and four in- ches in diameter, without any circular margin, but rather by ^ means of a narrow neck, as in Fig. 425. The sounds heard over tlie ^ heart, however, in the case of Catherine Syme, changed their character as "the disease advanced. At first, double valvular disease was suspected, but latterly, when the murmurs became reversed, and it was most carefully determined, by repeated examinations, that the niurmur at the apex was with the second, and that at the base was with the first, sound, they were attributed to propagation down- wards from the aneurismal tumour. I am by no means satisfied, how- e^■er, that this theory is correct with regard to cardiac murmurs so distinct as those in the present case, associated with aneurismal tumours and a healthy heart. I con- tent myself, therefore, for the present, with placing the facts on record, as their accuracy is undoubted, and they were con- firmed not only by my own repeated examinations, but by those of tlie clinical class and of the clerks, all of" whom took great interest in the case. The question of putting a ligature on the vessel having been decided by the Infirmary surgeons in the negative, the only other question of treatment Avas the prolongation of life. The source of danger was evidently the dyspnoea, and the frequent attacks of spasmodic laryngeal obstruction, so common in aneui-ismal cases from pressure of the tumour on the recurrent nerve. The trachea was also considerably pressed upon and pushed Fig. 424 Fis. 425. Fio-. 424. Rough sketch of the aneurism aud adjoming parts ; a, opening into the larynx : Z>, hne of original incision which inferiorlv came close upon the tumour ; c, aneurismal tumour ; d, point where the obstructed vena innominata had ulcerated into the tumour ; e, right carotid ; / right jugular vein ; g, left carotid ; h, left subclavian. Fio-. 425. Diagram of an aneurism of the arteria innominata, in which the tumour sprung from the dilated vessel with a narrow neck, and in which no sounds were audible. 572 DISEASES OF THE CIRCULATOBY SYSTEil. aside ; but this could not liave accounted for the paroxysms of suffocat- ing dyspnoea, for although diminished in calibre, it was still largely open for the admission of air. On the other hand, the recurrent nerve was found after death thickened, and embedded in dense cellular tissue immediately behmd the tumour. Under such circumstances, it has been proposed, by passing a tube into the larynx or trachea, to avert the effects of these spasms. In the present case, tracheotomy could not be peifornied ; and whenever the deep-seated venous obstruction is of such a character as to cause enlargement of the supei-ficial veins, laryngo- tomy is the operation that should be attempted. This at length was accomplished with momentary relief ; but I have no hesitationin say- ing that the difficulty of expectoration, and the consequent clogging of the air tubes, led to results equally distressing and fatal as the spasmodic attacks. It has, indeed, been said, that in these cases the operation is generally delayed too long, and that by waiting until there is much secretion of mucus and diminution of strength, no very good effects can be reasonably expected. But in cases of aneurism, it is at best only to be considered as a palliative ; and considering how very difficult expec- toration must always be under such circumstances, I consider it very doubtful whether it is ever justifiable except as a dernier ressort. Cer- tainly the case now recorded is anything but favourable to the practice. In this case, it was observable that after the incisions in the integu- ment weie made, without tracheotomy having been performed, great relief was occasioned, which continued upwards of two days, "Was this owing to the few ounces of blood lost during the operation, or to the idea which she had adopted that the operation would cause relief? However it may be explained, there can be no doubt that the excessive dyspnoea and other urgent symptoms were alleviated as if by a charm, in consequence of the unsuccessful attempts to open the trachea. Case CXI.* — Aneurism of Transverse Ao'rtic Arch — Chronic Pericarditis v;ith Effu- sion — Tubercular Lungs — Anasarca — Former Popliteal Aneurism cured by com- pression. HiSTORT. — George Fairweather, set. 32, a labourer — admitted January 20th, 1854. Originallj- a farrier, he entered the army in 1839, and served twelve years. In 1842. while in India, he was laid up with rheumatic pains. A year ago, while employed in the Edinburgh police force, he wa.s obliged to run a great distance in the dis- charge of his dut}-. Shortly afterwards, an aneurism made its appearance in the right popliteal space. Of this he was cured in the Glasgow Infirmary by means of compression. He has since been troubled with cough and pain in the breast, and between the shoulders. Last August he became very hoarse, and entered the Glas- gow Infirmary, where he remained for two months. Towards the close of that period he noticed that his feet were swollen, and began to sufler fi-om palpitation, with pain in the prtecordial region. He was dismissed from the Hospital as incurable. The swelling in the ankles now increased, and passed up the legs to tlie abdomen. On the 1st December last he returned to the Glasgow Infirmary, and left it three days ago. without having experienced any rehef. Since then his urine has become much diminished, and yesterday it was entirely suppressed. * Reported by ilr. Almeric Seymour, Clinical Clerk. ANEURISM. 573 Symptoms on Admission. — The point where the apex of the heart beats cannot be made out ; the cardiac impulse is not felt in its usual position ; and the cardiac sounds are inaudible over the region of the apex. At the base of the heart the sounds are quite healthy, and also over the centre of the sternum. The transverse cardiac duluess is fully four inches. There is an unusual dulness above the left nifyple, extending over a space about the size of the palm of the hand; here the nor- mal cardiac sounds are heard. They are also heard, unaltered in character, all over the manubrium of the sternum as high as the first intercostal space. Pulse G6, very weak and irregular, and somewhat stronger in the right wrist than in the left. Over the right lung percussion is normal ; posteriorly there is dulness at the lower two- thirds of the left side. Loud, sonorous, and sibilating rales audible over most of the chest on inspiration and expiration: the latter movement being much prolonged. Cough troublesome, and accompanied with a peculiar crowing sound. Sputum froth}-, gelatinous, and tinged with blood. When the cough comes on he has great dyspnoea, and respiration is accompanied by a wheezing laryngeal sound. He can- not lie upon his right side, from a sensation of choking that comes on ; he feels easier when in a semi-erect position, or on the left side ; dyspnoea is most trouble- some at night. Tongue moist and furred ; appetite good ; has a feeling of oppressive tightness in the epigastrium after taking food ; hepatic duluess four inches ; bowels rather loose. A small quantity of urine has been passed since last night ; it deposits a pink sediment, which clears up on being heated ; sp. gr. 1022. The whole surface of the body is oedematous ; abdomen and scrotum much distended ; face and hands livid, and cold to the touch ; feels cold all over the surface of the body. 5 Infus. Digitalis % iss ; Sp. uEtlier. Nitric. 3 iij ; Acd. Potassce. 3 iss ; Aquoi % iv. M. One ounce to he taken three times a day. Progress of the Case. — January 'list to 26lh. — Has continued the above mix- ture, and was ordered to apply very strong infusion of digitalis over the abdomen. The anasarca is much diminished, fifty ounces of urine having been passed within the last twenty-four hours. Hands rather cold. Physical signs as before Pulse 120, of better strength. No diflerence in the pulse of either wrist. The cough being very troublesome, last night he was ordered a mixture containing ^S^j. JSther. Xitric. and Sul. Mur. Morphice. Considerable dyspnoea after taking solid food. A bed-sore has formed on the left gluteal region, from his always lying on that side. J^ Potassce Bitart. 3 j quater in die. Jan. 26ih to Feb. 1st. — The dropsy has become much less, having entirely left the legs ; the size of the abdomen is also diminished ; there is more anasarca on the right side of the chest, on which he generally lies, than on the left. On one occasion, the amount of urine passed amounted to 150 ounces in the twenty-four hours. On the 31st he had great pain under the left clavicle, with fric- tion at the base of right lung ; six leeches icere ajyplied over the painfid sjmL As the cough is very troublesome, let him take a drachm of Tr. Opii Cam2}h. at bed-time. Continue the digitalis internally, but stop the external application. Feb. 1st to &th. — Cough has been very troublesome, but has been relieved by opium, Sp. ^Ether. Mt. and chloroform internally. Gth. — The cardiac sounds may be heard, normal in cha- racter, over the right side, commencing from the third rib ; the impulse may also be seen and felt in that locality. There is also dulness, which may be observed as high as the top of the sternum, extends in a sloping direction to the third rib, and can be elicited down the whole right side. Feb. I5ih. — Almost total dulness and want of expansion over the left side before and behind ; nor is any respiration heard except at the apex. Apply a blister (6 by 5) to the middle and inferior part of the left side. Feb. IGth to 25fh. — On the 16th had a violent paroxysm of coughing, last- ing for ten minutes, and attended with profuse purulent expectoration. Ordered the following :— 1^ Misturoi Scilke § v ; Tr. Opii Camph. 3 j. A tabh-spoonful to be taken 57-1 DISEASES OF THE CIRCULATORY SYSTEM. vjhen the cough is urgent. A morphia draught at bed-tirae. These remedies relieved the cough. The sputum became more frothy and gelatinous. He also slept better. On the 25th, there is ahiiost total dulness over a space nearly three inches in dia- meter, in the left sterno-clavicular angle, with gradually increasing clearness towards the outer subclavian space. There is no respiration in the former region, and mode- rate natural respiration in the latter. Over the rest of the left side, in front and laterally, percussion is very dull, and respiration all but absent. There is general dulness, and very feeble respu-ation in the upper half of the left back, with prolonged sibilation after coughing ; respiration is bronchial and feeble in the lower half On the right side, percussion is clear, with puerile respiration, both before and behind, except for about three inches to the right of the upper sternum, where percussion is somewhat dull He has still occasionally a difficult and copious expectoration of a tough mucous matter. Cardiac sounds natural, except a very slight tendency to reduplication of the second. Feb. 2oth to March Ath —Continued in much the same state till the evening of March 3d, when another fit of coughing and dyspnoea came on. Sulphuric tether, and others of the medicines mentioned above, were adminis- tered. He sunk, however, and died at half-past 11 a.m., March 4th. Sectio Cadaveris. — Forty-eiyht hours after death. Thorax. — The pericardium was much distended, and contained 12 oz. of clear serum. Its lining membrane was very hard in soaie places, from the presence of chronic lymph. The heart and its valves were health3^ Between the arteria inno- minata and the left carotid was a small dilatation of the arch. Immediately below the origin of the left subclavian, an aneurism, the size of a large orange, of rounded form, and three inches in diameter, originated from the aorta by a thick neck. It pressed forward and to the left side, immediately above the pericardium, slightly compressing the trachea and left bronchus. The recurrent nerve was seen to pass in front of the aneurism uninjured. On examination of the aneurism, it was found that the internal and middle coats of the aorta had given way, the pouch being formed of the outer coat, and of condensed areolar tissue. Above the aortic valves, and over the arch, the inner layers of the vessel were atheromatous. In the cavity of the left pleura were two pints of serum and some chronic bands of lymph. The left lung was universally condensed, and on section was seen to contain a large quantity of tubercle, generally in masses the size of a pea and larger. Some of these had sof- tened, but there was no cavity. The intervening pulmonary tissue was condensed and hepatised. Rigiit lung was voluminous, with a few miliary tubercles scattered through it. Abdomex. — Abdominal organs healthy. Commentary. — In this case during- life it was carefully determined that the cardiac sounds were healthy, that the cardiac dulness was in- creased to twice its normal extent, and that there was unusual dulness above the left iiipi)le in the sterno-clavicular region. These facts were subsequently explained by the demonstration, on dissection, of a healthy heart, of chronic pericarditis with effusion, and of a large aneurism springing from the transverse aortic arch, stretching towards the left side. Over the aneurism in this case no sounds were audible, a circum- stance probably attributable to the thick neck, by which it came oif fi'om the main vessel, as explained in the last commentary. The limb, whicli was the seat of the popliteal aneurism cured by compression, was sub- sequently injected and dissected with care, and may be now seen forming a very tine preparation in the surgical collection of Mr. Spence ANEURISM. 575 of this citv. The popliteal artery is completely occluded, the circula- tion having been maintained through the enlarged anastomosing vessels. Case CXII.* — Aneurism of Loiver Portion of the Thoracic Aorta, pressing on the Thoracic Duct — Aneurism of Abdominal Aorta — Chronic Ulcer of Stomach — Chronic Tubercular Abscesses of Liver and Riijht Kidney — Liver and Left, Kidney Waxy — Leucocythemia. History. — Janet Young, act. 50 — admitted June 16lh, 1854. States that her appetite has been impaired for the last three years, that she has been subject to chronic rlieumatism, and last September had a severe bowel complaint, which lasted fourteen weeks. For the last ten years has suffered from vomiting, which has been more or less constant, and the matters ejected have occasionally been of a dark cop- per colour. Since the occurrence of the diarrhoea she has become very emaciated. Symptoms on Admission. — The whole body is extremely emaciated, and she is very weak. Tongue moist and clean. Appetite pretty good. No vomiting at present. Complains of pain and tenderness in the epigastrium, and on palpation a distinct tumour can be felt, with a strong impulse, a little to the right of the mesian line in the position of the pylorus. It . is apparently solid, of uneven shape, about the size of a hen's egg ; but its limits cannot be accurately determined. On auscultation over the tumour a loud blowing sound, synchronous with the aortic pulse, is audible. Bowels regular. Apex of heart beats between sixth and seventh ribs. Its size and sounds are normal. Pulse 88, of good strength. Urine pale, sp. gr. 1010, slightly coagulable on the addition of heat and nitric acid. Respiration and other s3'mptoms normal. Ilabeat Tr. lodid. Ferri min. x. ter indies. Progress of the Case. — On the 19th of June she commenced vomiting, a symp- tom which continued, with slight intermissions, during the rest of the month, gene- rally coming on four hours after taking a meal. There was also considerable pain in the region of the tumour, which was relieved by the occasional application of two leeches, followed by warm fomentations. Various remedies were given with a view of checking the vomiting, of which small pieces of ice allowed to dissolve in tlie mouth appeared most effectual. Nourishment was frequently given in small quan- tities. During the months of August and September, the vomiting became far less frequent, although occasionally still distressing. All this time nutrients were con- stantly administered with wine, and although these were frequently retained, and even taken with appetite, the emaciation progressively increased. On examining the blood, it was found to possess an increased number of colourless corpuscles. A series of observations also was made to determine whether fat was passed in the foeces, but they were quite healthy, and the bowels on the whole were regular. She also slept well. During the months of September, October, and November, she remained much in the same condition, occasionally complaining of a little more local pain in the epigastric tumour and abdomen, and latterly of cough and palpitation. For the next three months, there was at times severe vomiting, but otherwise no marked change. The urine remained coagulable and of low specific gravity, occa- sionally presenting under the microscope a few waxy casts and pus corpuscles. During March the emaciation was apparently extreme, the pulse weak, and nutritive injections by the rectum were added to the nutrients and wine given by the mouth. The vomiting was greatly diminished, but for some days she suffered from conjunc- tivitis. There was also restlessness at night, which was relieved by morphia * Reported by Mr. T. Walker, Clinical Clerk. 576 DISEASES OF THE CIRCULATORY SYSTEM. draughts. Her weakness very gradually increased, and without any other symptom she expired, April 16th, 1855. Sectio Cadaveris. — Forty hours after death. Thorax. — Both lungs had some puckerings near the apex, and contained some old tubercular matter. The heart was healthy. Near the lower part of the thoracic aorta was an aneurismal dilatation, about the size of a walnut, which projected to the left of the vertelDral column, directly over the thoracic duct, which it appeared to compress. Abdomen. — Arising from the anterior part of the abdominal aorta, at the root of the coeliac axis and superior mesenteric artery, was an aneurism of a rounded form, about two inches in diameter, which projected forwards, and was nearly filled with firm layers of fibrin. Both the vessels named were thrust forward, separated to the extent of an incii, but were in themselves healthy. (University Museum, Prep. 2333, a.) The stomach was of natural size; on its lesser curvature, about halfway between the cardiac and pyloric orifices, but rather nearer the latter, there was an ulcer of an oval form with depressed surface, callous margin and base, and about the size of a filbert. The edges were smooth, as dense as ligament, presented on section a white glistening appearance, and in some places were a quarter of an inch thick. The fiver weighed 2 lbs. On section it contained a number of masses of tubercular matter. Some of them had softened and given rise to abscesses. The hepatic tissue itself was waxy. The right kidney was very small, being 2^ inches long and IJ inch broad. On section there escaped a yellowish white fluid and some cheesy matter. The tissue of the kidney was quite gone, and its place sup- plied by the cavities, which presented the usual appearance of scrofulous abscesses. This kidney weighed one ounce. The left kidney was of large size and waxy. The spleen was natural. Commentary. — On the admission of this woman it became a question whether the tumour in the pyloric region was an aneurism or a can- cerous mass lying over the aorta. The symptoms were those of organic disease of the stomach. As the disease progressed and the emaciation became more urgent, the tumour could be more easily handled, and its rounded form and marked impulse favoured the opinion of its being aneurismal. The frequent vomiting, however, still pointed to disease of the stomach, and served to explain much of the emaciation which existed, but not altogether, as it was observed, that she still retained a considerable amount of nourishment, especially at some lengthened periods when the stomach was quiescent. The idea was then formed that there might be some disease at the head of the pancreas ; but, after careful examination, no unusual amount of fat could be detected in the stools. Latterly the vomiting was comparatively trifling, but still the emaciation was progressive, and became at length extreme. On dissection after death, these facts were explained by the discovery of a small thoracic aneurism pressing upon the thoracic duct in addition to the abdominal one, which had become rounder and harder than when first discovered. The lungs and liver exhibited well-marked examples of tubercular and scrofulous deposits which had been arrested in their progress. The diminution of the stomachic symptoms also Avas accounted for by the gradual healing and cicatrization of the gastric ulcer. It might have been supposed that the abdominal aneurism was progressing towards a spontaneous cure, as it was nearly filled with ANEURISM. 577 dense coagulated fibrin. The commencement of a tlioracic aneurism above, however, sufficiently accounts for this, as will be explained more particularly in the commentary on the next case. Case CXII.*— Aneurism of the Superior Mesenteric Artery and Aorta — Obscure Aneurism of Descending Thoracic Aorta — Treatment hy the Method of Valsalva — Pleuritis — Caries of the Vertebrce, Softening of the Spinal Cord and ParapUgia — SvAden Death hy Poisoning with TiiKture of Aconite. History. — Henry Smith, eet. 3.5, sailor — admitted December 19th, 1849. States that, about twelve months ago, while at sea, he received a severe blow on the back from the tiUer of the vessel He was knocked down, and lay insensible for a short time. Since then he has experienced pain in the abdomen and back, and latterly pulsation in the abdomen, and a sensation of tingling and numbness in the thighs, legs, and feet, especially on the left side. States that about three weeks aftpr the accident, he was admitted into tlie Liverpool Inlirmary, where he remained for about eleven months. He was treated by opiates and other anodynes, and latterly also by leeching and cupping over the pained part of the abdomen. From this treatment he did not receive much benefit. Symptoms ox Admission. — On admission, he is of a dark complexion ; appearance strong and robust. A tumour is distinctly seen pulsatmg in the left hypochondriac region. It is of an oval form, and measures about three inches transversely ; its long diameter cannot be ascertained, as its superior portion ascends below the ribs ; but the inferior and lateral margins can be distinctly felt. He complains of great pain and tenderness in the region of the tumour, and of a beating wliich is increased on exertion, and also upon assuming the erect posture. He feels easiest when lying doubled up, resting on his elbows and knees, and in this position he is generally seen durmg the day. The pulsation of the tumour is forcible, synchronous with, or immediately succeeding, the heart's impulse. On auscultation, a soft bellows mur- mur is distinctly heard over the tumour, and is loudest at the lower part. The apex of the heart beats about an inch below the nipple. Impulse tolerably strong. On percussion, the cardiac dulness extends transversely about two and a half inches. On auscultation, the sounds are normal in character ; the first is heard loudest over the apex, just below the nipple ; and the second is most distinct at least three inches above and to the inside. He has no cough or expectoration. The right side of the chest is more resonant on percxission than the left, both in front and behind. On auscultation, the respiratory murmurs are normal Appetite tolerably good. Bowels regular. Urine natural in quantity; sp. gr. 1-025, not coagulable; presents a deposit of Uthate of ammonia. Ordered a morphia draught at night. Progress of the Case. — December 23d. — Has never slept properly since his admission. States that it requires a very large opiate to produce any efiect upon him. Ordered to be bled to syncope, and his diet to be as follows : — Breakfast, Bread, four ounces ; milk, eight ounces. Dinner, Steak, two ounces ; bread, two ounces. Supper, Bread, two ounces ; tea, eight ounces. 24tt. — He was bled to thirty ounces, without syncope or nausea being induced. The blood drawn exhibits a distinct buffy coat. Pulse 88, weak and soft. Pain easier, and sleeps better at night. 2Mh. — Dislikes beef for dinner, and would prefer a little rice pudding with the oread at dinner. To have one ounce of mutton, and three ounces of rice pudding for dinner. Twelve leeches to be applied over the tumour. 26th. — Leeches bled freely, * Reported by Messrs. H. M. Balfour. TV. Clark, and A. Dewar, CHnical Clerks. 37 578 DISEASES OF THE CIRCULATORY SYSTEM. and he is now easier. Urine still presents a deposit of lithates. 30^^.— Complains of constipation ; pain in abdomen rather increased. To have Elect Senna, 3 j daily. Ten leeches to be applied to tJie region of the tumour. 3lst. — Leeches did not bleed so well Paul stQl severe. Applicet. Emplast. Cantharid. (3x3) 2Mrii dolenti. 1850, January 2d. — Blister gave some relief Pulse stronger. Ordered to he hied to § xij. 3d — The blood exhibited the Ijuffy coat, but in a less marked degree than formerly. No faintness or nausea was induced. Tivo ounces of bread to be taken off his breakfast and half an ounce off his supper. To be allowed a bottle of lemonade daily. 1th. — Sleeps very badly. 5 Sol. Mur.Morph.; Tinct. Eyoscyam. a.a., 3ss; Aqua 3ss. M., to he taken every evening, dth. — Sleeps rather better. Pain in tumour somewhat increased. Eight leeches to be applied. lOth. — Leeches gave relief 13th. — Still complains of constipation, lb have a cohcynth and hyoscyamus pill daily. IQth. — States, that for the last three or four days he has felt much stronger, and the pain and pulsation in the tumour have increased proportionally. Ten leeches to be applied. I'tth. — Leeches gave relief, but stUl he does not sleep weU. 21s/. — Pulse tolerably strong. Ordered to be bled to syncope. 22d. — He was bled yesterday to twenty-six ounces, without mducing faintness or nausea. To-day his pulse is weak and soft, and he expresses himself much easier. The blood exhibited a distmct buflfy coat. Urine loaded with lithates 2bth. — Yesterday he was ordered to be bled until some faintness was induced, and 28 oz. were abstracted before that effect was occasioned. To-day the blood is cupped, the pulse weak, and the urine loaded with lithates. A chloroform draught at night. 2dth.— Again bled to 10 oz. Feb. Sth. — Great pain in the tumour at night, preventing sleep, for which sedative draughts and enemas afford little reUef. 20 oz. of blood were in consequence taken from the arm to-day, which produced faintness, and at once removed the pain. \^th. — Size and unpulse of tumour evidently dimmished. Does not think he is much weaker since admission, but is unable to sit up so long. Pulse small. To-day pain returned in tumour. 12 leeches to he applied. March 2d. — Bled yesterday to 14 oz., without inducing syncope. Blood not buffed. IQth. — Pam returned with violence. Again bled to 23 oz. I9th. — Again bled to 8 oz. He has continued on the low diet, which was altered to-day as foUows: — Breakfast, 1 biscuit (1^ oz.), tea, half a pint; Dinner, 2 biscuits (2^ oz.), eggs 2; Supper, 1 biscuit (IJ oz.), tea, half a pint. The analysis of the blood drawn on the 19th is as follows: — Specific gravity of serum . . . . . 1028 SoUds in 1000 parts :— Fibrin 4-6 Globules 42-7 Serous solids 88-2 Water 864-5 1000 Ajwil Gth.—Bled again to 13 oz. loth. — Was strong enough to walk in the back- green, but felt exhausted after it. 21s^ — Bled yesterday to 34 oz., at his urgent request, insisting that he felt nothmg, until he fell back in a state of syncope, from which he slowly recovered. To-day appearance anemic, pulse feeble, feels weak. May 5th. — Has been suffering from constipation, which has been relieved by colo- cynth and henbane pills. Pulsation in the tumour evidently diminishing. To-day, complains of shooting pains in the back, between the shoulders, and do-mi the arms. As he dislikes the eggs, 4 oz. of calves'-foot jelly were ordered instead, the other articles of diet remaining the same. June 1st. — Considerable pain, and no sleep for three days. 8 leeches to he applied. 11 ih. — 2 oz. of meat instead of the calves'-foot ANEURISM. 579 jelly. July \1tli. — Has occasionally been walking a little in the open air, which, however, causes some pain. Apply 12 leeches. Aug. dih. — Pain on walking, caused by hemorrhoids, for wluch injections of cold water have been ordered with benefit. IGlh. — Pain in tumour returned. Apply 12 leeches^ which caused fahitness, for which 3 ij of ivine were given. 30th. — Went out of the house yesterday by per- mission. Oct. 20th. — Has been allowed to go out of the house once a-week for exercise. To-day pain in tumour severe. Apply 8 leeches. 2oih. — The tumour was observed to be movable to-day. "When he lies on his left side, the prominence is concealed below the cartilages of the ribs, but when he turns on his back, it moves three or four inches towards the right side. He says he has only noticed this mobility during the last week. A'ov. 20th. — Complains of a sharp pain under the left clavicle, and six leeches were applied there in consequence. 2Gih. — Pain under clavicle con- tinues, but was removed by cupping on the 22d and to-day. Dec. 2~tth. — Bled to z viij, to remove pain in tumour. 1851, February nth. — Since last report, has continued to feel pain in the tumour. Again bled to 3 viij. 20e was in the Infirmary two years and a half, and during the whole of that time its progress excited unusual interest. We had to do with, — Is/, A thoracic aneurism ; 2d, An aneurism of the superior mesenteric artery ;* 3tZ, The treatment of aneurism by Val- salva's method ; 4/^, Acute passing into chronic pleurisy ; 5 /A, Gradually increasing, and at length complete paraplegia; and 6//i, Poisoning by aconite, and the most rapid death by that drug on record. I shall notice the principal facts of his case in succession, point out the difficulties of the diao-nosis, the effects of the treatment employed, and state what occurs to me with regard to the mode of his death. The Thoracic Aneurism. — The thoracic aneurism in Smith's case was not suspected during life. On looking back upon the facts observed when he was admitted, I find that, after receiving the injury which pro- duced the disease, he complained of pain in the back, as well as the abdomen. It is also stated that, when admitted into the Infirmary, "the right side of the chest is more resonant on percussion than the left, both in" front and behind." These facts were too vague at the time to enable me to distinguish a thoracic aneurism in addition to the abdominal one, more especially as the respiratory murmurs were normal ; there was no cough, expectoration, or other pulmonary lesion. The idea, therefore, of a thoracic aneurism never occurred to me, nor if it had is it likely * For other cases of aneurism of the superior mesenteric artery, see case by Dr. Donald Monro, in " Observations on Aneurism." by the Sydenham Society, p. 130 : by Dr. EUiotson, in Lancet, August 29, 183.5; by Dr. Arthur Wilson, Medico-Chir. Transactions, vol. 24 ; by Mr. James Douglas, in Medical Gazette, February 25. 1842 : by Dr. "W Gairdner. inMonihly Journal of Med. Science, January. 1850; by Dr. John Ogle, in Trans, of Patholog. Soc, vol. 8 ; and by Dr. Haldane, in Edinb. Med. Journal, October, 1858. 582 DISEASES OF THE CIKCULATOEY SYSTEM. that it conld have been confirmed, altliough now, on looking back, tbe importance of tlie facts above stated is apparent, and they prove that such aneurism really existed when he first came into the house. On going over the reports which were kept of his progress during the two years and a half he was in the infii-mary, I find it stated that, on the 6th of April, when under the care of Dr. Christison, he "complained of shoot- ino- pains in the back, between the shoulders, and down the arms." On the 20th of November, in the same year, when under Dr. Alison's care, he "complained of a sharp pain under the left clavicle." On both occa- sions the pain was of short duration. I can find no other symptoms which could be attributed to the thoracic aneurism until the 29th of January, 1852, when he was seized with all the symptoms of acute pleurisy. For a long time previously his chest had not been examined, but when, on this occasion, it was percussed, the whole of the left side was found to be dull, both anteriorly and posteriorly. This, as well as all the other symptoms noticed at that time, was ascribed to pleurisy witli a large amount of exudation, and on carefully weighing these symp- toms and physical signs, I do not see how we could have arrived at any other conclusion ; for a pleurisy did certainly exist, as proved by the fric- tion during life, and by the dense chronic adhesions found after death, althoucli now we can have little doubt that the dulness, increased vocal resonance, and other signs, were for the most part dependent on the aneurismal tumour. Another symptom usually present in thoracic aneurism Avas absent, viz., hannoptysis, or bloody sputum. On one occa- sion only was this observed, viz., on February 2d, four days after the pleurisy was established. I remember that it induced me to examine Lis chest with the utmost care, with a view of discovering if pneumonia also existed ; but, as stated in the report, no crepitation could anywhere be discovered. I am satisfied, from the careful examination at that time, as well as when he first came into the house, that there was no blowing or other abnormal sound in the chest caused by the aneurism. It is not to be wondered at, therefore, that from this period the dulness on the left side of the thorax, unaccompanied with other symptoms, should be referred to chronic pleurisy, rather than to a thoracic aneurism. It so happened, also, that there was a man in the ward labouriiig under chronic pleurisy on one side, who presented all the thoracic symptoms and signs which existed in Smith. It appears, therefore, that the detection of the aneurism was almost impossible; for, supposing even that it had been suspected and that attention had been directed to confirm such a theory, I am not aware of any arguments by which it could be supported. An idea, bowever, that it would be impossible at any time to discover such an aneurism, would be erroneous, and would do discredit to physical dia- gnosis ; for there can be little doubt that had the chest been carefully re-examined — say a short period before the attack of pleurisy — I think it would then have been apparent that a tumour existed in the chest, and if so, that tumour, fi-om its seat and concomitant circumstances, would have been declared to be aneurism low down in the thorax. It was sim- ply because no suspicion of its existence occurred to us, and because no physical examination of the chest was made at that time, that the tumour was not detected during life. The Abdominal Aneurism. — "When Smith entered the house the ANEURISM. 583 abdominal aneurism was of considerable size. It measured three inches across. Its inferior and lateral margins only could be felt, the superior portions being covered by the ribs. The impression conveyed to me by examining the tumour, however, was that it was about the size of a cocoa-nut. It was prominent, especially when he stood up, and pulsated strongly. There can be no doubt that its volume must have undergone considerable diminution; for, previous to his death, it felt through the integuments about the size of a small hen's egg ; — in some of the reports, it is said of a pigeon's egg, and of a walnut. Yet, as you see, it is the size of a laro;e oranue, elongated. Its form is a long oval, one extremitv of its long axis resting deep upon the vertebra?, the other directed towards the skin. Hence, during life, we could only feel one of its rounded ends. You observe, however, that the whole tumour is dense and resistant, — and on section it presents numerous concentric laminte of coagulated fibrin, with a small canal running through the centre, keeping up the communication between the aorta and the superior mesenteric artery. The man presented habitually a jaundiced skin, which was doubtless owing to the pressure of the tumour on the duode- num and biliary ducts. The Paraplegia and Spinal Softeninr/. — He first complained of weakness in the lower extremities early in January 1852 ; at the end of tiuit month my period of attendance on the wards ceased. In the report of March 1st, I find it stated that there was decided paralysis of motion in the inferior extremities, while sensation still resulted when they were touched. On April 8th, the paralysis was complete, — that is, volition failed to cause movement in the lower extremities, and stimuli applied to them failed to induce sensation. Involuntary movements, however, occurred, consisting of twitchings and startings, but he never had pain in the limbs. In cases of myelitis the usual symptoms are, pricking and tino-jing in the soles of the feet. These symptoms were absent, and the reason of this may, I think, be found in the nature of the softening in the spinal cord. It contained no granular cells, the result of exudation, and its transformation into fatty granules ; but the tubular substance of the cord was broken down, forming round and oval fragments of the tubes. Hence it was a mechanical softening, the result of gradual pressure merely. These distinctions have not been hitherto suflSciently attended to in pathology. (See p. 310.) You will observe that the aneurismal tumour commenced pressing on the left side, and fi-om before backwards, and the symptoms indicate that weakness was felt in the left inferior extremity before the right one was afi'ected, — and that motion was paralysed first, sensation last. Treatment h[/ Valsalva's Method. — A short tinie previous to the admission of Smith, I treated another case of abdominal aneurism by the method of Valsalva, for a period of foity days, — at the expiration of which time, he walked out of the house, with little assistance, to the nearest cab-stand, a distance of nearly 250 yards, and left the city.* In the case of Smith, therefore, the bleedings were more frequently repeated, and greater in amount, while the diet w-as even more dimi- nished ; and yet, after nearly a month's treatment, the pulse was of such * See Monthly Journal, February 1850, p. 169. 584 DISEASES OF THE CIRCULATORY SYSTEM. good strength, tliat I ordered venesection to syncope — an etFect tliat was not pioduced after the loss of twenty-six ounces of blood — so that the clerk, afraid to proceed farther, bound up the arm. Three days after- wards, twenty-eight ounces of blood were removed, with the effect of only producing a feeling of faintness. Similar bleedings were practised at no distant intervals, besides numerous applications of leeches, and the restricted diet; and yet the report of 21st April 1850 is, "that he was bled to thirty-four ounces, at his urgent request, insisting that he felt nothing, until he fell back in a state of syncope." I am induced to sup- pose, therefore, that in this case, as in the preceding one, the treatment had not been carried out to its full extent. The nurse, indeed, now informs me, that perhaps during the first two months his diet was really limited ; but she thinks so simply because, at that period, he sufi^"erecl great pain and seemed very anxious to follow the advice given to him. Subsequently, there is every reason to suppose that he obtained food from his companions, or from some other source. I find from the reports, indeed, that whilst his diet was still nominally at a verv reduced amount,^ up to July, he was at the same time walking about with considerable vigour. Fi'om my attempts at carrying out Valsalva's treatment in these two cases, I conclude that it is impossible to practise it on patients in an open ward, or indeed under anv circumstances, without a degree of sur- veiUance that it would be very difficult to obtain. The good effects of the treatment, notwithstanding its imperfect nature, were so evident as to strike all who witnessed it, and to cause the patient continually to request that he might be bled. In fact, after every general bleeding, the dragging pains, and other uneasv sensations, he experienced in the abdomen, invariably left him, and he enjoyed longer or shorter periods of perfect ease ; then, as the pain giadually returned, and it became unbearable, he was again relieved by bleeding ; and so on. During the progress of his case, also, it was observed that the abdominal tumour gradually diminished in size, and became hai'der. In October, the tumour was ascertained by Dr.'Christison to be some- what movable ; but in the following December, when I examined it, it was again stationary. During the whole of 1851 he enjoyed comparative comfort, — occasionally, however, feeling abdominal pain, which was relieved by leeches or bleeding. At the beginning of 1852, the general opinion of all who examined him was, that, on the whole, this case was a remarkable example of the good eftects of Valsalva's treatment. Then, however, the paraplegia came on, indicating that the disease was really not conquered, but, by its pressure backwards, was affecting the spinal cord. Then came the attack of pleurisy and the paraplegia ; and from this period it was evident the disease would terminate fatally. The examination of the body after death was, in this case, not only important, as determining the nature of the aneurism, and in a diagnostic point of view; but it served, in ray opinion, to point out what value ought to be attributed to Valsalva's treatment. It aftords an example of a wide generalisation to which the cultivators of rational medicine have been gradually tending, — viz., that not only is the examination of the body after death necessary for diagnosis and pathology, but that it is essential, in order that we may properly appreciate therapeutics, and the utility of different plans of treatment. Let us suppose, for instance, that ANEUEISil. 585 this man had died at the commencement of 1852 from the attack of pleurisy, and that, as so often happens, we liad been refused permission to open the bodv, my conviction is, that under such circumstances this case would have "been recorded in the annals of medicine as a successful instance of cure by the method of Valsalva. But now, when all the facts are before us, it is evident that the diminution of the abdominal swellino; was owing to the increase of the thoracic one ; and that, as the force of the current of blood became lessened by the enlargement of the aneurismal dilatation above, so the flow of blood was retarded in the tumour below. In consecpience, the concentric depositions of fibrin, the lessened size of the abdominal swelling, and the more permanent relief of pain, instead of being attributable to the treatment as we had supposed, must now be more rationally ascribed to the increase of a thoracic aneui-ism, not detected during life, which had produced these results mechanicallv, and altogether independently of art. The treatment of internal aneurisms by the method of Valsalva, has for some time been discouraged in this country, on the ground tliat it gives rise to a general irritability, and to symptoms of a distressing nature, which are often intolerable; whilst, on the other hand, it is seldom attended by a permanently good efl'ect. In the case before us, as well as in that I formerlv treated, no unpleasant symptoms could fairly be ascribed to the practice ; but, on the contrary, it produced (especially the bleedings) well-marked relief. The question of the permanency of these good effects is, I admit, in no way supported by my experience. But another important practical point, namely, the temporary relief which bleeding causes, without arresting the progress of organic maladies, here meets with an excellent illustration. Poi-' monly when there is aneurism of the innominata, when the weaker pulse will be on the right side. In aneurisms of the arch, on the other hand, the feebler pulse is usually on the left side. The retardation of the pulse, when it occurs, is owing to causes very similar to those which affect its strength. 4. The symptoms, which are present in cases of thoracic aneurism, vary according to the size of the tumour, and the parts on which it presses. When seated at the upper part of the chest, it may, by pressure on the larynx, produce alteration of the voice, more or less cough, and stridulous respiration ; by affecting the branches of the eighth pair, occasion increase or diminution of their special functions; impede deglutition by constricting the oesophagus; or modify the respiratory murmur by pressing on the trachea or larger bronchi. Occasionally there is a crepitating murmur in the lung, with many of the signs and symptoms of pneumonia, for which it has often been mistaken, including rusty sputum, dulness, and increased vocal reso- 590 DISEASES OF THE CIRCULATORY SYSTEM. nance. Pressure of the tumour on the axillary vessels and nerves may induce more or less oedema of the extremities, and paralysis more or less complete. Sometimes there are dull, gnawing, or lancinating pains in various parts of the chest ; but nothing is more remarkable than the size and formidable nature of some aneurisms which have caused little pain. Occasionally there is a feeling of oppression and constric- tion — dyspna-a with or without exertion, and haemoptysis to a greater or less extent. The combination of the results obtained by percussion, auscultation, palpation, and vascular impulse, and the functional symptoms, vary infinitely in different cases, and their careful detection, combined with a knowledge of physiology, Avill in the majority of cases enable us to form a correct opinion as to the nature of the disease, vlt must not be forgotten, however, that there are some cases which have been so obscure as to baffle the efforts of the most able physicians ; and that, generally speaking, the deeper the aneurism the greater the difticulty of detecting its exact nature, and the complications connected with it. It is also well ascertained that the symptoms may be simulated by a tumour situated outside and upon the vessel ; and occasional mistakes, made bv the most experienced surgeons — men who, during their profes- sional lives, have carefully examined a large number of these tumours — prove the excessive difficulty of detecting aneurisms, even when situated in the limbs or in the neck. How much more difficult must be the appreciation of these symptoms, when the aneurisms are below the sternum or clavicles, not to speak of their occurrence deep in the thorax. Yet these very symptoms, tor/ether u-nizance of the patient. Yet such is the case before us. For when I demonstrated to the clinical class at the bed-side the tym- PLEURITIS. 625 paiiitic sound over the right chest on percussion, the absence of heahhy respiration, the metallic notes Avith the respiratory murmurs, and the brazen amphoric vocal resonance, he himself denied that there was any- thing wrong with his chest, and smiled at the trouble we gave ourselves in examining it. In his case, as in Case CXXIV., after the acute rheu- matism subsided, we had the greatest difficulty in keeping him in the house for the purpose of observation. On his o;oing out, however, he himself at length became satisfied that his breathing was not so good as it ought to be, and on his re-admission subsequently, we had the plea- sure, under the influence of nutrients, to see the morbid murmurs dis- appear, the chest gradually contract, and his general health re-establish itself. What might have been the consequence, if by means of phy- sical signs we had not detected this morbid condition, but had dismissed him from the house as soon as he had recovered from his rheumatism, cannot positively be said ; but judging from what followed, I have myself no doubt that he would rapidly have sunk exhausted. I saw him several times after his first dismissal, and he was only supported by the most energetic use of nutrients and wine. Case CXXVIII.* — Empyema, following Chronic Phthisis — Paracentesis Thoracis — Paeuiiw-Thora.x — Singular mode of Death from Enormom Distension of the Sloraach a?id Emphysema of its Coats — Tubercular Pleuritis — Adherent Peri- cardium — Waxy Spleen — Tubercle in the Kidneys. History. — Allan Brown, aet. 26, a gilder — admitted Xovember 26, 1856. States that about twelve months ago, he suddenly, at night, experienced pain about the heart in drawing breath, together with shivering and febrile symptoms. For three days the pain was acute ; it then disappeared, to come back, however, at different times, lasting for a day or two. and then disappearing again. During the six months preceding this attack, he had had a short, and, for the most part, a dry cough, with frothy, white, and gelatinous sputum. This has continued ever since ; and on one occasion, eight months since, he spat up blood. Six months ago he noticed the left side enlarging ; two months afterwards he became unfit for work, and also unable to lie in bed on the right side. About this period he was subject to profuse sweat- ings, which have since gradually declined. His appetite, at no time great, has become yet more defective, especially during the last few months. His thirst has always been considerable. Symptoms ox Admission'. — There is marked depression of the right chest under the clavicle. On the left side there is a bulging in the mammary region outwards and forwards Posteriorly there is a general protrusion of the left side of chest mferiorly, and fulness of the intercostal spaces, but to no great extent, except at the extreme base and over the lumbar region, where there is fluctuation and extreme tenderness on pressure, with redness and increase of temperature. The chest measures — Level of Four inches Nipple. lower. Left side IS 17 Eight side 18J- 16i This examination was conducted throughout while the patient was in the sitting posture. During respiration there is an expansive motion on the right side, espe- cially under the clavicle and in the infra-axillary region, but on the left side there is * Eeported by Mr. H. X. Maclaurin, Clinical Clerk. 40 626 DISEASES OF THE RESPIRATORY SYSTEM. no correspondiDg motion. There is also slight vocal fremitus on the right side, but none on the left. On percussion there is absolute dulness on the left side anteriorly, laterally, and posteriorly. On the right side anteriorly there is comparative resonance, but not loud nor clear, down to the level of the third rib. Below that level, over a region in which the cardiac pulsation may be felt, there is dulness. Laterally and posteriorly the percussion is good. On auscultation on the right side anteriorly down to tlie level of the third rib, also laterally and posteriorly, the respiratory murmurs are dry and somewhat blowing in character and intensified in tone. On the left side no respiration is audible, except near the sternal end of the clavicle anteriorlj^, and near the inferior angle of the scapula posteriorly. In these regions the respiratory murmur is heard faintly. Vocal resonance is greater over right apex, and posteriorly over the whole side, than over the corresponding left. There is great dyspnoea, so that the patient frequently cannot answer questions until he recovers breath. The cough is short, shallow, and gasping, and when excited continues for a considerable time, the patient's face becoming flushed, Sputum is scanty, and expectorated with difficulty. The cardiac impulse is between the fifth and sixth ribs on the right side, an inch and a half below and to the outside of the right nipple. Cardiac sounds healthy. Pulse 130, small and weak. At this stage of the examination the patient Ijccarae much troubled with spasmodic cough, so that further interrogation was considered unadvisable. To have 5 iij- of icine, steak diet, extra milk, and an egg for breakfast. Progress op the Case. — On the 8th and 9th N'oveniber he was troubled with slight diarrhoea. On the 10th he had slight rigors. At evening visit the following facts were elicited : — At the base of the right lateral region, strong fremitus corre- sponding to the respiratory rhythm ma}' be felt on applying the hand. No particular pain exists in this spot, except on pressure, and no dulness can be made out. Fric- tion may be heard with inspiration and expiration as high as the lower third of the scapula posteriorlj% laterally as high as the eighth rib, and anteriorly only at the base. Vocal fremitus unimpaired. Pulse 120; small, weak, and somewhat hard. Kov. llth. — Friction was still audible; the pulse was 112, soft; the skin was cool; the diarrhoea stopped, or nearly so ; the urine gave a large precipitate of lithates, and contained abundant chlorides. Nov. 12th. — The operation of paracentesis thoracis was performed by Mr. Syme in the following manner: A free incision was made in the lower part of the left back at the spot where the tumour was pointing. A considerable thickness of muscle had to be cut through, and the wound enlarged by means of the finger before any matter escaped. After this, about sixty ounces of dirtj'-yellow sanious pus were withdrawn, passing with force at each expiration. In tlie evening, forty ounces more of pus escaped. Breathing was easier than before the operation ; cough not so readily excited ; patient lies more on his back than before. Pulse 9G, weak and soft. Nov. ISih. — Percussion is now tj-mpauitic over the left side anteriorly; laterally and jiosteriorly, where the integument is oedematous, percussion gives great sense of resistance, with deep amphoric resonance. Vocal resonance posteriorly and anteriorly on the same side is amphoric, with whis- pering pectoriloquy. With inspiration under left clavicle, friction sound is audible; anteriorly, respiration is exceedingly faint ; posteriorly there is tubular breathing less distinct towards the base ; close to the spine over upper two-thirds of the lung, respiratory murmur is audible, but feint in comparison with the right side. On the right side, harsh inspiration and prolonged expiration continue to be heard, and vocal resonance is loud ; friction murmurs have disappeared from the anterior and lateral regions. Cardiac apex beats two inches to the left and one inch below the right nii^ple. Pulse 108, soft and feeble. Tongue dry and bright red; appetite defective; occasional thirst; bowels regular. Great weakness, and considerable PLEURITIS. 627 general uneasiness, but no local pain ; occasional rigors. Xov. loth. — At tlie left apex, and over left infra-mammary region, metallic tinlcling was heard at the close of inspiration, and vocal resonance was loudly metallic in character. Xov. lUtli. — The following measurements were taken at the same levels as those mentioned when he was admitted: — Level of Four inches Xipple. lower. Left side 15f 15| Right side 17^ 17 At tliis time the pulse varied from 120 to 130; it was small and feeble. The patient complained much of the heat and foetor of the discliarge. Small granulations were seen ou the edges of the wound. Xov. 20th. — The following report was made ; — Three and a half inches below right nipple, rough friction sound with inspiration and expiration ; five inches below, and two and a half inches to the outer side of right nipple, a rumbling friction with expiration ; inspiration harsh and short, but otherwise free. One inch below, and four inches to the outer side of the same point, a finer friction sound with expiration alone. An inch and a half above same nipple respiratory murmurs are heard, intense in tone, accompanied during close of inspira- tion, and during expiration, with a sound superficial, and rough, resembling coarse crepitation. Two and a half inches above the same nipple, a mucous rale of the same character, coarse and dragging, accompanies inspiration only. Above this point) over the upper two ribs, the respiratory murmurs are harsh and loud. These obser- vations were made while patient lay on his left side ; his weakness precluded an examination of the back. His eyes are sunk; there is a cold clammy sweat on the face; occasional feeling of chiUiness. Nov. 26th. — No change since last report. To-day his appetite has improved to such an extent that he was able to take two eggs for breakfast. Loud metallic tinkling still audible over the left chest. Xuv. 30ih. — Metallic tinkling is now no longer audible. Dec. -iih. — The following measure- ments were taken : — Level of Four inches Xipple. lower. Left side . , , . . . 15 15 Eight side 16 15^ The second level was that of the ensiform cartilage. Dec. 8th. — A sore of the size of a fouqjenny piece was observed over the sacrum, which caused the patient consider- able pain. He continued to improve up to the 12th. His appetite increased ; he slept well; no more rigors occurred, and his pulse feU to 96. Dec. 13t?i. — Last night about eleven o'clock he was seized with severe pain in the upper part of the abdomen, which prevented him from sleeping. This morning the pain still continues ; it is increased by firm pressure, but he can easily bear slight pressure. Respiration is abdominal as well as thoracic. Appetite gone ; bowels opened freely a few hours ago; dejections natural. Pulse 108, small, but not hard or strong. Skin hot; the look is not particularly anxious. Dee. loth. — Three discoloured spots were found over the sacrum, with a very small ulcer, wliich, however, had a healthy granulating appearance. Continues to complain of abdominal pain. Yesterday, four loose stools were passed, which produced considerable uneasiness. To-day he has had but one stool; there is considerable tenderness on pressure, and distension from tympanitis over tlie whole left flank. Pulse 96, feeble, soft. Dec. IGih. — He was greatly relieved, and he continued in a comfortable condition till the 18th. On the evening of that day he was attacked by vomiting and a sensation of fulness in the abdomen, both of which he believed to be due to his having taken a quantity of lemonade. The vomiting continued till eleven p.ji., when it ceased; the matters vomited were partlj' fluid and partly solid, and evidently consisted of alimentary substances. 628 DISEASES OF THE EESPIRATOEY SYSTEil. Tenderness on pressure in the region of the recti muscles ; bowels opened this morn- ing; dejections natural. Respirations 30, somewhat laboured. Pulse 120, small, somewhat hard, but quite compressible ; consciousness perfect ; skin hot and dry ; cheek tlushed. Dec. 19th — A remission of the symptoms took place. On the 20th, vomiting recurred, together As-ith abdominal pain and tenderness, as described in the report of the 18th. These continued to become severe till the morning of the 22d, when he sunk, with all the marks of great depression of the entire system. He died at 2 A.M. on the 2 2d. From the moment of the patient's entering the hospital, every eflbrt was made to snstain his strength by means of the most nourishing diet, together with wine. Diarrhoea was put a stop to by the use of cretaceous mixtures, and the rigors were successfully treated with quinine. The vomiting was diminished by bismuth and aromatic powder, and towards the end of the case he was greatly relieved by the use of brand}-, and ice internally. Effervescing lemonade was allowed latterly to allay the patient's thirst. Sectio Cadaveris. — Twerdy-eujlit hours after death. Body considerably emaciated. On reflecting the integuments, and removing the sternum and ribs anteriorly, so as to expose the thoracic and abdominal cavities, the contained viscera were observed to be dis- placed as follows : — The left thoracic cavity presented an empty space, in consequence of the lung being compressed and tightly bound down to the spinal column (Fig. 429, h). The heart was in the centre of the body, passing somewhat to the right side. The stomach was enormously dilated, ex- tending to the pubes, and concealing all the abdominal viscera, except a portion of the right lobe of the Uver and colon (Fig. 429, e). Thorax. — On opening the thorax, there was an escape of foetid air from the left side. The ijericardium was everywhere strongly adherent. The heart and its valves healthy, weighing with pericardium, 8^ oz The left pleural cavity contained about 6 oz. of dirty foetid purulent fluid. The surfaces of the pleurse, parietal and visceral, were covered with a layer of chronic lymph, having scattered throughout its substance opaque yellow spots of the size of millet seeds, resembling tubercle. This layer of lymph could readily be scraped off, and was seen to be about one eighth of an inch in thickness, having a soft pulpy layer internally, and where attached externally, to be highly vascular. The lung was bound down to the spmal column by firm and Fig. 429. Relative position of the thoracic and abdominal viscera, on reflectmg the integuments in Allan Brown's case. a. Empty left thoracic cavity ; h, left lung ; c, right lung; d, heart; e, enormously distended stomach; /, liver; g, colon. PLEURITIS. 629 dense adhesions. Its tissue was compressed and carnified, and its size reduced to a spindle-sliaped body about five inches long, and two inches in its greatest diameter (Fig. 429, b). On insufflation it expanded very imperfectly. At the apex there was a cavity tlie size of a walnut, having a distinct lining membrane, and filled with soft, cheesy, tubercular matter, evidently of old standing. Scattered through the sub- stance of t}\e lung were numerous small masses of tubercles, but no other cavities. The right lung was universally adherent by dense chronic adhesions. It was moderately voluminou.s, and at the apex were numerous stellate puckerings, corre- sponding to dense fibrous cicatrices in the substance of the pulmonary tissue, but without concretions. Abdomex. — Tlie stomach was enormously dilated as formerly described (Fig. 429, e). On opening it, it was found to be distended with air, and somewhat twisted round on itself at the junction of the cardia and oesophagus. All the coats were very thin, apparently from the distension. The mucous coat was health}-, and no abrasions could be discovered in it. But between the serous and muscular, as well as the muscular and mucous coats, numerous bullae of air were visible, which could be moved about bj' pressure of the fingers, evidently dependent on the existence of some gas in the texture, which was in no waj' putrid, nor was the gas itself of foetid colour. In the coecum and ascending colon were numerous small depressions in the mucous coat, the cicatrices of former ulcers. There was nowhere any trace of recent intestinal ulcerations. The spleen weighed 8 oz. ; sp. gr. 1063. Its pulp was health}', but the malpigliian bodies were enlarged throughout, and resembled grains of boiled sago. The kidneys were pale, and had two or three small masses of tubercle imbedded in the cortical substance. Liver and other organs healthy. Commentary. — The place for making an opening- into the thoracic cavity in empyema should always be chosen with the greatest care. The general rule is, that if the pus causes a prominent tumour, to punc- ture there, but if not, then one of the intercostal spaces between the fifth and seventh ribs should be chosen, but so as to avoid the heart and diaphragm. In the above case, with bulging of the thoracic walls infe- riorlv and posteriorly, the opening was made at the most prominent part bv a large incision, and the offensive matter it contained replaced by air. This proceeding, which converts an empyema at once into pneumo- thorax, it is argued, can have no ill effect, so long as the aperture remains free, and the air thereby prevented from becoming iVx'tid. The operation was had recourse to more as a palliative than as a curative proceeding in the present case, the phthisical complication rendering- ultimate recovery very improbable. My impression, however, is, that under more favourable circumstances, the small puncture, avoiding admission of air as much as possible, holds out the best prospect of success. The mode of death in this case was very remarkable, and indeed, so far as I am aware, unique. The man to relieve his thirst was allowed two or three bottles of effervescing lemonade as drink during the day. It would appear, that on the 15th of December he complained of fulness of the stomach, and tympanitic distension of the abdomen, which symp- toms, however, excited no great attention, although they may have origi- nated in the same cause, which apparently produced the more violent complaints that came on subsequently. On the evening of the ISth he was seized suddenly with all the symptoms of perforation of the bowel, and on examining him next day, such was what I believed to have DISEASES OF THE RESPIRATORY SYSTEM. occurred. There was great abdominal tympanitic swelling, excessive pain, vomiting, etc. But on dissection we found that these symptoms depended on great distension of the stomach, with emphysema of its coats, the latter a lesion, which I believe was then observed for the first time. It was not caused by putrefaction ; and the question arose, How was it produced ? It turned out on inquiry fi-om the nurse and neigh- houring patients, that the man had kept his bottles of effervescing lemonade till the evening, and drank at least the contents of two of them in quick succession. It is probable, therefore, that the extrication of gas had disteniled the stomach, and caused it to twist round partly on itself at the cardia, so as to prevent its escape. Hence the distension and pain, and why probably the contained air, not finding a ready exit through either the cardia or pylorus, had forced its way between the coats of the organ itself. ^Yith regard to the other facts of this case, they present in a well marked form all the characteristic phenomena, first of empyema of the left side, and secondly, of pneumo-thorax. A disquisition on these two thoracic diseases, their diagnosis and treatment, would lead me too far. There is only one point to Avhich I think it necessary to refer, namely, the cause of metallic tinkling; and I do so merely to say that notwith- standing the ingenious theories which have been advanced to account for it, they all appear to me faulty. I have satisfied myself that the break- ing of bubbles of air on the sui-face of fluid, or the splashing of water in a cavity containing air, will not ahcays explain the occurrence. On one occasion I heard metallic tinkling most distinct over the lung in a man dying of phthisis. After death I commenced the examination by mak- ing an opening between the ribs cautiously, over the centre of the tym- panitic space, thinking that air would escape. But the pleurje were uni- versally adherent. There was no cavity whatever, but simply hard nodules of tubercle, scattered throughout a highly emphysematous lung. PNEUMONIA. Case CXXIX.* — Pneumonia on Right Side and slight Pleuritis — Recovery. History. — Roderick MTarlane. set. 20, a gardener of healthy and robust constitu- tion — admitted December ITlh, 1856. On the 12th instant felt imwell, with a sen- sation of cold in the back. On the 13th had pain in the right infra-axillary region, increased on deep inspiration, with hot skin, headache, thirst, and loss of appetite, symptoms which have continued ever since. On the 14th, cough appeared with scanty expectoration. Has taken a dose of castor-oil and some pills. Symptoms ox Admissiox. — Expansion on both sides of chest equal. Respirations twenty-four in the minute, not laboured. Can lie on either side, but prefers lying on the back. Pain during deep inspiration over right infra- axillary region; slight cough; scanty expectoration — frothy and mucous. On percussion, cracked-pot reso- nance extends from clavicle to fifth rib on right side. Below this level, percussion is dull. There is also decided dulness posteriorly from spine of scapula to base. Elsewhere percussion natural. On auscultation, puerile respiration over left front ; * Reported by Dr. J. Glen, Resident Clinical Physician. PNEUMONIA. 631 over right front superiorly respiration is harsh, witliout rale ; below fifth ril), it is suppressed. Posteriorly over two lower thirds, double friction is audible, with fine crepitation at the close of inspiration ; on left side occasional sibilus, with a few moist rattles at close of inspiration over lower third. The vocal resonance is increased and sharp on right side anteriorly, but greatly increased and oegophouic posteriorly over area of dulness. Pulse 104, incompressible and full. Skin hot and dry. Tongue in centre brown, dry, and cracked ; edges moist and clean. No appetite ; great thirst; bowels always regular, but have been opened by laxatives. Urine natural. Other functions normal. I^ Sol. Antim. Tart. 3 ss ; Aqum Ammon. Acet. §j; Aquce ^ viss. M. Habeat sextam partem quartd qudque liord. Progress op the Case. — December I8th. — Grazing friction audible over the right infra-mammary region. Crepitation distinct over rigiit back inferiorly. Pulse 120, soft. Sputum scantj^, consisting of orange-coloured, gelatinous masses. Other- wise the same. Dec. 20th. — Crepitations very coarse over right back. Fever abated. Tongue moist and clean. Pulse 72, of good strength. Temperature of skin natural. Omiit. mist. Dec. 22d. — Crepitation and friction disappeared from right back. Abundant sediment of lithates in the urine. 5 Sp. ^ther. Kit. 3 iij ; Viii. Sem. Golchici, 3j; Aqu(e. ad 3 vj. M. Two table-spoon fids to be taken every four hours. Dec. 24 - partially filled with a dirty-coloured fluid, and opened directly into a #^^^^ bronchial tube, the size of a crow quill, at the other extremity of which ''^^i^^i the foreign body was found at a future stage of the dissection. In the Fig. 480. neighbourhood of this cavity, and throughout the whole of the inferior and posterior parts, the lung was riddled with numerous small cavities, vaiying in size from that of a hazel nut to that of a pea. Some of these were closed and filled with a fluid similar to that found in the one at the apex ; others were nearly empty, more or less aufractuou.s, and communicated freely with the bronchial tubes ; the walls of some were formed of a thick dense membrane ; those of others were soft and ragged. The middle part of the anterior, and •©•■. Fig. 431. a small portion of the inferior border were in a state of grey hepatization, and were the only parts free from cavities. On laying open the right bronchus, a small piece of bone was found at the bifurcation of the middle primary division ; it was lying almost loose, and came away witliout any force being used ; it was quite clean, and bore a strong resemblance to part of a vertebra of a small animal, being of an irregular elongated form, and presenting several sharp spicula. The mucous membrane at the part was thickened, but quite free from ulceration, and not more vascular than that of the other bronchi. The trachea and the bronchi of both lungs were stained of a dark grey colour, but otherwise presented nothing abnormal. In the left 2^leura there Fio-. 430. Fragment of chicken bone found in the right bronchus, in Neal's case. Fig. 431. Fluid in the chronic abscess of the riglit lung in Xeal's case, a. Fibrous tissue; b, broken down pus cells; c, crystals of triple phosphate; and d, urate of am- monia — (Jamts Slruihcrs.) 250 diam. PXEUMOXIA. 657 were three or four ounces of clear serum. The lung was healthy, except a small portion at the inferior border which was hepatized, and studded with small, grey, indurated nodules, the size of corn-pickles. These consisted, as ascertained by the microscope, of accumulations of altered epithelium, with much granular fatty matter. The apex of the lung was free of deposit, and there was no tubercle in any part. The bronchial glands, especially those on the right side, were greatly h}-pertrophied, several of them being as large as pigeon's eggs ; they contained no foreign matter. The heart was of the normal size ; its muscular and valvular structures were healthy ; and all the cavities contained both firm decolorised and dark loose clots. The blood, examined under the microscope, presented the red and while corpuscles in the usual proportions. Abdomex.— The abdominal viscera were in all respects normal. Microscopic Examixation.— The fluid from the abscess at the apex of the right lung, on being examined under the microscope, was found to contain sm^ll shreds of fibrous tissue, broken down pus globules, and a large number of crystals of the triple phosphate and of the urate of ammonia. Fig. 431. Commentary. — The physical signs in this case clearly indicated the existence of a cavity in the right lung, which, from its position, and troni the general history'of the case, was not likely to be tubercular.^ On the other hand its gangrenous character was revealed by the peculiar odour, and his account oi its origin rendered it probable that the cause was a foreign body impacted in the bronchus. At the same time, he was never verv certain as to the fact of having swallowed the piece of bone, and, in many conversations I had with him on that point, he invariably stated that "such was merely his impression, but he was not sure. It is of importance to notice this fact, because it seems very probable that when in St. George's Hospital, his account may have been a doubtful one there also, and may have prevented recourse to an operation which then might possibly have been undertaken with success. It would be inte- resTing to know whether at that time his chest had been carefully examined by auscultation, or whether general symptoms only were attended to, and, in consequence of these being slight, he was dismissed in a fortnight. Certainly, it cannot be imagined that if any certainty existed as to the impaction at that time of a foreign body in the lung, no effort would have been made to extract it, especially when the uniform ultimate fatality of such an occurrence is taken into consideration. At all events, this "case points out how, in a young man of perfect health, structural disorganization slowly, but surely, proceeds after such an occurrence, and it strongly inculcates the necessity of early careful examination and of operative interference. Another cause of gangrene in the lung, is the occasional impaction of clots of blood, whether t1ie result of phlebitis or from floating coagnla coming from the right side of the heart. As an example, we may cite a well-imrked case given by Mr. G. W. Callender, in the ninth volume of the Pathological Society's Transactions. One of the tertiary divisions of the pulmonary artery was occupied by a layer of decolorized fibrin in the form of a hollow globule. Its diameter was about two lines greater than that of the artery below, so that at this point the vessel seemed to have undergone some shght dilatation. Just beyond the place at which this clot had obstructed the canal, the artery bifurcated. The 42 658 DISEASES OF THE EESPIRATOEY SYSTE:m:. blood liad penetrated one of its divisions by means of a short and narrow channel, formed by the side of the above-mentioned clot, which was prolonged into the vessel, occupying about half its calibre. The other . ^, . division at the point where it ^ -/ "' ' - ' again bifurcated, had one of '"^■^ " its divisions obstructed by another clot, which, unlike the others, was solid through- out. The portion of pulmo- nary tissue with which this arterv communicated, was in a state of gangrene, as also was its pleural covering. In this case various masses of coagulated fibrin were ad- herent to the tricuspid valve, Fit:. 432. and the clots found in the branches of the pulmonary artery m the lung, were most likely derived from them, as the vein itself was healthy. The hollowing out of the nearer of these coagula to the heart also was probably owing to the sub- sequent action of the current of blood, whilst the one further distant remained solid, and completely arrested the circulation. PHTHISIS PULMOXALIS. Case C^lAX .*—PhtMsis Pulmonalis in its last Stage, with Incompetency of the Aortic Valves— Cod Liver Oil and Nutrients— Compkle Recovery. History.— Patrick Barclay, ?et 15, admitted June 25, 1849. His previous history indicated tliat lie had been of scrofulous habit from infancy. He attended the indus- trial school regularly until a week ago, but could not take much exercise on accoimt of a sore leg, which originated twelve months previously in a faU. His diet has for a long time been very poor. On the 18th he was attacked with cough, and this has continued till admission. He also complains of dyspnoea on exertion. SviiPTOMS ON Admissiox.— On admission, he is excessively emaciated. He complains of cough, which is sometimes very prolonged, but has no pain nor difficulty of breathing. The chest expands well on inspiration. Cough easily excited, and occasionally severe. Sputa viscid, frothy, and tinged with blood. On percussion, there is great duluess of the right side, especially under the clavicle ; the left side is also dull to a slight extent On auscultation, distinct bronchophony, loud friction rale, and mucous rale, approaching cavernous, are heard in the upper right side in front; and these become more faint towards the lower part of the lung. On the left side, friction rales are also heard in the upper part in front. Behind, on the right side, vocal resonance not so distinct, but rales the same as in front. Pulse 111, strong and sharp. The heart's apex beats below sixth rib;' * Reported by Messrs. Hugh Balfour, Sanderson, and Dewar, Clinical Clerks. Fig. 432. Part of the left lung, with clots occupying branches of the pulmonary artery. — ( Calktider. ) PHTHISIS PULMOXALIS. 659 impulse increased ; but percussion does not indicate lateral expansion. On auscul- tation, a chirping musical murmur is heard over the apex of the heart, at the end of the first sound. This murmur becomes much more faint towards the base. To the lett of the manubrium of the sternum, a bellows murmur takes the place of the second sound. This murmur is quite concealed by loud friction rales, when respiration is going on, but is immediately perceived when the patient holds his breatli. Tongue sUghtly furred; appetite good; some thirst. BoM'els regular. Urine natural; sp. gr. 1020 — not coagulable. The chest, face, and arms, are covered with an eruption of prurigo, which be has had several times. On the right thigh, towards the lower part, there are several cicatrices, and three sinuses, which communicate with d5ad bone. Is much troubled with sweating, wliich at night is ver}^ profuse. To have good diet with sweet milk morning and evening, and a dessei't- spoonfal of Ood- Liver Oil three times a day. 5 ^'^i- Scilke § iv ; Tinct. Opii Amnion. | ss ; Aq Cinnam. § iss ; Aquce § iij. M Half-an-ounce three times a day. Progress of the Case.— June 3(J<7t.— Friction rale less. Gurglmg rale on right side. U})per part of chest to be rubbed luith Tartar Emetic Ointment. July 2rf.— Chirping murmur has become faint, and occasionally is inaudible. Has vomited his food several times. Half a drachm of Xaphtha to be added to mixture ; to have beer for drink. 5 //i.— Chirping murmur quite gone. 8//t. — Chirping murmur returned. Cough severe, causing vomituig. Eruption, brought out by ointment, painful. Omit the Ointment and Mixture. 5 Pulv. Tragacanih. Co. Zi; Naphthce Medic. I \] Sol. Mur. Morph. 3 iij ; Syrup. Aurantii 3 ss ; Mist. Scillce 3 v. M. A table- spoonful thrice a day. 2lst. — A seton was introduced beneath the right clavicle. Still vomits in the niorniug, but takes food and medicine better. Aug. Gth. — The expiratory murmurs under right clavicle are now quite dry. Vomiting is dimi- nished. Omit the Mi.xture. 'fy Ferri Oitrat. 3ss; Tinct. et Syrupi Aurantii, aa lss;Infus. Calumbce '^yI M. A table-spoonful three times a day. 12th. — The seton discharges freely, causing great irritation, and is to be withdrawn. Sejii. 'ilk. — Appearance of patient much improved. Sounds of cavity in chest continue dry. Takes now again a table-spoonful of the oil three times a day. Oct. 28. — Musical murmur has entirely disappeared. He is becoming quite fat, and is able to go about the ward all day. Complains only of slight cough at night, and palpitation on exertion. The right infra-clavicular region is becoming fiat. Omit the mixture and also the Cod-Liver Od. Xov. 18th. — Cough has returned, with slight mucous expectoration; and on auscultation, mucous and sibilant rales are heard all over the chest. Ordered to recommence the oU g Mist. Scilke I vss ; Vini Ipecac. 3 ij ; Sol. Mur. Morph. 3 i- M. A table-spoonful three times a day. From this time he rapidly improved. The cavity became perfectly dry, and respiration over it was accompanied by blowing murmurs. Cough and expectora- tion greatly diminished. His general appearance is healthy, and he is very stout. On January ISih, it is noted that, on percussion, a distinct cracked-pot sound is heard in the right mfra-clavicular region, and faintly also on the left side. On auscultation the heart's sounds are loud all over the chest, the second sound being accompanied with a distinct bellows murmur. Musical murmur has never returned. There is bronchophony and prolonged expiration in the right infra-clavicular region, but no moist sounds. Sleeps well, and is very little troubled with cough. Does not sweat; is very fat; appetite good. This boy, as far as all general symptoms are concerned, may be regarded as having been m good health for the last two months. Feb. 21ih.—0n percussion, the chest was tolerably resonant on both sides; but there was slight dulncss under the right clavicle. On ausculta- tion, the inspiration is loud, and of a blowing character, in right infra-clavicular region ; but the murmur is much softer than formerly. Expiration is still prolonged, 660 DISEASES OF THE EESPIRATORY SYSTEM. and there is considerable vocal resonance, but not amounting to bronchophony — no naoist rales. In the corresponding situation on the left side, the inspiration is somewhat harsh, and respiration slightly prolonged; vocal resonance normal ; loud bellows murmur, with the second sound of the heart, heard over nearly the whole chest. His general health is good; he expresses himself as being quite well. He appears stout and strong ; but his countenance is somewhat sallow and cachectic. He has no expectoration or sweating, and the cough is trifling, and only present in the morning. He is about to return to the Industrial School, and resume the learning of his trade as a shoemaker. Dismissed. He was re-admitted August 26(h, 18.50. Since leaving the house he has been at the Industrial School, but has been frequently exposed to cold; and latterly the cough and expectoration, which he says had quite left him, have returned, and been gradually getting more severe. The sweating returned with the cough. A week before admission, he, with the other boys of the school, went to Portobello to bathe, and, notwithstanding his remonstrances, the master insisted on his going into the water, saying it would do him good. He, however, became much worse. On admis- sion, the physical signs were coarse moist rale uuder the right clavicle, imperfect pectoriloquy, and creaking friction noises, harsh inspiration, and prolonged expira- tion under left clavicle ; but the dulness in this position is very slight, when, com- pared with that of the opposite side. He again, by means of cod-liver oil, good diet, and counter-irritation, became strong and stout; again the cough, expectoration, and other symptoms ceased, and lie was discharged March 1th, 1851. The report on that day is, " marked dulness and increased vocal resonance under right clavicle ; the inspiration is harsh but dry." Once again admitted July 5th, 1851. — He says that on leaving the ward in March last, he had two detached pieces of the right thigh-bone extracted by Mr. Syme, and remained in the surgical hospital for five weeks. Since then he has been constantly employed in light garden work, and, notwithstanding poverty of food, he continued in tolerably good health till a week ago. On percussion, there is slight dulness only under the right clavicle, and posteriorly the resonance is good and equal on both sides. Under the right clavicle, the inspiration is heard to be harsh and blowing — no moist rale. There is also loud double friction murmur over the upper fourth of right lung, especially at the apex, and slight friction may be detected here and there over the whole of the right side. Under the left clavicle, inspiration some- what exaggerated in tone, but the breath sounds everywhere normal. He looks pale and thin. There is severe cough, with mucous expectoration, but the appetite is good, and there is, on the whole, a marked improvement in his general appearance. Impulse of the heart and loud blowing murmur at the base still present. 'Wound in the thigh nearly healed. Further Progress of the Case. — He has continued to do well since his admis- sion into the house. The cough rapidly diminished, and is now only present in the morning on waking. His bodily functions, he says, are in every respect perfectly well performed. The wound in the thigh is cicatrised, and were it not for the car- diac disease, this lad might be considered in robust health. The following is the result of a careful examination of the chest, made December 23d, 1851: — "On per- cussion, shglit dulness under the right clavicle. On auscultation, inspiratory murmur somewhat harsh under both clavicles, but most so on right side. The vocal resonance also is slightly exaggerated over the apex on right side. In every other respect, the lungs appear to be healthy. There is great impulse of the heart stiU, and over the apex there is heard, with the second sound, a blowing murmur, which is very loud at the base. He remained in the house until March 1th, 1852 when he was dis- missed in all respects perfectly well. PHTHISIS PULMONALIS. 661 August 9ih, 1852. — Presented himself at the visit to-day. Since his dismissal in March, has been emploj-ed by a dyer, and during his occupation has been greatly exposed to wet and cold. He has only been able to earn five shillings a-week, so that his diet has been very poor, both in quantity and quality. His health, not- withstanding, has been tolerably good, although he is now much thinner than when he left the Infirmaiy. On percussion there is clear resonance under both clavicles, but on the right side very slight dulness with increased resistance is perceptible. On auscultation, the inspiration under right clavicle is somewhat harsh, but the re- spiratory murmurs on the whole are very good. Vocal resonance slightly increased. Under the left clavicle there is harshness, with fine sibilation and friction during inspiration. The expiration is prolonged, and there is also slight increase of vocal resonance. The blowing murmur at the base of the heart with the second sound still very distinct. Otherwise is quite healthy. He has a sister settled at Piiiladel- phia, and has formed the intention of joining her in the United States. Ftbruary 6th, 1853 — Presented himself at the Infirmary to-daj^, and was carefully examined by Dr. Bennett, Dr. Christison, the various clerks, and students. The physical signs are the same as at last report, the breath sounds, however, being more soit and natural. He has been prevented leaving for PhiladeliDliia, as he intended last August, and since then has been carrying on the occupation of light porter to a dyer. His general health has been good, although he has undergone much exposure to cold and wet. He leaves for Philadelpliia to-morrow, taking witli him a letter recommending him to the care of Professor Wood of that city. In a letter from Dr. "Wood to Dr. Bennett, dated March 28ih, 1853, it was stated that Barclay had presented himself a week previously. " Being at the time extremely busy, I gave the boy, who told me that he was quite destitute, a small sum of money, telling him to use it for his support ; in the meantime to look out for employment, which is not difficult to be had in this country for persons of his class, and to call on me again before long. He promised to do so. I have not seen him since." In a subsequent letter (1856) from Dr. Dunglisou, who at Dr. Bennett's request asked Dr. Wood concerning him, it appeared that he had not since been heard of. Commentary. — I am not acquainted with any recoi'ded case, which, throughout its progress, has been examined with more cave, in wliich phthisis, in its last stage, was more unequivocally manifested, and which was more decidedly the siabject of a complete cure, than the one now given. The lad was under my observation from June 1849 to February 1853, a period of forty-three months, and during that time he was respectively examined in the clinical ward by four winter and two sum- mer classes of students, as well as by my professorial colleagues. Of the facts and accuracy of the record in the ward book there can be no doubt; and it is equally certain that we watched the arrest of tubercular condensation at the apex of the left lung, and the cicatrization of a large tubercular excavation in the apex of the right lung. Moreover, a care- ful study of this case will show that this result was not bi'ought alwnt by the mere spontaneous efforts of nature. On the contrary, gTeat diffi- culties had to be surmounted, numerous symptoms removed, and most important complications guarded against. Indeed, the effects of treat- ment could never be more unequivocally manifested in anv case than they have been in this. On admission, he presented the wasting charac- ters of the disease in its last stage. The emaciation was extreme ; the cough and sweating most distressing; and the physical signs demon- strated a cavity as large as the fist, in the right lung. Under the use 662 DISEASES OF THE EESPIEATORT SYSTEil, of the oil bis strength rallied. After a time it was given up, on account of his becoming so fat. Gurgling rales, and other signs of softened exudation, however, once more became apparent, and again disappeared when the use of the oil was resumed. He continued to take it from time to time afterwards, and it became appaient that the pulmonary signs varied according to his ability of digesting the oil. The same fact was demonstrated throughout the progress of the case, clearlv showing the intimate relation which exists between the local disease and the general nutritive powers of the economy. During no part of the time this boy was under treatment did he experience any difficulty in taking the oil. On the contrary, it occa- sioned no uneasiness in the stomach, and was readily digested, and this, although the food was at one period frequently vomited, owing appa- rently to the violence of the cough. Its influence on his general health was most remarkable, as well as upon the local disease in the lungs. From a state of extreme eiliaciation he became so stout that it was feared the oil would occasion obesity ; and was therefore, for a time, discontinued. His appetite was always good — a circumstance I have noticed as being very favourable, not only for the beneficial action of cod-liver oil, but for the successful treatment of phthisis generally. Indeed, it is the anorexia, nausea, and dyspeptic symptoms which con- stitute the great difficulty the phvsician has to overcome in the manage- ment of the disease, as is well illustrated in the following case : — Case CXLT.* — Pldhisis Pulmonalis — Amendment from Treatment and Disappear- ance of Symptoms — Their Subsequent Return — Death. History. — Jane HamOton, a dressmaker, set. IS — admitted September 12, 1849. She stated that last April her general health began to fail ; the appetite was bad ; cough with expectoration came on ; cold sweats appeared on the face, hands, and feet ; the catamenia, which had never been very regular, were suppressed ; and she became so weak that she could not stand. Since then there has been a temporary improvement ; but for some time back she has become worse. Stmptoms ox Adsiissiox. — On admission she was pale and emaciated, and so weak that she was unable to sit up above a few minutes at a time. There was copious perspiration during sleep, a severe cough, with abundant yellowish viscid sputa — no pain in the chest, which was well formed externally. The tongue was covered with a brown fur ; appetite capricious and bad ; bowels open every second day. The treatment consisted of tonics, expectorants, and counter-irritation to the chest, which produced considerable amendment. I took charge of the case in the middle of October, and found, on careful percussion, dulness below the right clavicle, with loud mucous rale over the upper third of right chest. There were also sonorous and sibilant rales over the greater part of both lungs, anteriorly and posteriorly. By means of expectorants and counter-irritants, the bronchitic symptoms and signs were subdued by the Isi of Xovemier ; but the dulness and moist rales under the right clavicle stiU continued. A taUe-spoonful of cod live)- oil icas then ordered to he taken three times a day. Progress of the Case. — The remedy was suspended on the Sth, on account of a febrile attack she then experienced, which was ushered in with headache and * Reported by ilr. Alexander Struthers, Clinical Clerk. PHTHISIS rULMONALIS. 663 rigors, and accompanied witli accelerated but soft pulse, heat of skin, loss of appetite, frequent nausea and vomiting, and considerable spinal irritation. It was not until November 30th that these symptoms were so far removed, and the tone of the stomach augmented — by means, first, of antimonials, and subsequently of naphtha, alkalies, vegetable bitters, and stimulants — that the oil was again ordered. It pro- duced considerable nausea, however, so that, after persevering in its use for ten days, it was again suspended. It was once more had recourse to on the lAih of December, and was readily i-etained on the stomach. A few days subsequently, the dose was increased to four table-spoonfuls daily. December 30th. — There is now a very evi- dent improvement in the general liealth. Her strength is so for increased that she sits up a considerable portion of the day. The perspirations have nearly disappeared. The expectoration is still thick and purulent, but not so copious. She is evidently much stouter, and the skin is of a more healthy colour. The catamenia have also reappeared. There is still dulness under the right clavicle on percussion. The coarse moist rale has disappeared, and a fine crepitating murmur only is heard wjth the inspiration towards the acromial end of the clavicle. — There is prolonged expira- tion, and increased vocal resonance. From this time she continued to improve. On the 1st of January the oil was reduced to three table-spoonfuls daily. A small blister was occasionally applied to the upper part of the right chest anteriorly, and an expectorant mixture given to facilitate the expectoration, which, though dimi- nished in quantity, retained its viscid and purulent character. On the 30th of Janu- ary the inspiratory murmur had acquired a certain degree of harshness, but here and there very fine crepitation could still be detected. She left the Infirmary on the 2Uh of February. I examined the chest carefully on the "ith of March. There was still dulness, but not so marked as formerly, under the right clavicle ; no crepitation on auscultation, but harshness of the inspiratory murmur, prolonged expiration, some friction noises, and increased vocal resonance. She was stout, of healthy appearance, and expressed herself as being quite well ; but the expectoration of purulent matter still continued to a slight degree, with occasional cougli. Shortly afterwards she went to Dundee to carry on her occupation as a milliner, when the confinement, late hours, and irre- gular food, soon caused a return of her more urgent symptoms. She again entered the Infirmary, and once more, after a few months, was dismissed relieved. On the last occasion, she was admitted under another physician. August I9th, 3 852, the dis- ease having progressed to its last stage during the interval. She died September 8th. No examination of the hody could be obtained. Commentary. — In this case, the local disease had not, on admission, proceeded to the advanced stage observable in the former one, for the phvsical signs in the girl exhibited at most bronchitis, with softening of the tubercular exudation at the apex of the right hing, whereas in the boy they demonstrated that a large cavity existed in one lung, whilst the other was also affected. There was the same general prostration, how- ever, and the same emaciation, excessive weakness, profuse perspiration, purulent expectoration, and distressing cough. But there was this dif- ference in the antecedent circumstances of the two cases — namely, that the bov liad a good appetite, but had been subjected to an insufficient diet, whilst the girl had no appetite, although she possessed the means of gratifying it. In the first case nutrition was imperfect from deficient quantity of food, the digestive organs being tolerably healthy ; in the second, it was imperfect on account of the dyspepsia and disordered state of the stomach rendering it impossible that a sufficient quantity 664: DISEASES OF THE EESPIEATORY SYSTEM. could be consumed. The result in both was the same, — namely, im- poverishment of the blood, and tubercular exudation into the pulmonary organs. The practical management of these two cases Avas considerably modi- fied by the circumstances to which I have just alluded. In the boy, there was no difKculty in overcoming the imperfect nutrition. We have seen that he took the cod-liver oil, and digested it and his food with the greatest facility. In the girl, all thoughts of food caused disgust, and the cod-liver oil produced nausea, and for some time could not be tole- rated. For a considerable period, therefore, the treatment of this case was preparatory, and directed to the diminution of the dyspeptic symp- toms, and removal of those complications which prevented any success- ful attack on the more important disease. Thus my first eiforts were directed to alleviating the bronchitis, which wias accomplished by means of expectorants and counter-irritants. Cod- liver oil was then ordered, but it occasioned nausea, and was suspended on account of a febrile attack she now experienced. On her recovery from this, the nausea, vomiting, and dyspeptic symptoms were treated by means of naphtha, alkalies, vegetable bitters, and carminatives, with apparent benefit; but, on recurring to the oil, the}' again returned ; so that, after persevering for ten days, it became again necessary to a-ive up its employment. In a few days, however, it was once more tried, and on this occasion with success. It was then taken readily ; a marked amend- ment followed ; the dose was increased to four table-spoonfuls daily, and it was astonishing to see how rapidly she improved. Her streno-th increased, the emaciation and cachectic look dit^appeared, the skin assumed a healthy colour, and she became positively stout and fat, so that she was scarcely recognisable. The cough almost ceased, the expec- toration greatly diminished, the perspirations did not appear at nioht, the catamenia returned, she sat up the entire day, and at length considered herself so well, that, on being allowed to leave the hospital for a day, she did not return. She called on me a few days afterwai'ds, Avhen I found that, although the constitutional symptoms had almost entirely disap- peared, and her general health might be called good, traces of the local disease were still apparent, as stated in the report. This case, therefore exhibits the obstacles which the physician has not unfrequently to over- come before he can carry out that line of treatment bv means of which the abnormal nutrition is to be obviated, and the tubercular exudation checked ; but it also inculcates the importance of perseverance, and exhibits the good etfects which may result from persisting in a treatment dictated by cocrect pathological principles. Notwithstanding the great benefit produced in this case, a return to imperfect diet and a sedentary employment once more induced all the symptoms and dangerous etfects which in the hospital were removed with so much trouble. Nor, unless we could convert such institutions into establishments for the permanent support and surveillance of phthisical cases, is it easy to see how this can be prevented. Certain it is, that we are very seldom enabled to retain a case so long under treatment, as we did that of Barclay. Although, by means of judicious treatment, we frequently check the progress of phthisis, and restore the patient to a good state of health, it most commonly happens that the patient, if he PHTHISIS PULMONALIS. 665 be in a public hospital, insists on going out, and, if a private case, he abandons those remedies and precautions which are absolutely necessary to his existence. Hence it too frequently happens, that, even after such considerable amendment as we have seen take place — after restoration from a state of the most complete prostration to one of almost vigorous health — the causes which originated the disease induce its return, and the patient sinks, after one or more relapses. It is of all things most important, thei-efore, to keep a careful watch over phthisical cases long after the constitutional symptoms have disappeared, and, in fact, so long as the physical signs indicate any traces of the disease. This, for obvi- ous reasons, can be accomplished much better in private than in hospital practice. Case CXLYI.*— Phthisis Puhnonalis— Large Vomica on Left Side— Caries of Left Wrist Joint — Febricula — Variola — Scrofuhixs Nephritis. History. — John Fiiilay, set. 19 — admitted into the dinical ward December 20th, 1850. Says that he has been troubled with cough and expectoration, more or less, for the last six years, accompanied by occasional diarrhoea. For the last three weeks he has been in the surgical clinical ward, under Mr. Syme, for scrofulous caries of the left wrist joint. He has spat blood now and then, but to no great extent. SYiiPTOMS ON Aujiissiox. — On percussion, the right chest is everywhere resonant ; but there is marked dulness over the whole of left chest, most complete in the sub- clavicular and supra-scapular regions. On auscultation, loud mucous rales are heard over the whole of left chest anteriorly, with gTirgling and pectoriloquy under the clavicle. Posteriorly and inferiorly on this side, tliere is a harsh tubular breathing? with prolongation of the expiration. There is puerile respiration on the right side, but otherwise nothing abnormal. His external appearance is pale, presenting all the so-called characters of the scrofulous diathesis. There is great emaciation, and development seems to have been arrested, as he does not look above 12 years of age. The left wrist-joint is immovable, considerably swollen, with several carious open- ings discharging pus. Frequent cough, with copious muco-purulent expectoration. Pulse 80, feeble. Tongue clean. Considerable nausea, and total loss of appetite. His diarrhoea has recently been checked by lead and opium pills. (For treatment, see Commentary.) Progress of the Case. — For the next three months the loss of appetite, sickness, and vomiting occurred at intervals, and the i^liysical signs remained the same. From this period, however, his general health underwent gradual improvement, the cough was not so severe, and the expectoration became more mucous. The sweating greatly dmiinished, and he took food more readily. Towards the end of Maj^, he had evidently gained much in flesh, and the discharge from the scrofulous sores in the wrist was trifling. The physical signs were so far altered, that the mucous rales over greater part of left side were not so coarse or diflused, and the gurgling under the clavicle was now of a splashing character, and more limited. Pectoriloquy in this situation was complete, and there was absence of expansion during respiration. There could now also be heard harsh inspiration, with prolonged expiration under the riglit clavicle ; the resonance on percussion also was here slightly impaired. During June, he was much troubled with nausea and vomiting. On tlie 21st he was attacked with rigors, followed by all the symptoms of continued fever, which terminated by diaphoresis on the seventh day. Shortly after, he was attacked with * Reported by Messrs. Sanderson and Dewar, Clinical Clerks. 666 DISEASES OF THE EESPIRATORY SYSTEM. variola, wliicli ran its usual course. During July and August, there was gradual but marked improvement of his general health. At the end of the last-named month, the left wrist-joint was firmly anchylosed, and all the carious openings had closed up. He still had occasional diarrhoea. There was still duluess on left side, but the mucous rales were not heard so low down anteriorly. Fine crepitation with increased vocal resonance was now audible under the right clavicle. Up to the middle of October he continued .slowly to improve ; the sweatings aud diarrhoea had ceased, aud the cough was much less severe. He now complained of considerable pain during micturition, and on examining the urine it was found to contain nume- rous pus-corpuscles, and to be coagulable by heat and nitric acid. He continued to feel pain on urinating, and to pass pus bj' the urethra during the month of October. On the 3d of November the report is : — " Marked dulness on percussion over the left chest anteriorly, and under the clavicle cracked-pot sound. Posteriorly it is resonant. On auscultation, loud friction is heard from below up to the level of the nipple, and above this, loud mucous rattles passing into gurgling under the clavicle. Perfect pectoriloquy in this situation. On right side, puerile respiration ; and pos- teriorly sibilant rale at the termination of the inspiration. Xo sweating or diarrhoea. Still occasional nausea and vomiting. General strength much improved, and now walks about the ward, sitting up a great portion of the day."' The report on the 2lst of December IS : — "Still marked dulness over the whole of left side, except under the clavicle, where it is tj-mpanitic, with cracked-pot sound. Resonance on right side good. Under acromial end of left clavicle feeble, and distant gurgling is heard — the respiration having more of a blowing character than formerly, with perfect pectoriloquy. The moist rales over the other parts of this side have disap- peared. On right side, puerile respiration is heard over the inferior half of lung ; otherwise, the breath-sounds are normal Posteriorly dulness of the whole of left side, but there is no cracked-pot sound. On auscultation, the signs are the same as are heard anteriorly. His general health has much improved. Still complains of occasional nausea and vomiting, but on the whole takes his food well. Urine limpid, containing small shreds, wliich, on examination with the microscope, are seen to be composed of numerous pus-corpuscles embedded in mucus ; slightly coagulable on the addition of heat and nitric acid. Pain on micturition diminished." From this time he continued, on the whole, to impi'ove steadily, and was so well during the summer of 1852, as to walk about constantly in the open air, aud went out of the house, by his own desire, on the 1st of the following August. About the middle of October, however, having been well in the interval, he fell down and injured his back. On the following day, he experienced rigors, followed by febrile symptoms, total loss of appetite, and hematuria. He was re-admitted November 1, when it was ascertained that considerable quantities of pus were passed with the urine, which, he says, had also been occasionally tinged with blood. There was pain on micturition, but none in the lumbar region. On examining the left lung, loud gurgling was heard both with inspiration and expiration, extending from the clavicle down to the upper margin of the third rib. There was great dulness on percussion. Below the clavicle, loud pectoriloquy, and lower down, cegophony. Under the right clavicle there was fine moist rale on inspiration, and increased vocal resonance, but tlie chest expanded well on this side, and was otherwise normal. The fever, prostration, and discharge of pus by urine continued without intermis- sion, and he died December 4, 1852. Sectio Cadet veris. — Forty hours after death. Body greatly emaciated ; the right carpal bones anchylosed, with marks of nume- rous old sinuses on the skin in their neighbourhood. PHTHISIS PULMOXALIS, 667 Chest.— Plcui-fe on the right side adherent at the apex, by loose bands of chronic lymph. The right lung indurated at the apex over an extent the size of a lien's egg, and strongly puckered externally. On section, this hidurated portion was seen to contain several encysted cretaceous concretions, with the intervening pulmonary substance condensed, hard, and fibrous. A few chronic mOiary tubercles were also scattered through the upper lobe ; but the rest of the lung was spongy, crepitant, and healthy. The pleura on the left side were everywhere Bi-mly adherent, and over the superior half of the lung, which was much atrophied, they were converted into a dense white librous mass, three-fourths of an mch thick, which gradually diminished m thickness inferiorly. The left lung was not the volume of the closed fist ; it was non-crepitant, felt indurated, but at the same time flaccid, evidently from mternal cavities. On section, the entke mass was riddled with cavities more or less communicating with each other, containing purulent matter, and having a smooth lining membrane. Many of them presented a pouch-like form, and were identical with what have been described as dilatations of the bronchi At the apex were two encysted calcareous concretions, of the size of millet seeds, but there were no other traces of tubercular deposits. The fibrous structure between the cavities consisted of a close dense fibrous texture, of bluish colour, from pigmentary deposits, in which no remams of pulmonary structure could be found. Tlie bronchi contained a considerable quantity of viscid, muco-purulent matter. Heart, larynx, and trachea healthy. Abuojiex. — The large intestines, especially tlie coecum, were congested, exhi- biting here and there patches of slate-coloured pigment, with traces of cicatrised ulcerations, together with one superficial chronic erosion about half an inch in dia- meter, of irregular form. The kidneys were of natural size, and on section displayed dilatation of the pelves, with pouch-like enlargements, the result of scrofulous abscesses, filled with pus. The secreting substance was everywhere atrophied, and the tubular substance in many places obliterated. Mesenteric glands and other organs healthy. Microscopic Ex.\iiiXATiox. — A careful microscopic examination of the luiing membrane of tlie pulmonary abscesses exhibited nothing but fibrous tissue, desti- tute of epithelium. There was nowhere any trace of a mucous surface. Commentary. — The treatmeut of tliis case was conducted on tlie prin- ciples, and according to the rules afterwards to be detailed. It was directed principally to improve the appetite, diminish the nausea, vomit- ino;, and diarrhoea, and support the streiigth by means of cod-liver oil an"d o-enerons diet. E.vternally, repeated blisters were applied. During the aUaek of febricula and variola, antimonials were given in small doses. Latterly numerous remedies were administered to lessen the pains dur- ing micturition, such as anodynes ; uva ursae ; bals. copaiba? ; diuretics, etc. ; but an enema of starch and solution of morphia succeeded better than anvthino- else. It was always observed that in proportion as the dyspeptic svraptoms were relieved, and the assimilation of cod-liver oil aiid food took place, so his health improved ; and by great care he Avas not onlv kept alive for two years, but I had sanguine expectation of an ultimate recovery, when he met with the accident which, by e.vcitiug acute disease in the kidneys, caused his death. This case presented many points of resemblance to that of Barclay (Case CXLIV.), especially in the scrofulous diathesis and scrofulous caries of the bones, and the cavity under one clavicle on admission. The dis- eased lung was more extensively affected, however, and the derangement 668 DISEASES OF THE RESPIRATORY SYSTEil, of the stomach more violent and persistent. Indeed, throughout the pro- gress of his case, the cliief difficulty in the treatment was the management of the stomach and bowels. The cod-liver oil and diet did not pi'oduce the same marked effect as in the case of Barclay, but their operation, though slow, was still very decided ; and for a longtime I considered that the pulmonary k^sion in this lad was in progress of cure, exactly in the same manner as took place in Case CXLIV. The dissection alter death demonstrated that in fact the lung was undergoing contraction, and that the tubercular disease was being arrested. It presented a remarkable specimen of one of the modes in which this is. occasionally accom- plished, namely, by the formation of pouches or cavities, the lining mem- branes of which become smooth, and cease to exude tubercle. This con- dition of the lung has been described by morbid anatomists under the name of dilated bronchi, and by Dr. Corrigan, as cirrhosis of the lung.* In the first case it has been imagined to result from chronic bronchitis, whereby the bronchi are dilated from within ; f and in the second, from the formation of fibrous matters, the contraction of which causes this enlargement from without. A consideration of the details of this case, however, must convince every physician that we had here to do with large tubercular excavations, which, by compressing the lung, had obliterated the Avhole of its texture, and converted it into a contracted fibrous envelope of these excavations. All trace of tubercular matter had disappeared, with the exception of two small cretaceous concretions, and the respira- tory function was entirely carried on by means of the opposite lung, in which chronic tubercle to a limited extent, and very latent, was found. "Whether, under such circumstances, the pulmonary lesion would ulti- matelv have healed, it is difficult to say ; but there can be no doubt he mioht have lived a long time in this condition had he not met with the accident which caused his death. But that many such lesions may be arrested, and life continue, is proved by the observations of Reynaud, who has given figures of what he calls dilatations of the bronchi, many of which were evidently the result of tubercular ulceration.]; Cruveilhier § has also figured a lung presenting similar appearances. In the case of another man, called Joseph Finnic, which closely resem- bled that of Finlay, I diagnosed, during life, the same contraction of the hmg from tubercular excavations, and the same chronic dilatations in connection with the bronchi. This man died of Bright's disease in the Roval Infirmary, January, 1853 ; and on dissection a similar state of the pulmonary texture was discovered, with the exception that the atrophy of the organ was not so great, whilst traces of tubercular infiltration were more evident. Case CXLTII.]! — Phthisis Pulmonalis — Vomica on Right Side — Death from Hmnoptysis. HiSTOKY. — Walter Cairns, £et. 3.5, stone-cutter — admitted into the clinical ward * Dublin Medical Journal, vol. xiii. 1838. f Laennec, vol. i. p. 201. X Memoires de I'Academie Royale de Medicine, tome 4'"«, Plate 4, Fig. 1 ; Plate 5, Fig. 1 ; Plate 7, Fig. 2. § Anatomie Pathologique, Livraison 32, Plate 5, Fig. 3. II Reported by Messrs. Cunningham and Calder, Clinical Clerks. PHTHISIS pul:moxalis. 669 February 10, 1851. On the 25th of last July he was discharged from the corps of Sappers and Miners at Gibraltar, in consequence of chest complaint. Shortly after, he was admitted into tlie hospital at Woohvich for a fistula in ano. He was dis- charged in March, and commenced work as a stone-cutter. In September, cough and expectoration came on — symptoms which have been gradually increasing until now. Symptoms ox Admission*. — On percussion, tliere is complete dulness under the right clavicle, extending three inches downwards. On auscultation, a loud mucous rale is lieard in this situation, with bronchophony. On the left side, inspiration under clavicle harsh, and expiration prolonged. Frequent and severe cough, with purulent expectoration; constant pain in right side of chest; pulse 120, small and weak; tongue slightly farred; appetite greatly impaired; vomiting during severe fits of coughing; diarrhoea; profuse sweating at night. He is thin, but not emaciated. Fistula in ano still present. Progress of the Case. — Towards the latter part of February, the mucous rale under right clavicle was changed into loud gurgling, and the bronchophony into loud pectoriloquy. All the other symptoms continued. During March, the diarrhoea considerably diminished, but the cough and expectoration increased so as to destroy rest at night. During April and May, tlie symptoms were stationary ; towards the end of the latter month, it was observed that the cough was not so severe, but that the breathing was more difficult. The dulness on percussion had extended inferiorly, and moist rales could be heard over the whole right side, increasing in coarseness from below upwards. Increased vocal resonance also was more diflused, with strong fremitus. On the oth of June, diarrhoea returned, and the sputa were streaked with blood. On the ITth, the diarrhoea had abated, but he experienced great pain and annoyance from the fistula in ano, which poured forth a profuse discharge. On the 25th three or four ounces of pure blood were expectorated. Cracked-pot sound is distinctly elicited on percussion below the right clavicle. Fine crepitation may also be heard during inspiration, under left clavicle, with increased dulness on percussion. Choking sensation in the throat; pain in epigastrium; no diarrhoea. June 2Sth. — The sputa have continued to be mingled with blood, and occasionallj- mouthfuls of this fluid, quite pure, have been expectorated. At four o'clock this morning, he brought up 10 oz. of blood, mingled with a matter resembling coffee grounds, appa- rently from the stomach. Shortly after, about 16 oz. of florid blood gushed from his mouth, when he sank back in the bed and expired. Cod-liver oil and nutritious diet were given during the first few days, but the stomach was intolerant of it. Afterwards, the diarrhoea was combated by various astringents, such as opium, acetate of lead, tannin, and gallic acid. He also took, at intervals, quinine, sulphuric and nitric acids, and bitter infusions. In May, the suf- focative cough was much relieved by an emetic of ipecacuanha and sulphate of zinc. The local pams in the chest were greath^ relieved by the occasional application of a few leeches and blisters. During the two first attacks of hasmoptysis, gallic acid was given in two grain doses every hour, with cold a&usion on the chest. Latterly, the vomiting was checked by a mixture of naphtha, Tr. of Cardamoms, and Inf. Calumbse. Sectlo Cadaveris. — Thirty-two hours after death. The body, though thin, was not greatly emaciated, there being three-eighths of an inch of fat between the abdominal integuments. Lips and nostrils stained with blood which had issued from the nose. Thorax — Right pleural cavity contained about six oz. of fluid, and its serous walls were united by strong and close adhesions over the upper lobe of the lung. The left pleurae are adherent by a few easily torn adliesions. Both lungs present 670 DISEASES OF THE RESPIRATORY SYSTEM. anteriorly extensive emphysema, with considerable but uniform dilatation of the air vesicles. The bronchi on both sides contained bloody frothy fluid, the blood pre- dominating on the right side. Right Lung. — The upper and a considerable part of middle lobe much diminished in volume posteriorly by compression. There are several irregular cavities in the summit, the largest not exceeding the size of a wal- nut, with indurated walls. The lower lobe consists of emphysematous and con- densed tissue, the latter containing more or less miliary and encysted tubercles, some of the latter as large as a pea. Scattered throughout the inferior lobe, were nume- rous extravasated patches of blood, varying in size from a pin's head to that of a cot- fee-bean, but not interfering with the crepitation of the lung. Left Lung. — Below the pleura-costalis were numerous miliary tubercles, scattered over the whole surfoce, but aggregated more densely towards tlie apex. Here and there were some yellow tubercular masses the size of a pea, witli pucl\erings corresponding to them on the pleural surface. On section the summit of tlie organ contained small miliary tuber- cles. The substance of the inferior lobe contained very few tubercles, but was dense, less crepitant than usual, and contained some of the sanguineous patches observed in the opposite lung. Other organs healthy. Commentary. — This was a case of chronic phthisis, whicli on dissec- tion presented old ulceration on one side, and recent tubercular deposits on the other. It proved latal Ity extensive hemorrhage, which caused sinking in a previously debilitated person. The fistula in ano may have contributed to the weakness, for the surgeons who were consulted refused to interfere, on the ground that the operation was not likely to be suc- cessful in a phthisical individual. Death from htemoptysis is on the whole a rare termination of phthisis. l)r. Walshe only met with two in 131 cases, and I believe the proportion to be even much smaller than this. He observes, that ^^ a first hemorrhage having been severe, \t is unlikely that a subsequent one will kill directly." But Cairns had three distinct attacks of hemorrhage, the last of which ims directly fatal. The treatment of this case was conducted by my colleagues for four months before I .saw him, on the palliative plan ; and I may appeal to the facts it presents, in proof that such treatment produced no etfect in any way checking the progress of the disease. In this respect it ofters a marked contrast to the preceding cases, in which the treatment was directed by the pathological principles to be afterwards detailed, and had for its object increasing the nutritive jmivers throiKjh tlie primoi vice. Case CXLVIIL* — Phthisis Pulmonalis — Tivo Vomicce on Bight Side — Small Cavi- ties on Left Side — Death from Exhaustion. History. — ilargaret Moffat, £et. 40, a washerwoman — was admitted into the clinical ward, April 5th, 1851. For upwards of three years she has been subject to cough, expectoration, and dyspnoea. Three weeks ago, after exposure to wet and cold, she was attacked with severe pain in the right side, and the other symptoms became aggravated. In this state she has continued until admission. Symptoms on Admission. — The report say.s, there was " little or no alteration on percussion." Over the part complained of in the infra-mammary region there were loud friction noises, which were also diffused posteriorly over the inferior third of * Reported by Messrs. Pearse and Hoile, Clinical Clerks. PHTHISIS PULMOXALIS. 671 right lung. Over the upper portion of the lung, anteriorly, were dry blowing sounds, with harsh inspiration; but posteriorly, crepitation was heard over the apex. Over the left back, tine moist rattles were heard. Sharp acute pain, increased on inspira- tion, below right mamma ; cough troublesome, witii copious expectoration of muco- purulent matter, here and there streaked with blood ; considerable dyspnoea. Pulse frequent and soft ; tongue covered with a brown fur ; loss of appetite ; thirst ; skin moist. Progress of the Case. — The pain in the side subsided on the following day, after the application of six leeches; but she complained, during April and May, of occa- sional return of the pain, and was particularly distressed, in addition to her other symptoms, by attacks of dyspnoea. I took charge of this case in the middle of June, when marked dulness was ascertained to exist over the upper third of the right lung, both anteriorly and posteriorly, with mucous rale and increased vocal resonance ; and on tlie left side, posteriorly, there was still crepitation. Sputum continued abundant, consisting of purulent matter of gelatinous consistence. Appetite bad. Profuse sweating at night. These signs and symptoms underwent veiy little varia- tion until her death, on the 30th of July. The treatment consisted at first of leeches to the side, expectorant and anodyne mixtures, with an aether draught at night. In May she was ordered | ^'j. of wine daily, decoction of senega, with 3 ss. doses of Tr. lobel. inflat. Towards the end of the month, blisters were applied externally, and dilute sulphuric acid given internally, in doses of ten drops. In the middle of June, chalybeate and tonic mixtures were ordered, with cod-liver oil, without any efiect in restoring the appetite or renovating the nutritive process. Sectio Cadaveris. — Forty hours after death. Body greatly emaciated. Thorax. — There were three or four ounces of fluid in the left pleura. Every- where firm adhesions between the pleurae on the right side. At the apex of the rigiit lung, the pleurfe were thickened to the extent of an inch, by the formation of a dense, white, fibrous structure. Right Lung.— There were two cavities at the apex, of irregular shape, and the size of hens' eggs. Numerous smaller ones ex- isted, scattered throughout the lung. The pulmonary tissue was almost entirely non-crepitant, dark coloured, atrophied, and indurated. Inferiorly there were nodules of a pink fleshy material, which, on microscopic examination, were found to consist of fatty degeneration, and were composed of a multitude of fatty mole- cules and granules, with compound granular corpuscles. The bronchial glands were much enlarged, several of them indurated, and the size of a walnut. Left Lung was mostly crepitant, but contained some indurated tissue, surrounding small cavities at the apex, the largest the size of a hazel-nut. In the lower lobe pos- teriorly, there was some oedematous and non-crepitant tissue. Bronchial glands also enlarged, but less than on the other side. All the other organs health}'. Commentary. — This must have been a very chronic case of phthisis, probably of much longer standing than she stated on coming into the house. ' The rio-ht hmg was universally condensed, contracted, and nodules of the tubercular matter itself, mingled, perliaps, with pneu- monic exudations, had passed into fatty degeneration, and presented a vcllow pinkish colour. There were none of the more violent symptoms of derano-ed digestive action in this case, such as vomiting or diarrhoea; and I wo°uld ag^iin point to the fact, that the palliative treatment entirely failed to makeauy impression on the malady. DISEASES OF THE RESPIRATORY SYSTEM. Case CXLIX.^— Phthisic PuhnonaUs— Large Vomica ivith rneumo-Thorax{?) on Left Side— Softened Tubercle on Eight Side— Bright s Disease. History.— James Hutchison, tet. 26, a stone-mason — admitted into the cUnical ward June 16th, 1851. Last September, after unusual exposure to wet and stormy weather while prosecuting his occupation, was seized with distinct rigors, followed by severe pain in the chest, dyspnoea, and cough. The cough and pain left him in Januar^v, but the dyspnoea has continued. About the end of last March, he ob- served "oedema of the legs, and tliat the urine was diminished in quantity, and was occasionally high coloured. Tiiese symptoms have continued since. Symptoms ox Admission. — There is marked dulness on percussion over the left side of chest anteriorly and posteriorly, most complete inferiorly. On auscultation, the respiratory murmurs are absent at the lower two-thirds of left lung ; but over the superior third there is loud gurgling, both anteriorly and posteriorly. Tocal resonance is everywhere increased, but over the apex there is a harsh, braz.en, almost metallic sound, on coughing. Posteriorly and inferiorly, there is cegopliony. On the right side, there is dulness in the subclavicular and supra-scapular regions, with crepitation and increased vocal resonance. The rest of the lung is resonant, with harsh and puerUe respiration. Cough prolonged and reverberating ; sputum scanty; muco-purulent ; pulse 72, soft; urine diminished in quantit}-, of deep red colour sp. gr. 1020, highly coagulable by heat, and on the addition of nitric acid; great 'debility, with a feeling of weakness in the lumbar region; appetite bad; thirst- acid taste in the mouth; nausea after taking food; bowels loose, but no diarrhoea; considerable emaciation; skuiantemic; inferior extremities cedematous ; prepuce and scrotum much distended; general anasarca, but not to so great an extent as has previously existed. Progress of the Case.— The pulmonary signs and symptoms remained the same, but under the action of the digitalis and squill pills, and a chalybeate mixture, with 'tonics and carminatives, the anasarca greatly diminished in ten days. The urine also became clear, but retained its coagulability. Vomiting, however, ap- peared ; he could take no food, and the general weakness increased. He insisted on going out, though in a dying condition, on the 30//i oj June, and expued a few days afterwards. Commentcmj. — The extent of the disease in this case, involving the whole of one Inng, and part of the other, together with the extensive disoro-anization which induced pneumo-thorax, etc., was in itself of fatal auo-urv. But when to this is superadded the most complete prostra- tion derano-ement of the digestive system, and extensive degeneration of t'he kidneys, with oedema of the lower extremities, it may well be supposed that the case admitted of nothing but palliatives. These were applied to the relief of the renal symptoms, and had partially succeeded when he left the house. Case Ch.\— Chronic Phthisis— Enlarged Liver — Albuminuria— Large Excavation in Left Lung — Cicatrices and Induration of Bight Lung — Waxy Liver and Kidneys — Tubercular Ulceration of Intestines. History. — Margaret Clark, tet. 39— admitted November 12th, 1844. Slie says * Reported by Mr. ^Y. M. Calder, Clinical Clerk. f Reported by Mr. Bum Murdoch, CUnical Clerk. PHTHISIS PULMONALIS. 673 that for two years previous to admission slie was labouring under frequent attacks of cough, with profuse expectoration and spitting of blood. During this period she has become greatly emaciated and very wealv, sweating at night, with occasional diarrhoea. Catamenia have been absent during the last three months. Symptoms 0>f Admissiox. — There is frequent prolonged cough, often causing vomiting, with copious purulent expectoration. Marked dulness on left side of chest, with loud cracked-pot resonance, and flattening of ribs under the clavicle. Under right clavicle dulness also evident, but resonance good over the rest of the lung. On auscultation over left side, loud gurgling is audible, with pectoriloquy, extending over the whole anterior surface, but diminishing somewliat towards the base. Under right clavicle there is loud mucous rale on inspiration, with broncho- phony. Breath sounds inferiorly normal. Posteriorly, the physical signs are similar to those in front. There is considerable dyspnoea on exertion. Heart sounds normal. Pulse 110, feeble. Total loss of appetite with anorexia and vomiting after taking food. Tongue slightly furred. No diarrhoea at present, but says she is very subject to attacks of it. Body greatly emaciated, and copious sweating at night. Other functions normal. $ Naphthce Medicin. 3 j ; Tr. Card, comp. 5 j ; Mist. Camph. f v. M. A sixth part to be taken three times a day. Milk mixed luith an equal part of lime tvater, and strong beef tea ivith toast, to be taken frequently in small quantities. Progress of the Case — April \&th. — From the time of her admission until now the physical signs have remained the same, with the exception that the moist rattles at the apex of right lung have gradually diminished, and have now nearly disap- peared. At each catamenial period there has been considerable haemoptysis con- tinuing several days, and amounting often to several ounces per day. Shortly after admission the appetite improved, she took nutrients with § iij of wine, and two and sometimes three table-spoonfuls of cod-liver oil daily. From time to time the latter remedy was suspended, and bitter vegetable infusions and tinctures adminis- tered, occasionally mixed with chalybeates. Every now and then an attack of diarrhoea has come on, which has been restrained by chalk mixture and astringents. Hence she has been alternately better and worse as to symptoms, but at present she is decidedly better than when she entered the house. July 1th. — Since last report the liver has been observed to have gradually enlarged. It can now be felt extend- ing below the level of the umbilicus on the right side, presenting a rounded margin and forming a distinct abdominal tumour. The emaciation is extreme, and latterly there has been considerable vomiting and diarrhoea. There is a hectic flush on the cheeks. The skin is warm ; pulse 120, feeble; jarofuse sweating at niglat ; loud gur- gling rales still audible on left side of chest, with cracked-pot sound on percussion, and pectoriloquy. On right side there is loud vocal resonance under clavicle, slight dulness on percussion, and dry cavernous or hoarse tubular breathing. Cough still troublesome, especially at night. Sputum purulent and copious, occasionally tinged with blood. For the last few days has passed little urine, which Is albuminous, and the feet are slightly oedematous. To have § ij of gin instead of wine. 5 "Si?', ^ther. Nit. §ss; Tr. Digitalis 3ij; Mist. Scilloe c. ad ?vj. M. One table-spoonfid to be taken three times a day. July 2Uh. — Urine still highly albuminous and scanty, though diuretics have been freely given, including supertartrate of potass. Liver now much larger, and extends down to Poupart's ligament when she sits up. (Edema has extended above the knee. AYeakness has increased. August IQth — Has continued in the same exhausted condition, every care having been taken to support her strength by small quantities of nutritious food. She has experienced little pain, and latterly obtained sleep at night by tether and morphia draughts. At 4 am. this morning, respiration became very ditKcult, and shortly after she died. 43 674: DISEASES OF THE RESPIRATORY SYSTEM. Sectio Cadaveris. — Thirty-one hours after death. Body greatly emaciated. Thorax. — Both pleurae strongly adherent throughout by chronic adiiesions. Apices of both lungs much puckered externally. The whole of the superior lobe of left lung hollowed out so as to form a cavern the" size of a large cocoa-nut, contain- ing foetid air and about four ounces of dirty pus. Its walls were lined by a distinct pyogenic membrane, and consisted externally only of thickened pleura, and inter- nally of a layer of indurated lung about half an inch in thickness. In the inferior lobe were several masses of infiltrated tubercle, which in some places were softened, forming small purulent collections, varying in size from a pea to that of a hazel nut. Throughout the upper lobe of right lung there were a few excavations, quite drj% varying in size from a millet seed to that of a small nut. The parenchyma between these was much indurated by chronic pneumonia, and of an iron-grey colour from pigmentary deposits. At the apex were several cretaceous concretions about the size of peas. One of these was the size of an almond nut, and elongated in form, and all were enclosed in indurated capsules. The two inferior lobes were emphyse- matous anteriorl3^ In the centre of the lowest one was an indurated white patch, the size of half-a-crown, with radii stretching from it in all directions. On cutting through it, it was seen to consist externally of dense white fibrous tissue, an eighth of an inch in thickness, and immediatel}- below it was a mass of indurated tubercle, the size of a hazel nut, of iron-gre}- colour, containing gritty points of cretaceous matter. Other similar masses of varying size, but widely .scattered, gave a nodulated feel to the two inferior lobes on this side. Heart healthy. Abdomex. — The liver was not only enlarged, but altered greatly in shape. The right lobe was so elongated as to extend down to the crest of the ilium. The length from above downwards was 12 inches ; breadth, 8 inches. Length of left lobe was 8 inches ; breadth, 5 inches. Its entire weight was Tibs. 9 oz. The greatest thickness of the organ from behind forwards was four inches. In texture it was of waxj' consistence and appearance, of a dirty yellow colour, dense feel, smooth sec- tion, presenting semi-translucent edges. The s/^fceft weighed 7oz. odr., and was healthy. The mucous membrane of the coecum was of a black tint, which extended up the ascending and half way across the transverse colon, gradually diminishing in intensity. This discoloured portion of the membrane was studded over with chronic tubercular ulcers in various stages of healing, mingled with numerous cicatrices and . puckerings. The largest of the open ulcers were the size of a siiilling, with irregular raised edges, and dirty yellowish base. Mesenteric glands everywhere enlarged, of a wliite colour and indurated ; some contained tubercular deposits. Both kidneys waxy ; externally pale, indurated, and rough ; internally, cortical substance atro- phied, pale, and on section having translucent edges. The uterus contained in its inferior wall a fibrous tumour the size of a walnut. Three others the size of peas were on its anterior surface ; ovaries contracted, rugose, and of semi-cartilaginous consi.?tence. Other organs healthy. Microscopic Ex.\iiiN"ATiox. — The tubercle everywhere presented its usual cha- racters. The cells of the liver had undergone a remai'kable change, being colourless, refracting light, deprived of nuclei, and forming, when compressed together, a trans- lucent, amorphous mas.s. The black matter in the coecum was composed of mole- cules and irregular masses of black pigment. Commentary. — This case of chronic phthisis, which we watched for nine months, appeared to be on the point of death when she entered the Tiifinnarv. The prostration was extreme, and an enormous excavation PHTHISIS PULMONALIS. 675 even then existed in the left, with smaller ones in the right Inng, Care- ful treatment directed to restore the tone of the stomach, nutrients administered in small quantities, with wine and cod-liver oil, caused a gradual restoration, and my opinion is, that from that time tlie pulmo- nary disease continued to diminish. The cavities on the right side became dry, cicatrices and ci'etaceous transformations of tlie tubercular matter proceeded, and the large excavation on the left side became smaller and more circumscribed. The liver first, and then the kidneys, next underwent the waxy transformation ; oedema came on and she sunk. I have already alluded to the peculiar character of this degeneration of the liver and kidney (p. 214). It is exceedingly common in phthisical cases, and in this instance was recognised and examined histologically with great care in 1845. Formerly it was confounded with fatty dege- neration, and it has been supposed that cod-liver oil tends to its produc- tion. But a knowledge of the true nature of the waxy degeneration nmst negative such a supposition, as the liver is altogether free from fat. The interruption to the portal and renal circulations, and the diminished flow of urine, produced more or less anasarca, a complication which sooner or later is uniformly fatal. The foregoing series of cases illustrate tolerably well the advantages which attend what may be denominated a curative, as distinguished from a palliative, treatment of phthisis. It is exceedingly rare, however, that we can demonstrate among hospital cases a complete cure of the disease in its advanced stage, such as took place in Barclay. (Case CXLIV.) In the majority of instances, no sooner is amendment effected, than they insist on going- out. A few return with the disease advanced, again get better, and so on, until at length they die. Many others, I am satisfied, get permanently well. In private cases, however, recovery is much more frequently observed ; and now that physical diagnosis has enabled us with great certainty to recognise the disease and follow its progress, we can have no doubt of the superior advantages of a curative over a palliative practice. To carry out the former, however, upon cor- rect principles, it is proper to. have a knowledge — 1st, Of the natural progress of the disease ; 2d, Of its pathology and general treatment; and 3d, Of the special treatment, in reference to symptoms and complica- tions. It may be well to make a few observations on each of these heads. I. — On the Natural Progress of Phthisis Puhnonalis — The Tendency to Ulceration — The Modes of Arrestment. At first tubercle is deposited in the state of a fluid exudation from the capillaries in the same manner that lymph is. In this condition it insinuates itself into the interstices of the pulmonary parenchyma, passes through the lining membrane of the air vesicles, and fills their interior. Numerous successful injections of pneumonic, tubercular, and cancerous lungs, in my possession, demonstrate that the exudation in all is poured out in the same manner,, and occupies the same position in the pul- monary texture. A miliary tubtn-cle may, in this manner, block up 676 DISEASES OF THE RESPIRATORY SYSTEM. from three to twent}^ of these air vesicles, (Figs, 135, 130.) It now coagulates and constitutes a foi'cig-n soli ^ the 100th of a millimetre " "''?\"' -? ^-■^' -^ ' in diameter. An unusual ^ =j number of these cells also '-' existed in the blood, as was C!' „" % ,- '?..•' determined both before and after death. (See Leucoey- themia.) ^(^- •- ^ FiL' 440 Commentary. — In tlie case before ns, the chest was frequently Fig. 439. Corpuscles in cancerous juice squeezed from the thyroid body. Fig. 440. The same, after the addition of acetic acid, showing the cancer cells, and those peculiar to the gland, which were found in large numbers in the blood. 250 diam. 698 DISEASES OF THE RESPIRATORY SYSTEM. examined ■with great care, and was ascertained to be everywhere resonant on percussion. Loud sonorous and moist rales were heard on both sides, especially posteriorly and itiferiorly. Hence there were all the signs of bronchitis, which was found afterwards to exist ; but there was associated with them unusually loud vocal resonance, equal on both sides. It occurred to me at the time that this latter sign was merely indicative of diminished volume in the lungs; but, after the dissection, it became manifest that it was owing to increased density of the organs, from the disseminated cancerous nodules. AVh ether the conjoined signs of augmented or unusual resonance of the lungs, bron- chitis and increased vocal resonance, will prove diagnostic in such cases, further experience only can determine. Doubtless, it will be always difficult to separate such signs, dependent on nodular cancer, ft'ora those connected with collapse of the lung, which is so common a result of chronic bronchitis. In the present case I was in great doubts notwith- standing my acquaintance with the valuable sign of tumour in the neck, as pointed out by Dr. Kilgour of Aberdeen.* The treatment, it must be obvious, could only be palliative. Cancer of the lung may occur in two distinct forms, — 1st, That of disseminated nodules ; 2d, That of infiltrated masses. In the former case there are no physical signs, or functional symptoms, which indicate the presence of cancer ; in the latter there are unusual dulness, and resistance on percussion, increased vocal resonance and tubular breath- ing, or diminished respiration, according to the density, position and extent of the cancerous infiltration. If with these signs there be indica- tions of the existence of cancer in other parts of the body, there will be little difficulty in forming the diagnosis; and even should this be absent, the history of the case, advanced period of life, and the non-existence of moist rattles will occasionally be sufficient. It must be confessed, how- ever, that notwithstanding the valuable labours of Stokes, Hughes, M'Donnell, AValshe, and Kilgour, the means of diagnosing this lesion with certaintv are very defective. In the present work, eight other cases are recorded in which cancer of the lung existed (Cases XXIX., XXXVII., XLIX , LXV., LXXL, LXXVI.,^LXXVII., and LXXXV.) In one of these the pleurte only were aft'ected (Case LXXYII.) With the exception of Case XXXYII., in which the posterior surface of the lungs could not be examined, the pulmonary organs were carefully per- cussed and auscultated in all. But in none did any combination or suc- cession of signs exist which could induce any one to pronounce that pul- monary cancer was present. Case LXXVI. alone presented the gelati- nous sputum tinged with blood, or the currant jelly expectoration described bv Stokes. In Case XLIX. there was ulceration and gangrene of the fungoid mass, with all the signs of pneumonia — and pneumonic condensation was found surrounding the epithelioma of the lung after death. In Case LXXI. there was thoracic aneurism, to which all the phvsical signs were attributable. "When infiltrated cancer exists to any amount in the apex of the lungs, associated with cancer in other organs, or with an evident tumour in the neck or mediastinum, the diagnosis is comparatively easy, * Montbly Journal of Medical Science, June 1850, CAEBONACEOUS LUNGS. 699 Xothing can be more variable than the minute strnctiire of cancer in the luno;^ AVhen recent, it may present delicate round or oval cells (Fifj. 119). When more advanced, it may exhibit large compound cells (FiJ. 126) as in Case LXXVI. When in the intiltrated form and soft'ened to any extent, I have seen the whole reduced to a mass of irre- jTularlv-formed nuclei, as in Fig. 325. On one occasion I found a large mass of brain-like looking cancer of the lung, somewhat fibrous, and principally composed of elongated fusiform corpuscles. CARBONACEOUS LUNGS. Case CLUl.*— Carbonaceous Lungs with Black Expectoraiion. History.— Thomas "Wilson, jet. 38, collier, from the Oakley Mines near Dunferm- line, was admitted into the clinical ward 26th July 1851. He states that he has been employed about coal mines for the last twenty-four years, during the principal part of which time he has been occupied in blasting rock for the sinking of pits, using large quantities of gunpowder daily. He is much exposed to cold and wet in this occupation, working almost constantly with wet feet, and frequently with the whole of his clothes drenched. During the laying open of a new surfece for the working of coal, he has often worked in an atmosphere barely capable of supporting the com- bustion of the miners' lamps; he has observed this particularly when working iron- stone. Notwithstanding, it was only about seven months ago that he began to be troubled with short dry cough, and difficulty of breathing. He continued to work till about four months ago, when the cough became more severe; he had much dys- pnoea, and frequent profuse perspiration, especially at night. Two weeks after this —that is, about fourteen weeks ago — he was laid up from work ; and about the same time, while under treatment, he began to spit much, and observed that the expectoration was of a deep black colour. The change was so sudden as to alarm him considerably. Symptoms on Admission'. — On admission, the thorax is of large dimensions and well formed. On percussion, there is slight comparative dulness on the left side of the chest over the upper half in front ; and there is also appreciable dulness over the same extent on the same side posteriorly. There is complete resonance on the right side anteriorly and posteriorly. On auscultation, for some inches below the clavicle on the left side, the inspiration is rough and harsh, and there is prolongation of the expiration. Lower down on the same side, there is also fine moist rale, and the vocal resonance is somewhat increased. On the right side there is loud pealing vocal resonance both anteriorly and posteriorly ; it is particularly loud in front immediately below the clavicle, but there is nothing abnormal to be detected in the respiratory sounds. The expansion of the chest is equal on both sides. Breathing is equal and unembarrassed while he is sitting or lying in bed, but on using much exertion, it be- comes short and difficult. There is some cough, but it is not very troublesome. States, that at the commencement of his illness, he could not lie on his left side; but at pre- sent he can lie in any position without uneasiness. The sputum is in considerable quantity, adheres tenaciously to the bottom of the spit-box, and is of an intense black colour. On being placed in Avater, a small portion of a lighter colour swims on the surface, but the greater part sinks immediately. On being allowed to stand for a * Reported by Mr. W. Calder, Clinical Clerk. 700 DISEASES OF THE RESPIRATORY SYSTEM. little, the supernatant water becomes nearly clear, the dense black mass remaining at the bottom of the dish. Acetic, sulphuric, and nitric acids and also aq. potassse, though boiled with tlie sputum, do not in the least affect its colour. The other s}-s- tenis are quite normal. Has good appetite, no sour or unpleasant taste in his mouth. Bowels are regular at present, and are generally so ; has never had diarrhoea. Does not sweat at night, nor unless when employed at his work. Pulse during examina- tiou was 88. soft and full; during his stay in the house has averaged about 76. He was ordered an expectorant mixture ; and during the last fortnight lie was in the house, he had three table-spoonfuls of cod-liver oil daily. He went out by his own desire in August, the S3nnptoms having undergone little change. Microscopic Examination of the Sputum. — On placing a small portion of the sputum below the microscope, many of the epitheUal cells are seen loaded with the black carbonaceous matter. In some of them, the nuclei are evident, the matter being deposited between them and the cell walls ; in others, the nuclei are quite concealed. In other parts of the field, all appearance of cells is lost, and nothing but apparently homogeneous black nia.sses are visible. Some of the cells ma}' also be seen ruptured, and tlie black contents poured out. (See Fig. 337.) Com/menlary. — The physical signs existinir in this case leave ns in lit- tle doubt that there was considerable condensation at the apex of both Inno's. Tills was indicated on one side by considerable dulness on per- cussion, and on the other by a pealing- vocal resonance. It is true, the resonance in this place was unaccompanied by any change in tlie per- cussion note, a circumstance that may be caused by the existence of slight emphysema counterbalancing the increased density of the puhno- nary tissue. The history of the man's case, the nature of his employ- ment, and the black sputum, at once indicated to us that this condensa- tion was owing to accumulation of carbonaceous matter in the lungs, a disease which is peculiarly apt to occur in coal-miners, the moulders in iron and copper, and a few other trades. Case CLIV.* — Carhonaceous Lungs with Black Expectoration in a Female, History. — Christina Nasmyth, a3t. 42, tlie wife of a coal miner residing near Mus- selburgh — admitted 21st May, 1857. For nine years previous to marriage she worked in a coal pit, being engaged in pushing the trucks along the tram-ways. She married at sixteen years of age, and has never since worked in the pit. She has had four children, all healthy. Her own health she declares to have been excel- lent till January, 1857. About this time she noticed a cough accompanied by sputum of inky black colour, and by sense of pain over the breast and between the shoulders. Her appetite failed, and she became very weak. Latterly her voice has become hoarse and broken. Medical treatment before admission had not been effectual. Symptoms on Admission. — No dyspnoea ; cougli is unfrequent, short, and ratlier dry; sputum scanty, consisting of frothy blood with tenacious masses of bluish- black mucus; painful sense of tightness over the breast; the voice is liarsh and broken. There is sliglit dulness under the right clavicle, with creaking sound during inspiration, prolonged expiration, and some increase of vocal resonance. Tliere is crack-pot soutid under left clavicle, bronchial respiration with a few moist sounds at close of inspiration, and increased vocal resonance ; posteriorly, percussion seems * Reported by S. de Melho Aserappa, Clinical Clerk. CARBONACEOUS LUNGS. 701 unimpaired ; no moist sounds are audible, but occasional sibilant and snoring sounds during expiration over middle of both lungs. The cardiac organ is normal in posi- tion and size ; the first sound is rough at apex ; the pulse is 80, and of good strength. Appetite is defective ; occasional thirst in the mornings ; no vomiting; considerable flatulence; bowels are open generally every second day; menstruation regular; urine 1010 sp. gr., otherwise normal. Progress of the Case. — May 23d. — No trace of blood in the sputum, which consists of several tenacious masses of a bluish-black colour, floating in a slightly viscous mucus. On microscopic examination, there are seen numerous molecules of pigment occasionally lying free, but sometimes contained in large cells ; there are also visible a few bundles of fibrous and elastic tissue. Ordered milk and steak diet. 26th. — Xo moist sounds are now audible under left clavicle; respiration continues to be loudly bronchial at left apex, and less so, but still unusually loud over the right ; hoarseness of voice has diminished. 27th. — Ordered Emplastrum Picis (6 by 6) to be applied over the chest. 28th. — No change in respiratory murmurs, nor in sputum ; some dyspnoea, and considerable debility. Is ordered a mixture of sweet spirits of nitre and aromatic spirits of ammonia. 29fh. — The black masses are now fewer in number. June 1st. — Hoarseness of voice has ceased; sputum more scanty, with fewer black masses; appetite is improved; patient walks daily about the ward. June Gih. — Has continued in the same state as in last report ; is anxious now to return to her family, and is accordingly discharged to-day relieved. Commentary. — It would appear from the account of this woman, that from the age of seven to that of sixteen years she worked in a coal-pit. She then married, ceased to work in the pit, and continued healthy for twentv-six years. Then for the first time cough came on accompanied with black spit and disorganization of the lung. This circumstance proves that the tendency to carbonaceous formation may be formed several years before it becomes manifested in active disease, which may be induced subsequently by any of the ordinary causes which occasion bronchitis or pneumonia. Young girls are not now so much employed in coal-pits as formerly, and such a case as the above must now be con- sidered, in many points of view, as one of great rarity. From the circumstance of this disease being very common among the colliers in the neighbourhood of Edinbui-gh, it has been thoroughly studied here. In the first case that Avas recorded by Dr. James Gregory, the black matter was analysed by Dr. Christison, and shown by him to con- sist of pure carbon or lamp black, a result confirmed by every subsequent writer. The papers by Dr. William Thomson, inserted in the XX. and XXI. Vols, of the Transactions of the Medico-Chirurgical Society of London, contain a mass of important information concerning this disease ; and in a series of communications by the late Dr. Mackellar, inserted in the "]\Ionthly Journal" for 1845, you will find numerous facts and opinions regarding it, the results of long and extensive practice among the colliers of Haddingtonshire. On examining the lungs of those who die labouring under this disease, thev are found to present a deep black colour, which is most intense towards their apices. On section, the pulmonary tissue yields on pressure a copious black inky juice, which stains all surrounding objects, attaches itself to the inequalities on the skin of the hands, and insinuates itself 702 DISEASES OF THE RESPIRATORY SYSTEM. under the nails like fine black paint. At tlie apices of tlie lungs, the pulmonary tissue is generally more or less condensed, and the black matter thicker, and often of the consistence of putty. In advanced cases, ulcerations and cavities exist, exactly resembling in all their characters those of phthisis, with the exception that no tubercle can be discovered, and that the whole is of an intense black colour. Occasionally black indurated and gritty masses can be felt and dug out, which in some rare cases present a slight crystallized structure, like coal or crystallized car- bon. The morbid anatomy of the disease will be best understood by carefulh' examining the preparations which exist in the University Museum. On placing some of the black fluid squeezed from the lung under a microscope, and examining it with a power of 250 diameters linear, it is seen to consist of a multitude of black molecules of extreme minuteness floating in a liquid. Here and there may be observed cells, similar to those previously described as existing in the sputum, more or less loaded with similar molecules of black matter, on which the strongest chemical re-agents produce no efl'ect whatever. (See Figs. 56, 57, and 337.) I have frequently examined the disease in all its stages, and never found it to be referrable to the changes occurring in blood after hemorrhagic extravasations, as Yirchow supposes to be the case. When w^e endeavour to investigate the pathology of this disorder, we are met with a host of difliculties. Does it originate from the inhalation of carbonaceous particles floating in the atmosphere, or is it the result of a secretion of carbon in the pulmonary system itself? The principal fact on which the first opinion rests, is the frequency of the disease in colliers, and in moulders of iron and copper. Yet it is curious, that whilst it is common among the workmen of some coal pits, it is unknown among those employed in others, although the dust and powder is as finely levigated in one place as in the other. There is another curious fact connected with the disease in coal miners, viz., that those engaged in working at what is called the coal wall, and in sifting or transporting the coal, are little afi^ected ; whilst those who work at the stone wall are peculiarly liable. This working at the stone wall, consists in blasting the rock by means of gunpowder. Hence the prevalence of black deposits in the lungs has been by some not so much attributed to the dust of coal, as to the smoke of the explosions, or of the lamps carried by the miners, confined as it is in narrow passages, where little ventilation exists. Even this explanation has difliculties ; for it has been proved, that in some mines, where blasting is carried on very extensively, and where there is much coal dust, it does not exist at all ; and hence it has been supposed that there are some kinds of stone which disengage gases, or the working among which is much more deleterious than others. Thus Mr. Philip of Aberdour, who has had great experience in this disease, in a communication he made to Dr. Thomson, savs, " In working at stone work, that is, in sinking pits and driving mines of communication, the workmen are exposed, in an imminent degree, to the influence of the impure air; for, besides working in a confined space, and in a cul-de-sac, where the ventilation is very impertect, there is also a considerable exudation of the carbonic acid gas from the fresh cut surfaces of the CARBONACEOUS LUNGS. 703 minerals. In this impure air tliey continue to -work for many' liours daily, for some montlis, their operations being frequently carried on several yards in advance of where their lamps will burn." In another place, he says, "Those pits and mines which have been noted for the impurity of the air, have given origin to the greatest number of cases." Again, Mr. Steele of Craighall says, he considers the disease to be caused by running mines in stone, and working in impure air. He also observes, — " A principal reason is, that the stone contains some poisonous matter, which is probably of a metallic nature, as the workmen complain of it exciting a styptic and metallic taste in the mouth. A mine was carried across the strata in the Niddrv estate, the finishing of which required a number of vears. Six or eight of the miners employed in it died ; several were obliged to leave it, and only one of those who com- menced it was able to work in it throughout, and lived to see it com- pleted. There was a particular stone in this mine, which was repeatedly met with, and to which the miners gave the name of arsenic, which was found highly pestiferous. Its exact nature I am not acquainted with. In a stone mine, run some years ago in the Newbattle field, a great many men died, — the average length of time each of the miners employed in it lived being about two years. The mortality was ascribed to the nature of the stone." The facts connected with this peculiar black colouring of the lung leave it therefore undecided whether it be owing to the inhalation of coal dust, the smoke of gunpowder and oil lamps, or caibonic acid gas, entering the lung. Is the powder deposited directly and primarily in the minute tissue of the organ, or is the carbon deposited secondarily, and by a process of secretion from the blood ? Before we can answer these questions, there are two other series of cases, which it is necessary to take into consideration. 1st, Persons have been known to have the black spit, and black infiltrated appearance of the lungs, with caverns, without ever having been in a coal mine, or exjiosed in anr w;iv to gunpowder smoke. Several such cases are given in the paper of Dr. W. Thomson. One of these is by Dr. Browne, now Commissioner of Lunacy for Scotland ; another by the late Dr. Moir of Musselburgh. The subject of this last case was never exposed to noxious vapours, unless it might be carbonic acid, — as he was the proprietor of an extensive brewery, and in the daily habit of inspecting the tun-rooms, the large vats in which overflow with that deleterious gas. Another case was observed by the same gentleman, in the person of a coachman, where, after death, the lungs were found to contain collections of an inky or tarry fluid, which stained the fingers, as if with soot or charcoal. A fourth and similar case, in a woman, is related by Dr. Ycitch. In none of these cases were the individuals exposed to the fumes of smoke, or coal dust. I have myself seen several of such cases ; in one especially, a cyst in the bronchial gland existed, about the size of the human eye- ball, filled with a black inky fluid. 2(7, M. Guillot of Paris has brought forward another scries of cases in old persons.* He is physician to the hospital for aged people, and says there is scarcely^an individual of advanced life who does not present the * Archives Generales de Medecine, vol. 67. 704 DISEASES OF THE RESPIRATORY SYSTEM. carbonaceous deposit in the lung, generally most marked at the apex. The carbon often exists in crude masses, obliterating the vessels and bron- chial tubes. I have also seen many cases of this kind, and there can be no doubt that the longer we live, the"more carbon is deposited in the lungs. In intants, as is well known, those organs are of a light pink colour, and they become more grav and of a deep blue or black tint as life advances. What are we to conclude from these causes ? The black matter in all of them, when chemically examined, is undoubtedly free carbon, and is distiniruished bv the action of chemical agents; hence it is not likely to be an alteration" of hjematin, resulting from bloody extravasations into the pulmonarv tissue, as Virchow supposes. It never presents the brownish colour orstructural character we have shown to be present in coal,* a circumstance opposed to its being derived from without, in the form of dust. Dr. Pearsonf thought that we are always insensibly breathing an air more or less loaded with smoke, the results of combustion, and other impurities ; and that this of course accumulates the older we get. If this opinion were true, it should be more common in persons who inhabit densely populated and manufacturing towns, as London, Liver- pool, Manchester, or Glasgow. Yet we do not find this to be the case. The air in Paris is remarkably pure, the fires of manufactories are few, and vet there, according to (juillot, it is common. On the other hand, should we conclude that it is formed internally by a chemical process in all cases ? If so, must we ascribe it to the inhala- tion of carbonic acid gas, rather than to carbon in a minutely divided state, inspired from without ? In the present state of our knowledge, we cannot answer these questions with any exactitude. Another point of great interest is the apparent antagonism of carbona- ceous deposits with tubercle. We frequently find the black lungs of colliers to contain small or large ulcerated cavities, with bands crossiiig them; but we rarely find tubercle. In one or two cases chronic tubercle has been found ; but it does not appear that the caverns filled with black matter in the. miner are owing to tubercle. Such is the analogy, however, existing between these cavi- ties, and the symptoms they occasion, that the disease has been named " black phthisis" by severalpersons. Some have supposed that tubercu- lar tissue is first set up, and that the carbonaceous deposit is then insinu- ated among the textures and ulcerations. By others, and especially l>y the late Dr. Mackellar, it is maintaiue'l that there is never tubercle in these cases, and that ulceration is entirely owing to the accumulation of masses of carbon which are expectorated. I have carefully examined several lungs in various stages of the disease, but have never been able to satisfv m vself of the existence of tubercle. The difficulty of the investiga- tion, however, is very great, for it is probable that, did a tubercular exuda- tion exist, it would "be so impresrnated with the carbonaceous matter, as not to be recognisable even under high powers. On the other hand, the bronchial tubes are frequently loaded with purulent matter of the usual appearance, but which, instead of presenting pus-corpuscles, is loaded with particles closely resembling those found in softened tubercle. * See the Author's paper on the structure of various kinds of coal. Transaclions of the Royal Society of Edinburgh, vol. xxi. part I. f Philosophical Transactions, 1853. CARBONACEOUS LUNGS, 705 Giiillot has alluded to the well-known fact, that in old persons who pre- sent traces of tubercle, the cretaceous conci'Ctions are always surrounded by black matter. He thinks that the carbonaceous deposit compresses the capillaries which immediately surround the tubercle, prevents its further exudation, and so imluces cure. But this is by no means invaria- ble. Still it is an undoubted fact, that the black matter, like tubercle, always exists in greater proportion at the apex of the lung, and the rarity of recent tubercle in combination with it, leads us to suppose that it exerts a peculiar influence on tubercular deposits. I have also seen black matter surrounding tubercle of the peritoneum, but in this situation it has not been free carbon, for long immersion in spirit has caused the disappearance of all colour. (See Fig. 330.) So far as my observations have yet carried me, no difference is to be determined structurally between the pigment of melanosis and that of the disease under consideration. Some cells spit up by the miner, con- taining black granules, exactly resemble those in melanic cancer. (Com- pare Figs. 336 and 337.) On the other hand, there is a marked ditference in the chemical constitution ; as in the one, the black pigment, whatever be its nature, is fugitive, and removable by mineral acids ; in the other, fixed, and unchanged even under the blow-pipe. Hence all black deposits maybe divided into two classes; to distinguish which we mav call one class bv the name it has so long borne, viz., " melanotic^'' and the other, from its chemical composition, " carbonaceous.''' With regard to the treatment of individual cases of black phthisis, there is little to be said. The disease, once established, does not admit of cure bv art ; and it is a curious fact, that a man may work in a coal mine for many years without the black spit; but when it comes on, even should he leave the mine immediately, he will continue to expecto- rate carbonaceous matter for a long time afterwards. Of this both the cases before us are corroborative, and the circumstance is one which constitutes a strong argument in favour of those who contend for the disease being dependent upon a secretion rather than a mechanical deposition of carbon. A palliative treatment, guided by the nature of the svmptoras and strength of the constitution, is all that is admissible. The only means of preventing the disease seems to consist in ventilating the mines where colliers work, or adopting the means of carrying off the fumes to which the moulders of iron and copper are exposed. Such prophylactic measures are equally called for, whatever theory of the nature of the disorder shall ultimately be proved to be correct. 45 SECTION YIII. DISEASES OF THE GENITO-URINARY SYSTEM. In no department of medicine lias our knowledge of the diagnosis and treatment of disease made more rapid progress in recent times than iu that relating to disorders of the genito-urinary system. Notwithstand- ing what has been very justly said as to the impropriety and frequent danger of unnecessary mechanical exploration of the uterine passages with instruments, it cannot be denied that, used with judgment and dis- cretion, they have materially contributed to a recognition and successful treatment of lesions that would otherwise have been unknown or misun- derstood. The use of the microscope in the examination of the urine, conjoined with an histological investigation of morbid alterations in the kidney, hitherto grouped together under the name of " Bright's Disease," has also thrown a flood of light upon a class of disorders formerly involved in the greatest obscurity, besides opening up a field to the chemical pathologist in his endeavour to work out the transformations necessarj^ for the excretory processes, which cannot be too highly valued. From these various investigations medicine has already derived great advantage, and will doubtless obtain much more. The diseases of the generative organs of women, however, constitute at present so peculiarly a speciality of the obstetrician, that the only one of them that I shall allude to is OVARIAN DROPSY. Case CLV.* — Ovarian Dropsy — Frequent Paracentesis — Excision of both Ovaries — Strangulation of the Intestine — Phlebitis — Death from Ileus the seventieth day after the operation. History. — Jessie Fleming, unmarried, set. 20 — admitted July 5th, 184.5. She states, that eighteen months ago slie first perceived a tumour in the lower part of * Reported by Mr. D. P. Morris, Clinical Clerk. OVARIAN DROPSY. 707 the abdomen, deep seated in the middle of the hypogastrium. She remembers that she could push it aside in various directions without pain, and that at this time it was about the size of an orange. She can assign no cause for its appearance. The tumour rapidly increased in bulk, until at the end of ten months the abdomen was greatly distended — so much so, that respiration and progression were rendered difiScult. Paracentesis was now performed, and forty imperial pints of a viscid yellowish-coloured fluid were removed. The abdomen, however, again rapidly increased in size, and paracentesis was again had recourse to. The operation has now been performed six times, the intervals between each becoming less and less lengthened, and the amount of fluid, though always considerable, varying in amount. She says that immediately after every tapping, a tumour can be felt about the size of a child's head on each side of the abdomen ; that these tumours (she thinks there are two) are movable laterally, but seem to grow from below. She thinks the one on the left side is larger and higher up than that on tlie right. Her general health has been little affected by the disease. Symptoms ox Admission'. — At present, July 6th, she complains of pain in the head, which is stated to be dull and hea\y, and seated principally over tlie forehead. It comes on occasionally, and lasts for three or four days at a time. She has pain in the loins very frequently, especially when the dropsy is large. Special senses and common sensibility normal. Her sleep is much disturbed by breatlilessness. and by the semi-erect posture the dropsy requu-es. Motion is impeded by the size of the abdomen, and from its great weight. There is much muscular weakness. The abdomen measures 48^ inches at its largest girih, which is just above the navel. It fluctuates distinctly. Dulness of the liver cannot be defined by percussion. The skin of the abdomen is marked by transverse fissures or marks of a purplish colour; it often feels very hot and as if it were bursting ; tongue clean ; appetite a little impaired ; no thirst or sickness ; bowels regular ; stools somewhat fluid, but of healthy a.spect ; urine scanty, thick, high coloured, of acid reaction containing a yellowish brown sediment, but unaffected by heat; skin dry, not warmer than usual. She states that she never perspires. Has no cough or pectoral complaints except dyspnoea, which is very severe at night. On auscultation the chest appears to be healthy. Pulse 88, sharp and small ; heart's sounds apparently abrupt, but natural. The cataraenia have appeared at irregular intervals, sometimes of three weeks, at others five weeks, and when present are profuse. Progress of the Case. — From this time she remained generally in about the same condition. The urine passed in the twenty-four hours never exceeded twelve ounces, and on one occasion was as low as six ounces. The abdomen gradually became more tense and the dyspnoea more urgent. July \2th. — ilr. Syme performed the operation of paracentesis of the abdomen. Tlie trocar was introduced to the left of the linea alba, about two inches above the pubic bone. Five imperial gallons of a yellow-coloured transparent fluid were removed. The last four ounces which came off were viscid like white of egg, and contained a few yellowish opaque flocculi. The fluid was densely coagulable on application of heat or nitric acid. The flocculi, when examined with the microscope, were found to be composed not of lymph, as was at first supposed, but of numerous cells, varying in size from the 100th to tlie 40th of a millimetre in diameter. The great majority were about the 50th of a mil- limetre. They were slightly granular, of round and oval shape, unaSected by water, but becoming more transparent on the addition of acetic acid, and exhibiting a dis- tinct nucleus about the 140th of a millimetre in diameter. (See Fig. 70.) The nucleated cells were imbedded in a granular matter which could easily be broken down. Shortly after the operation, she complained of considerable pain in the abdomen towards the left side, which was not increased on pressure. Fifty minims 708 DISEASES OF THE GENITO-UPJNARY SYSTEil. of tincture of opium to be takea immediately. July loth. — Has continued to feel more or less pain in the abdomen, wliich is not superficial or peritoneal. The bowels have been freely opened by compound jalap powder, and she has passed from 48 to 50 oz. of urine daily. The puncture is now healed ; the abdomen is still voluminous but soft. On palpation, a tumour with distinct margins, about the size of the adult human head, may be distinctly felt, firmly attached inferiorly within the pelvis, but its upper portion movable to a considerable extent from side to side. She describes the pain as being of a dull, gnawing, and continued character ; not lancinating nor increased on movement. Pulse 98, of natural strength ; tongue slightly furred ; has tolerable appetite ; no thirst, but says she vomits everything she takes. The matters vomited are thrown up about ten minutes after each meal, in successive mouthfuls, accompanied by gnawing pains at the stomach These latter pains are felt under the false ribs on the right side. The stomach is often felt to be distended, followed by considerable eructations of gas; bowels have been open four or five times; urine much increased in amount since the operation ; to-day she passed thirty-eight ounces. The compound jalap powder was directed to be given again. July 18th. — To-day she was carefully examined by Professor Simpson, who employed his uterine bougie. By this means the fundus of the uterus was raised above the brim of the pelvis, where it was distinctly felt presenting its obtuse, rounded, natural form. The Professor stated his opinion that the tumour was connected to the left ovary by a narrow pedicle. Urine ten ounces. July 19th. — The examination of yesterday was followed by great pain. She described this as being " tremendous," and seated ui the back. The nurse said she cried out as a woman in labour. About two and a half hours afterwards a draught containing one drachm of solution of morphia was given. It relieved the pain, but it continued until 11 p.m. An anod\-iie and ether draught was then given, which was immediately rejected by vomiting. August 7th. —Since last report the vomiting has gradually abated, under the influence of opium and creosote pills. The urine, however, has again diminished in amount, and for the last ten days has only been from ten to twelve ounces, while the size of the abdomen has slowly increased to its former volume. To-day, paracentesis was performed by Dr. James Duncan, and five and a half gallons of fluid removed, presenting the same characters as that described July 12th. Soon after the operation, she experienced considerable pain in the back and upper parts of the abdomen, which ceased at midnight after taking a draught with half a drachm of the solution of morphia. Aug. 16ih. — Since last report has been in the Surgical Hospital Dr. Bennett pro- posed to the acting surgeons severally the operation of ovariotomy, which they declined to perform. To-day, accordingly, she returned to the medical ward. During the interval her general health has been good. The fluid in the abdomen is again accumulating. By a careful examination the tumour can be ascertained to be quite free from adhesions to the anterior walls oi" the abdomen. These latter can be pulled forwards and held steady, while the tumour is made to roll free beneath. Passed during the last 24= hours eighteen ounces of urine. The liver was carefully per- cussed. Its extreme dulness in the right hypochondrium is three inches ; it is pushed considerably upwards, the upper line of dulness being on a level with the nipple. She denies ever having suffered from dyspeptic symptoms, or so-called attacks of bile ; and her general health is in every respect good, and the amount of urine discharged diminishing. Her general health is not so robust as when she first entered the house. Dismissed from the Infirmary August 2Ath. September 3d— After leaving the Infirmary, she went into lodgings, having been placed by Dr. Bennett under the care of Dr. Handyside. On the 2d that gentleman performed paracentesis, and removed four gallons of fluid, and to-da}-, having satis- fied himself that it was a case urgently caUing for the performance of ovariotomy, OVARIAN DROPSY. 709 lie consented to perform it according to tlie request previously made to him by Dr. Bennett. Sept. SdA.— Bowels liave been opened four times during tlie uiglit, tlie last time at 8 this morning, from the purgative of Ext. Colocynth, gr. x., administered yesterday evening, and a domestic enema given this morning. Slie is in good health and spirits. Tongue clean. Operation of Ovariotomy. — The operation was performed, September 5th, at half-past 12 by Dr. Handy side, in the presence of Drs. Beilb}', Simpson, W. Campbell, A. D. Campbell, Baillie, Bennett, and Struthers, and Professor Goodslr. The temperature of the room was raised to 72°. The patient was placed on a table before a good light, her feet resting on a stool, and her shoulders raised and supported by pillows. Dr. Handyside, now standing to the right side of tlie patient, made, with a strong scalpel, an incision of about three inches in length through the skin and subcutaneous cellular tissue, midway between the umbilicus and pubes and over the linea alba. This incision was deepened carefully, the linea alba divided, and the peritoneum reached. A fold of this membrane was pinched up with the forceps, and a small opening made into it. Through this opening some glairy fluid escaped, indicating that the cavity of the abdomen had been opened. With a probe- pointed bistoury the peritoneum was now slit open to the extent of an inch less than the external wound. A large quantity of the glairy fluid then escaped, which occasioned some delay. Through this opening Dr. Handyside now introduced two of his fingers in order to ascertain that no adhesions existed on the exterior surface of the tumour. Xone being felt, the wound was dilated upwards for other three inches, with a probe-pointed bistoury, which was guided by two fingers introduced into the abdomen. Through this opening Dr. Handyside introduced his whole hand, and finding the tumour nowhere adherent, the wound was extended upwards to rather more than midway between the umbilicus and the ensiform cartilage, and do\vnwards to within two inches of the symphysis pubis. In cuttmg upwards, the umbilicus was avoided, the incision passing to the left side of it. Through the large opening the fundus of the tumour now presented, and the charge of it was committed to Professor Simpson, who drew it gently outwards. At this time, as well as before and after, care was taken to prevent protrusion of the intestmes. This was done by Mr. Goodsir, who, with both hands, pressed the edges of the wound downwards and backwards against the intestines and from the tumour. On the anterior aspect and fundus of the tumour were now observed several round smooth-edged apertures, through which some of the glairy fluid was seen to escape, being of the same character as that which had flowed from the peritoneal cavity, but rather more viscid in consistence. One of these openings was dUated with a bistoury, which allowed of the escape of a large quantity of the glairy fluid. This had the desired eftect of diminishing considerably the size of the tumour. The pedicle of the tumour was next examined, and it was found to consist of the left broad Ijo-ament of the uterus, somewhat elongated and enlarged, but not altered in texture. The uterus was seen to be of normal size, though of a rose-red colour, and to be unconnected with the tumour, except through the medium of the ligament. The pedicle of the tumour being now put on the stretch by exerting slight traction on the latter, a strong curved needle, in a fixed handle, and carrying a strong double ligature, was passed through its middle. The double end of the ligature being divided, each half was tied separately, so that each included one-half of the pedicle. Some delay was occasioned by the difficulty experienced in tying the ligatures, as the elasticity of the part included caused the first half of the knot to slacken before the other half could be thrown. The tumour now required to be removed. This was done by cutting carefully with a scalpel at about an inch beyond the part sur- rounded by the ligatures. In domg so, a cyst, which had extended down to the 710 DISEASES OF THE GEXITO-UEINARY SYSTEM. pedicle, was necessarilv opened, and some more of the glairy fluid escaped. During the division of the pedicle, venous blood escaped freely from the tumour, but after the removal of that latter, no bleeding occurred from the divided surface of the pedicle, although the mouth of at least one large artery was visible. The right ovary was now examined, and it was found to be enlarged to the size of a vralnut. and to con- tain several small cysts. Accordingly, Dr. Handyside proceeded to remove it also. A needle carrying a double hgature was passed through the middle of the ligament of the ovary, and the ends tied separately in the same manner as on the other side. Xo bleeding followed the division of the ligament beyond the ligature. The portions of the broad ligaments which were left were unaltered in structure. The four ends of ligature attached to each broad ligament were now tied together around the latter, and then three of the ends cut oS, so as to leave only one from each side hanging at the lower angle of the wound. The blood mixed with the remainder of the glairy fluid was now sponged carefully out of the lower part of the abdomen and the pelvis, which were exposed. The peritoneum lining the abdominal wall, as well as that covering part of the intestines, was now examined, and seen to be of a red colour ; but on no part was there any mark of the eflfusion of lympk Such of the intestines as were seen were quite natural in their appearance. All oozing of blood from the incisions in the abdominal wall having ceased, no vessel having required ligature, the edges of the wound, with the careful exclusion of the peritoneum only, were approximated and retained in accurate apposition by means of ten twisted sutures. Corresponding parts of the edges of the incision were indicated by the dark points and cross lines which were previously marked with the nitrate of silver, and which, on the now flaccid skin, were found to be of great use. A long pad of lint was now laid, as a compress, along each side of the wound, and a lighter one over it, and these were retained by broad strips of adhesive plaster. Lastly, over these pressure was made, and support given, by the ends of a double many-tailed bandage, which had been placed under the patient before the operation began, and which were crossed and pinned alternately at opposite sides of the abdomen. The patient was then placed in bed, a dry blanket having been previously wrapped round the thighs and pelvis. The patient bore the operation well. At one time she felt faint but svncope never occurred, so that no stimuU were given. The pulse never sunk below 80, but remained most of the time between 90 and 100. The operation occupied in all about forty minutes. Fifteen of these were taken up in the preliminary incision, examination, and removal of the large tumour, — five in the removal of the small one, and twenty in sponging out the pelvis, introducing the sutures, and applying the compresses, straps, and the many- tailed roller. ScTJSEQUEXT PROGRESS OF THE Case. — Immediately after the operation, otie drachm of the Solution of Morphia was administered. At 4 p.m. she complained of acute pain in the abdomen, and two grains of solid Opitim were given in the form of piU. At 8 P.M. another grain of Opium was taken. At 9 p.m. the pain ceased on her being turned in bed. The pulse was 100. soft, and eight oz. of urine were drawn oflF by the catheter. September 6/A.— Has taken during the night a drachm and a half of the solution of Morphia, which occasioned drowsiness but no sleep. At 2 p.m. there was slight difficulty of breathing. At 9 p.m. the pulse was 148, full and strong, and difficulty of breathing was increased ; 20 oz. of blood were taken from the arm. Sept. 7th. — At 2 P.M. was allowed to have a little warm gruel, followed by fifteen minims of the "black drop,'' as she was very irritable and restless. Sept. 8th. Last night had some beef-tea and toast, and slept several hours. The wound was dressed at 2 P.M. for the first time. Union by first intention had taken place every- where, except where the ligatures mterpose. Sept. lOth.—Woxmd discharging OYARIAX DROPSY. 711 freely around the ligatures. Complains of tormina and restlessness. Bowels open. At 9 P.M. there was considerable tenderness of the abdomen, and twenty-four leeches were applied. Sept. llth. — Passed a tolerable night. Abdominal tenderness dimi- nished, but still pain in left iliac region. Pulse 130, soft. Respirations 35, but easy. Twenty leeches to ie applied over seat of pain, and three grains of James'' powder, with half a grain of Opium, every three hoias. Soda ivater with Raspberry Vinegar for drink. Sept. 22d. — Since last report has gone on well— occasional symptoms having been carefully ti-eated. For the last few days has complained of cough, but on aus- cultation and percussion the lungs appear to be healthy. The nourishment has been gradually increased, and she has taken eggs and beef-tea, and to-day allowed two oz. of steak for dinner. Between three and four oz. of laudable pus escape daily from the wound round the ligatures. Sept. 28th. — Ts so well that she sat up in a chair for some time. Appetite much improved, and has been eating meat daily. October 3d— Has had slight diarrhoea. The discharge from the wound is copious and foetid. In the evening, on pulling one of the ligatures, it came away, with a slough about three inches long, and the diameter of a crow quill. To have a grain of Opium. Oct 10th. — Looseness of bowels returns occasionally notwithstanding the use of Lead and Opium Fills. Cough has been troublesome, with to-day tenacious sputa, slightly tinged here and there of a rusty colour. On examining the chest, a crepitating rale is heard for the tirst time about the middle third of left back, and iuferiorly there is sonorous rale, both with inspiration and expiration. Over the right back the respiratory murmurs are generally harsh, with increased vocal reson- ance, but no rale. On tightening the ligature, which is still firmly attached, about three ounces cf thick greenish otiensive pus flowed from the opening. To lie on the fcLce as much as possible. If, Mucilag. §j; Syr. Simp.; Vin. Ipecac. i.dL ^ss; Sol. Mur. Morph. 3 ij ; Aq. Font, ^iv; M. Sumat 3 ss quarto, qudque hord. At 9 P.M. the ligatures, on being firmly pulled, suddenly came away, producing a sensation as if she had received a blow in the abdomen. There was no slough attached, and the separation was not followed by blood, although flakes of dead tissue were observed in the pus. Pressure was made by pads over the iliac fossa and umbilical region, so as to direct the pus externally. Oct. 20th. — Since last report there has been much cough, with all the signs and symptoms of limited pneumonia of both lungs, poste- riorly and iuferiorly. The pulse has varied from 120 to 140, and been soft, and the treatment has consisted of rest in bed, anodynes at night, with wine and nutrients. Yesterday a blister was applied to the left thorax, inferiorlj'-, and to-day she is much better. All crepitation has disappeared; the cough has ceased. Over left back iuferiorly, near spinal column, there is a space the size of a hand, dull on percus.sion. In the last few days she has been eating food with appetite, and sitting up an hour daily. November \st. — Since last report, although the physical signs of chest have undergone little change, general health has been so good that she has been up daily, and walks freely about her room. About half an ounce of healthy pus is discharged daily from the wound. At half-past 4 p.m., during the temporary absence of the nurse, feeling very hungry, she went to the press, where the provisions were kept, and ate half a teacupful of arrowroot, half a pint of strong soup, a sraaU piece of roast beef, and a piece of bread, being all the food she could get at. Immediately afterwards, she experienced severe griping pains over the whole abdomen, followed by vomiting of the matters taken. The abdomen became distended and tympanitic above the umbilicus, and a cuiwe of intestine was very prominent in this situation and clear on percussion. A few drops of 01. Menth. Ftp. afforded slight relief, and ivarm fomentations were applied to the abdomen. Frequent vomiting of a greenish fluid, however, continued, and in the evening five grains of Ojmim ivere given in the form of suppository. Kov. 2d. — An enema was given at 10 a.u., and another four 712 DISEASES OF THE GENITO-URINARY SYSTEM, hours after\\-ards, without causing any evacuation from tlie bowels, which have not been opened since 6 p.ii. on the 3lsi of Octohtr. S p.m. — There has been frequent retching during the day, witli discharge of mouthfuls of mucus. Marked difierence between t3'mpanitic fulness and distension above the umbilicus, and the flatness and collapse of the abdomen below it. Had nothing to eat, and drank only a little cof- fee. 5 Calomel gr. viij ; Gum. Opii, gr. ij ; Conserv. Rosar. q. s. Ft. pil. ij. One to he taken immediately. Four pounds of warm loater to he injected slovjly. If no motion hy \2 o^clock, to have an enema, composed of an i'nfusion of six ounces of hailing water added to lb grains of tobacco. Kov. 3d. — The warm water injection returned imme- diately with much flatus and some small pieces of foeculent matter. The tobacco injection was not given. This mornmg the countenance is anxious; pulse 120, small ; tongue furred ; great thirst ; no appetite ; considerable distension of the upper part of the abdomen, and a distended knuckle of intestine prominent and stronglj' marked out below the integument, pressure on which causes tenderness. Twelve leeches to be applied to the abdomen. To have the tobacco injection. 8 p.m. — This morning the tobacco injection (not quite the whole of it) was given. It was retained ten minutes, and caused considerable collapse, with tremors and vomiting. Two large warm- water injections have been subsequently given, which have returned without foeces. No tenderness of abdomen, to which a turpentine embrocation is ordered to he applied. Nov. ith. — Complained last night of a throbbing pain in the calf of left leg, and swelling of foot and ankle. To-day the whole limb is swollen as high as the groin, and an induration is felt in the course of the femoral vein. The vomited mat- ters were clearly foeculent. From this time she gradually sank. She vomited from time to time matter sometimes fceculent, at others bilious, and occasionally felt colic pains. She became greatly emaciated, which permitted the swollen and tympanitic intestines to be strongly marked out above the umbilicus. The pulse varied from 130 to 150, and was not absolutely weak until the day she died. Calomel and opium pills were continued, with occasional injections per anum, and small quantities of nourishment. The mind remained unclouded to the last, and latterly the tympanitic distension of abdomen and swelling of right inferior extremity somewhat diminished. On Nov. I2th, at midnight, she requested the nurse to raise her up. This was done, w^hen she fell back and expired — the 70th day after the operation. Sectio Cadaveris. — Forty hours after death. The body was greatly emaciated. The head was not opened. Thorax — The cavity of the pleura on the left side contained about one ounce, and on the right about two ounces of serum. On the left side the pleurae were adhe- rent so strongly, that the lung was lacerated in removing it : this more especially between the inferior surface of the lung and upper surfoce of the diaphragm. On the right side the pleurte were adherent at the apex, and over inferior lobe, but the adhesions were easily torn through. The anterior margin of the upper lobe of the left lung was emphysematous; its posterior portion slightly engorged. On section it crepitated readily, and was healthy in structure. The inferior lobe felt dense exter- nally, and on section the parenchyma was of a brownish red colour; splenified; easily breaking down under the finger, and portions of it placed in water sunk nearly to the bottom of the vessel. The two upper lobes of the right lung very emphyse- matous anteriorly, engorged posteriorly and inferiorly, but otherwise healthy. The anterior half of the inferior lobe also emphysematous, with here and there indurated patches of chronic lobular pneumonia. The posterior half of this lobe was splenified throughout, as in the opposite lung. The lining membrane of the bronchi was healthy, here and there covered with mucus. Both lungs were small in volume. OVARIAX DROPSY. 713 The heart was small and pale. Its right cavities contained a firm dark coagulum. The valves and structure of the organ healthy. In the aorta there was a small but firm coagulum, partly decolorized. Abdomen'. — On reflecting the walls of the abdomen, a few clironic bands of lymph were torn through, uniting the opposite portions of peritoneum. The line of incision was firmly united except at its lower end, where a round opening existed about the size of a pea. On the peritoneal surface the union was marked by a dark blackish line, which was perfectly smooth and free from lymph. The omentum was thhi and transparent, destitute of fat, and stretched tightlj' over the intestines. Its inferior margin adhered strongly to the visceral and parietal peritoneum, about an inch above the pubic bones. The omentum was cut through transversely about its middle, and the intestines below exposed, which were greatly distended with gas. These were found to be portions of the ileum, the coQs of which were more or less adherent to each other, to the mesentery, omentum, and to the neighbouring organs, by bands of chronic lymph. The adhesions were now carefully torn through, the gut liberated and traced downwards Exactly five feet and a half from the coecum, above and to the left of the umbilicus, the intestine was constricted by a band of lymph, as if a ligature had been tied round it. Above the constriction the gut was distended to about the size of the wrist ; below, it was collapsed to the size of the little finger. Air could be pressed from the superior portion into the inferior, but the passage of water poured from above was completely checked at the seat of stricture. All the intestines above the stricture were greatly distended with gas ; those below it, including the coecum, colon, and rectum, were small and collapsed. The cavity of the pelvis was blocked up, and separated from the general cavity of the abdomen by firm adhesions between the surfaces of the abdominal walls, the omentum, and knuckles of intestine. The peritoneum in this place, and especially in the left ihac hollow, was covered with a dense layer of chronic lymph. This lymph was about one-eighth of an inch in thickness, of a dhtj' greenish colour, mixed with black pigmentary matter, of great hardness to the feel, and cut under the knife like cartilage. With some trouble, the united knuckles of intestine and portions of omentum involved were separated and drawn out. A cavity was thus exposed, about the size of an orange, situated between the uterus and rectum, lined throughout by the same dense, chronic lymph spoken of above. The anterior sur- face of the uterus was firmly united to the bladder by chronic adhesions. On the right side about one inch of the Fallopian tube and broad ligament remained, the extremities of which were closely united to the anterior wall of the cavity. On the left side the margins of the uterus and short pedicle of the broad hgament were so united to the walls of the cavity that they could not be separated. This cavity or pouch between the uterus and rectum communicated with the external opening, and was evidently the place where the pus during life had accumulated. A sinus opened into it superiorly, which on being traced upwards was seen to extend, above the descending colon, between the peritoneum and intestines as high as the diaphragm on the left side, where it terminated in a cul-de-sac, the size of a hen's egg. The sinus was about the size of the httle finger, and lined throughout by the same dense, greenish lymph formerly noticed. The cul-de-sac was full of dirty-yellow offensive pus, and bounded by a portion of the stomach and left lobe of the liver internally ; the diaphragm above and posteriorly ; and the colon and spleen externally and inferiorly. It also was lined with dense chronic lymph. The mucous membrane of the stomach and small intestines was healthy. The latter contained a clayey coloured soft foeculent matter. The large intestines were empty. No appearance of inflammation existed at the constricted part. The internal surface of the rectum, extending seven inches from the anus, was intensely vascular, thickened, and 714 DISEASES OF THE GEXITO-UEIXARY SYSTEM. inflamed. Six ulcers, varyiug in size from a sixpence to that of a shilling, were scattered over the diseased part of tlie gut, one of the largest being only an inch from its extremity. They were round in shape, and covered with a raised dirty greenish slough. The liver, kidneys, and spleen were ana?mic, but healthy in struc- ture. The femm-al and saphena veins could be felt hard and distended below the integuments. On dissection, these, as well as the external iliac vein, up to the point where it passed under the layer of lymph, in the left iliac hollow formerly described, were found to be obstructed by a coagulum of blood. This coagulum was adherent to the internal wall of the vessel, was partially decolorized, and of the consistence of soft cheese. This obstruction of the vessels ceased about three inches below Poupart's ligament. Description of the TuiiouRS removed. — The tumour which involved the left ovary, on being removed, weighed nine pounds and a half. It was of an oval form, measured thirteen inches in its longest, and nine inches and a half in its shortest diameter. Its envelope was composed of white, dense, and glistening fibrous tissue, having upon its external surface patches of various sizes, resembling chronic lymph. On its anterior surface might be seen openings, or ulcerations, varying in size. The edges of these ulcerations were smooth and rounded, and of the same thickness as the fibrous envelope. The cut surface, which had been near the ligature, now presented a large opening into the tumour, through which numerous cysts, varying in size from a pea to that of a billiard ball, protruded. The incision into it, made during the operation, had opened up one of these cj^sts about the size of a cocoa- nut. The tumour was sent to the University Museum, minutely injected by Mr. Goodsir and afterwards cut up, in order to show its internal structure. In dividing it, some of the internal cysts were found to be fuU of pus, whUst others contained the usual glairy fluid, common to these tumours. Three preparations were made from this tumour, which may be seen in the museum, and which demonstrate the following facts: — \st. A portion of the fibrous sac, showing the attachment of numerous cysts varying in size and shape. A minute injection has been thrown into the arteries (?) and exhibits how richly the walls of the internal cysts are supplied with blood-vessels. One of these cysts, about the size of a small hen's egg, has its upper half fully injected, whilst the lower half is pale. The margin between the two is uneven but abrupt, and from the creamy and distended appearance of the cyst, there can be no doubt that it is full of pus. 2d A portion of the fibrous sac, showing the incision which separated the tumour from its attachments. The opening is of an irregular form, about three inches in its longest diameter. 3d. A portion of the fibrous sac, showing the ulcerated openings formerly described. The right ovary was about the size of a walnut. It was formed externally of a dense fibrous capsule, and internally of several small cysts. The natural stroma of the organ had entirely disappeared. Commentary. — The life of this young woman was rendered miser- able by the enormous size of her abdomen, and the difficulty it caused to the functions of respiration, micturition, locomotion, etc. She earnestly desired that any operation should be performed which held out a prospect of relief, and bore the excision of both ovaries, which -was luost skilfully performed, with the greatest courage. From this she may be said to have recovered, for, notwithstanding the chest com- plication which arose, she was from the forty-eighth to the fifty-eighth OVARIAN DROPSY. 715 day after the operation so well, that she sat up and walked about with- out inconvenience. On this last day, feeling the intense hunger of a convalescent, she took advantage of the nurse's absence, and ate largely. The stomach tliereby was distended, the intestines displaced, so that a filament of chronic lymph, attached to the abdominal walls, became twisted round a portion of bowel, causing complete mechanical strangulation of it, and death twelve days later, Avith all the symptoms of ileus. To this accidental circumstance, and not to any direct intluence of the operation, must the fatal result be attributed. The question I have frequently asked myself is, A\ as I warranted in proposing and urging others to perform the operation ? The reasons that induced me to do so were the following : — 1st, The youth and good constitution of the patient; 2dli/, The disease was rendering her life miserable, and she earnestly wished the operation to be performed. 3dli/, Death seemed unavoidable at no distant period. At least it could not be anticipated that five gallons of fluid could be removed from the abdomen every three weeks for any length of time, without injury to the vital powers. 4thb/, Extirpation of the tumour appeared to be the only possible means of cure, itthli/. The care I had taken in forming the diagnosis, and my conviction of its accuracy, which was afterwards fully contirmed. Again, on looking at the statistics of the operation, previously pub- lished by Dr. Atlee,* I found that abdominal section had been performed for ovarian tumours, real or supposed, 101 times. If we extract from this list cases where the operation was not completed, and those on the point of death before the operation was begun, we shall have ninety remaining, in all of which the timaour was excised. Of these sixty-two recovered and twenty-eight died. Thus, whatever might be thought of the correctness of the statistics, the broad fact still remained, that an ovarian tumour had been extracted from living women in sixty -two cases with perfect success. An acquaintance with the structure and mode of development of these growths must convince us that the only other pos- sible mode of cure is by rupture of the cyst, and then only under parti- cular circumstances. This is an occurrence of extreme rarity, and yet, were we to be guided by the opinions of those surgeons who refuse to perform ovariotomy in any case, no other termination is to be expected, and the disease, notwithstanding the facts previously stated, is to be con- sidered as irremediable by art. But every case must stand upon its own merits, and when all the circumstances of the one detailed are taken into consideration, the perfect diagnosis that was established, and the probability of a speedily fatal termination (a probability afterwards ren- dered certain by the suppuration discovered to exist within the cysts), it must be granted that the operation, if admissible at all, was so in this instance. An important practical question presents itself in regard to the treat- ment after the operation, on which there was a difl:erence of opinion amono- the practitioners who witnessed the case and dissection, viz.. How the cavity or pouch containing pus, between the uterus and rectum, and the sinus leading from it up to the diaphragm, were connected with the pressure made on the abdomen by the many-tailed bandages and com- * American Journal of the Med. Sciences, April, 1845. 716 DISEASES OF THE GENITO-URINARY SYSTEM. presses, in order to direct the matter towards the external opening. Some have thought, that the pressure employed, instead of directing matter downwards, may have forced a portion of it upwards; while others are inclined to believe, that if the pressure, which latterly was much relaxed, had been more steadily continued, the formation of that cavity and sinus might have been prevented. The question is important, however, in reference rather to the proper treatment of future cases, than to the fatal event of this case ; for the symptoms of ileus and the death of the patient were obviously dependent on the constriction of the portion of ileum above noticed by a band of lymph which was at the distance of some inches from any part of the wound, and had no connection either witli the cavity or the sinus. Although various lesions were found after d^ath, their origin and con- nection with each other will easily be understood from a perusal of the case, and of the iJost mortem examination. Notwithstanding the unsuccessful termination of this case, I am still of opinion that ovariotomy is warrantable ^vllen the diagnosis of the tumour is certain, and other circumstances favourable. The more fre- quently it is performed, the more readily will experience dictate the avoidance of many errors that even now encumber the practice of it. When once recognised as a legitimate mode of treatment, and only per- formed in appropriate cases, there is every reason to hope, from the experience 'of the past, that the degree of mortality which has hitherto accompanied it will gradually diminish. Before such a result can be hoped for, however, it is necessary that our notions of the pathology and diagnosis of the disease should be improved. To these points 1 shall refer afterwards. Case CLYI.* — Ovarian Dropay — Si^ontaneous Ulcerative Oj^enivg of the Cyst into the Bladder, and Evacuation of its Contents — Jiecovery. History. — Anne Pjper, a sei-vant, set. 25, was admitted Nov. 8, 1848. She had been delivered fourteen daj-s previously of a male child in the Maternity Hospital, the labour being a natural one, and presenting nothing unusual. On the birth of tlie child, however, the abdomen still continued enlarged, and at first led to the sus- picion that another foetus remained in the uterus. After a time, the true nature of the case was rendered manifest, and a large swelling was detected, which was movable to a certain extent, and presented all the characters of an encysted tumour of the left ovary. SniPTOMS ox Admission. — The abdomen was swollen to about the size usual during the sixth or seventh month of pregnancy. The tumour extended from the epigastrium to the pubes, but bulged considerablj^ towards the left side. Its surface was irregular ; and two large nodules, each the size of a cocoa-nut, existed about its centre. It was tense and firm to the feel, somewhat elastic, but no fluctuation could be detected. The tumour was firmly fixed, and the seat of constant pain, especially in the left lumbar region, which was increased by pressure, bj" lying on the right side, or on assuming the erect posture. The urine was of a slightly yellow colour, and presented its normal characters. The digestive, respiratory, circulatory, nervous,' and integumentary oi'gans appeared to be healthy. She had observed the * Reported by Mr. James Struthers, Clinical Clerk. OVARIAN DROPSY. 717 tumour seven months before her dehvery ; and it has gone on gradually increasing, and been somewhat painful from the first. EifjM leeches were ordered to the most painful part of the abdomen. Progress op the Case. — For four days the patient remained in the same con- dition, the local pain, however, having been relieved by the leeches. On Nov. 12, my attention was directed to the urine, which now presented a copious white deposit, occupying two-flfchs of the jar, while the supernatant portion was of a light amber colour, and unusually viscid. The deposit was determined by the microscope to consist of pus, mingled with a few granule corpuscles. The clear portion was strongly coagulable by heat and nitric acid. At first it was imagined that the cyst had burst into the vagina, but the patient and nurse concurred in saying that there was no discharge between the intervals of micturition, and that all the fluid came from the bladder. The urine presented the same characters for the next three days ; the amount discharged during the twenty-four hours being about three pints. On the loth, the tumour had somewhat diminished in size, its hardness and tensity had disappeared, and distinct fluctuation was perceptible in it. A broad flannel roller ivas ordered to he applied firmly round the abdomen, and com- pression made by means of pasteboard, previously soaked and modelled to the abdominal surface. From this time, the abdomen rapidly diminished in volume, while the amount of purulent viscous fluid discliarged from the bladder varied from three to five pints in tlie twenty-four hours. The appetite and general health conthiued good; and she was ordered nutritious diet, with four ounces of wine daily. On the 23d, the amount of pus contained in the urine was greatly lessened, and the clear portion presented only a slight haziness on the addition of nitric acid. On the 21th the abdomen had regained its natural size, although a dense mass, evidently the collapsed ovarian sac, could readily be distinguished, occupying the left iliac and hypochondriac regions. The urine now also was natural in quantity, and presented only a slight sediment, consisting, as shown by the microscope, of some crystals of oxalate of lime, and a few pus globules. From this period she may be said to have recovered. She suffered occasionally from uneasy feelings on the left side, some- times amounting to pain, wliich were relieved by the application of four leeches, followed by a small blister. One of the leech bites ulcerated superficiallj^, but soon healed up. She was dismissed on the \Bth of December, expressing herself as being well in every respect, having been sitting up and running about the ward for the fortnight previous. The indurated mass in the left ihac region was greatly dimi- nished in size, but still very perceptible to the feel, though not to the eye. Commentary. — The history of this case can, I think, only lead to one conclusion, namely, that an ovarian encysted tumour was present on the left side ; that the individual cysts had, if not altogether, at all events for the most part, broken down to form one large cavity; that the contents of this cavity had suppurated, and a fistulous opening fornieil either into the ureter or the bladder (most probably the latter), through which the contained fluid was evacuated, permitting collapse of the sac and cure of the disease. The permanency of this cure would depend upon, whether all the secondary cysts had been ruptured and were broken down before the fistulous opening took place. This is a point which it was impossible to ascertain with certainty; but a careful examination of the woman before she left the Infirmary, convinced me that no rounded nodules or cysts could anywhere be felt. The only instance I am aware of, in which an opportunity presented itself of dissecting an ovarian encysted tumour some time after its 718 DISEASES OF THE GENITO-URINARY SYSTEM. spontaneous rupture, was in an individual I saw examined by tlie late Dr. Makellar.— (Mo// hotirs after death. Body generally anasarcous ; left forearm the seat of erysipelatous ulceration. Thorax. — Both lungs oedematous, with coherent pleural. On separating these on * Reported by Mr. Robert Byers, Clinical Clerk. 736 DISEASES OF THE GEXITO-URINARY SYSTEM. the right side posteriorly, the puhnonary texture broke up, being rendered soft by chronic pneumonia, and being ev'erywhere infiltrated vvitli serum. At the apex of right lung, a few cretaceous masses. Abdomen. — On the under surface of the right lobe of the liver, below the peritoneal coat, were several calcareous concretions the size of millet seeds, adherent in two places to the coats of veins, and projecting slightly into their canal (phlebolites). The gall-bladder was slightly thickened ; the cystic duct obstructed in its centre ; but the hepatic duct pervious. Both kidneys were of a pale yellow colour externally, slightly mottled with vascular patches. On section the cortical substance was slightly dimi- nished in thickness, and the cones unusually congested. An inch beyond the pylorus, the duodenum was perforated by a round ulcer, the size of a fourpenny-piece, the edges of which were adherent by soft lymph to the pancreas and a neighbouring coil of intestine. Internally the edge of the ulcer was black, and around it were several patches varying in size from a threepenny-piece to that of a shilling, quite black. The peritoneum contained about half a gallon of serum. Other organs normal. Microscopic Examination. — The cortical substance of the kidneys showed the convoluted tubes to be filled with desquamated epithelium, a considerable proportion of which had undergone the fatty degeneration. Commentari/. — Following on a prolonged ulceration in the arm, which had contined this patient to the surgical hospital, there snperveued de- sciuamative nephritis, general anasarca, and a-denia of the lungs, similar to what occurred in the two preceding cases. There was also present universal adhesion of both pleura^ and disorganization of the posterior and inferior half of the right lung, as I conceive, from a limited exuda- tion into its te.xture. What, however, constitutes a remarkable feature in this case, is the presence of a chronic ulcer in the duodenum, which had not been manifested bj' any symptom whatever ; which was attended bv limited hemorrhage into the mucous coat of the intestine internally, and externally by exudation, or so-called eftusion of lymph (peritonitis), without any local pain or uneasiness. The term Desquamative Xephi-itis was introduced by Dr. Johnson, to denominate a lesion in which the tubes of the kidney are blocked up, not only bv exudation, but by the separation and accumulation of their epithelial cells. Such descpiamation, I believe, occurs occasionally in all epithelial and epidermic structures. I have occasionally seen it in the lung, forming what may be called a desquamative or vesicular pneumonia. If it occurs generally throughout both kidneys, as in the three last cases narrated, it is usually fatal ; but if partial, and a sufficient number of tubes are left unobstructed, so as to admit of increased action under tlie stimulus of diuretics, a cure may be anticipated. Under such circumstances, also, a spontaneous recovery may be hoped for, which may be assisted by diaphoretics. So far from considering diuretics injurious, I believe that in such cases they hold out the only chance of successful treatment. Cuppiug and diaphoretics in such violent and rapid cases are wholly insutKcient to overcome the tubular obstruction, however they may occasionally relieve. On the other hand, the good effects of diuretics were well observed in Cases CLVIII. and CLIX. NEPHRITIS AND PYELITIS. tol Case CLXIII.* — Xephrilis foUowed by the fonnation of a large Abscess in the Eight Kidney, opening into tlie lumbar cellular tissue — Ulceration of Ureter and Bladder — Thickening of Mitral and Tricuspid Valves — Partial Atrophy of Lungs, icilh and without Induration — Partial (Edema. History. — ilargaret Martin, jet. 47, servant— admitted 18th October. 1852. She always enjoyed good health till about twelve months ago, when she was exposed to cold, and got her feet wet. Shortly after, she was attacked with dysuria. and observed that the urine was of a very dark red colour, and much diminished in quantity. A week afterwards, she experienced sharp cutting pains in the hypo- gastrium, stretching down tlie thighs. She was still able, however, to follow her usual occupation, till the beginning of September last, when she suffered from pain in region of right kidney, in the larger joints, and from oedema of the legs, especially the right. The bowels have been very costive, and the abdomen has become much distended. Four weeks ago she passed some very dark, bloody-looking matter in the urine, which continued of a red colour for live days. Her habits appear to have been rather intemperate. Symptoms on' Admission". — On admission, the tongue is loaded in the centre with a dark fur : great thirst, but appetite good ; bowels open. There is distinct fulness and dulness on percussion in the right lumbar region, extending as flir forward as the umbilicus, and fiUiug up the space between the felse ribs and crest of the ilium ; and there is great tenderness on pressure over the same extent. Has some pain in micturition, shooting down the thighs, especially on right side, which is also some- what oedematous. Urine passed in very small quantity, sp. gr. 1015. It is albumi- nous, and deposits on standing a copious sediment, showing under the microscope numerous pus and blood corpuscles. Pulse 90, of good strengtii, but occasionally intermitting. She has occasional palpitation. The cardiac dulness is somewhat increased transversely ; impulse very strong, and an indistinct hollow murmur accompanies the first sound, and is heard loudest at the apex. The thorax is con- sideral:)ly deformed, and the sternum highly arched ; but the chest is otherwise normal. Rabeat enema c. 01. Terebinth. 5 i- Progress of the Case — Kov. 20th. — ^The bowels not having been fully acted on by the enema, she was ordered last night, half a drachm of Compound p)ov:der of Jjlap, which caused copious stools. 5 Tnfus. Papav. 3 v ; Tinct. Eyoscyam. 3 ij ; Syrupi '^'x. M. Sumat r^ iter indie. Nov. 21. — Has been complaining much of pain in loins and right leg. She was ordered an enema vjith half a drachm of the Sol. of Morphia on the evening of the 20tli: and last night, the pain having again returned and prevented her from sleeping, she had the following draught: § Sol. Mur. Morph. 3 ss; Tinct. Hyoscyam. 3j ; Miicilaginis et Aq. Menth. aa §.ss. M. Xov. 22. — Feels much better to day. There is less swelling of abdomen, little or no pain in the hypogastrium, but a feeling of soreness in right lumbar region. Bowels con- fined; urine p;issed in small quantity, albuminous, and contains a large deposit, consisting chiefly of pus. Xov. 24. — Continues in the same state, but complains much of pain in bowels, which are still confined. Urine passed in small quantity. She was ordered yesterday the following: — § Bitart. Potass. 3 ii; Gamhog. gr. ij. 31. fi. pulv. hora somni sumend. et habeat inane Pulv. Doveri gr. xv. Tlie bowels were freely opened, with considerable rehef to painful distension of abdomen, but no diminution of the swelling and hardness. Appil. Tinct. lodin. ahdomini. Xov. 28. — Is complaining much of pain in abdomen and right leg. for which she had 10 grains * Reported by Mr. Francis M. RusseU, Chnical Clerk. 47 738 DISEASES OF THE GENITO-URINARY SYSTEM. of Dover's pmvder last night, with partial relief. The cough is now troubling her more, and she seems much weaker. 5 uWi. Chlor. 3 ij ; Sol. Mur. Morph. 3j ; Sj). Armnon. Aromat. 3 iij ; Mist Camph. | vss. M. Swnai 3 ss ter in die. Xov. 30.— On auscultation of chest, occasional moist rales are to be heard, with prolonged expiration ; but no increase of vocal resonance. The sounds of the heart very dis- tinct over the whole chest. The apex beats in epigastrium ; its action is irregular, and a blowing murmur accompanies the first sound. Tliere is still tenderness in right lumbar region, with great pain in right iliac ; the swelling of abdomen lias not diminislied, and upon deep pressure, a distinct fulness and liardness can be felt in right iliac fossa, to ivhich four leeches were ordered to be applied, folloived by ivarm fomentations. ]J Sp. jEther. Nit. I ss ; Liquor. Potass. 3 ij ; Mucilag. § ij ; Sol Mur. Morph. 3 iij ; Aquce § iij. M. Sumat | ss omni hord. Intermitt. alia medicamenta. Haheat Sp. Juniperi Co. % iii per diem. December 3.— Feels rather better, but bowels verj' costive, unaffected by a powder of calomel and jalap administered last night. The urine is still albuminous; sp. gr. 1015. Quantity not ascertained. There is now slight but painful oedema of right arm. Hah. enema catharticum. Dec. 6. — Bowels well open. She now feels much relieved of the pain in abdomen ; the tumour in right lumbar, umbilical, and iliac regions, remains unaffected. The cedema of leg has now disappeared ; but the pain and swelling of arm have gradually increased, and extend as far as the shoulder. The whole arm is exquisitely tender. No cir- cumscribed tumours can be anywhere detected in the arm or axilla. For the last three days, the quantity of urine has varied from 12 to 20 oz. in the 24 hours. There is still a'very copious mucus-like sediment ; when examined by the microscope no blood globules can now be detected ; but there are still numerous disintegrated pus corpuscles, with crystals of triple phosphates and amorphous urate of ammonia. The albumen has not disappeared. Lotion of Acetate of Lead and Opium to be ap2)lied to the arm, with warm fomentations. Dec. 8.— Complains of great pain in arm, which is very much swoUen, and generally hard, but pits slightly on pressure, and is of a white colour at the upper part ; but at the wrist it is much darker, and on tlie back of the hand two large phlyctenfe have formed during the night, and other portions of tlie surrounding surf;\ce vary in colour, from a slight red to a yellow and brownish green. There is some oedema of leg, but of slight extent ; and, for a few days back, some dark purple spots, permanent on pressure, have appeared on the inside of right thigh and knee. She complains much of loss of sensibility in the arm, and of cold feet, but their temperature appears natural to the touch. She is very weak, and takes no food. The pulse 120, feeble and fluttering. Urine sp. gr. 1015. Not affected by heat or nitric acid. It is now passed involuntarily in bed. U Sp. Amman. Arom. ; JSth. C/itor. aa 3 ij ; Tinct. Card. Co.lW: Mist. Camph. l\n; M. Sumat r] singulis horis. To have 4 oz. of Brandy. Dec. 9. — Died this morning about ten o'clock. Sectio Cadaverls. — Twentif-si.v hours after death. Anasarca, especially of right arm and leg, but nowhere extreme. A large tumour, elastic, not fluctuating, moderately tense, occupied the abdomen on the right side from the liver to the ilium, and from the loins to the umbilicus, projecting in either direction. Percussion over it generally dull. It can be limited from the liver, which is not large. TiiOR.vx. — Pericardium contains about an ounce of serum, and on the surface of the heart are numerous opaque fibrous patclies. Heart rather small. The free edo-es of the tricuspid and mitral valves were tliickened and rounded, but with no distinct appearance of deposit on their suriiice. In the substance of the septal seg- ment of mitral valve, near its roots, there were a few calcareous masses. "Weight of NEPHRITIS .AJS'D PYELITIS. 739 heart, 9^ oz. Lungs. — -Right pleura, normal; lung throughout free from adhesions; some serous engorgement, with considerable collapse posteriorly; anteriorly, no marked emphysema. Left Lung presents firm adhesions over upper lobe, which is much diminished in volume, and has a dense, scarcely crepitating tissue. Abdomen'. — On opening the abdomen, the tumour was found to be situated behind the ascending colon. The right lobe of the liver overlapped it in front to the extent of several inches, and was adherent to it by firm and close fibrous bands. The peri- toneum was stretched over the tumour so as to obliterate the mesocolic folds in front^ and keep the ascending colon closely in contact with it. It proved to be an absces.', containing about a quart of fluid, which was sero-purulent (with large proportion of pus), of a yellow colour, with a faint greenish tinge, and a good deal of toetor. The main sac of this abscess was situated in the lumbar cellular tissue of the right side, and had in front of it the right kidney, the interior of which communicated by several ulcerated openings with the cavity of the abscess. The posterior wall of the abscess rested on the lumbar muscles, and on the right side of the vertebrte, the periosteum of which was entire. The superior wall was very closely adherent to the liver, which, at its anterior part had a depression or excavation about half an inch in depth, and two or three inches in diameter. The left lobe of the liver was displaced upwards, and the right lobe was elongated downwards, being closely adherent to the right and upper aspect of the swelling. The stomach and neighbouring viscera were displaced by the tumour, but were healthy. Left kidney normal. Bight kidney much dis- organized; its size not altered; on section, numerous absce.sses containing pus like that within the tumour, occupying both the cortical and tubular part ; the walls of the abscess composed of floeculent and curdy greyish-yellow matter, presenting under the microscope the debris of cell forms, witli very numerous granules. The pelvis of the kidney could scarcely be identified, being converted into a receptacle for pus. The intervening tissue between the abscesses was condensed and indurated, and at some points enclosed a quantity of matter similar to that constituting the walls of tlie abscesses. Several angular calculi, the size of mustard seeds, were impacted in one of the infundibula. the mucous membrane of which was smootli and free from ulceration. On examination, they proved to be composed chiefly of phosphatic earthy salts and animal matter. The ureter was thickened throughout, not dilated ; the mucous membrane totally disorganized, rough, and resembling the walls of tiie renal abscesses. The bladder had also fully one half of the mucous membrane removed in irregular patches by ulceration ; the remaining parts were much congested, but smooth. Xo deposit of calcareous matter in any quantity. The ulceration of the vesical mucous membrane extended to the neck of the bladder, and ended abruptly at the commencement of the urethra, which, with the exception of some congestion of the mucous membrane, was nomiaL The uterus contained a polypus, the size of a bean, composed principally of the mucous membrane, and attached to the posterior wall Os uteri slightly tinged, of a purplish colour. Ovaries, vagincL and external parts normal Other organs normal. Commentary. — The occurrence of abscess in the kidney is often a verv insidious disease, existing frequently for many months, and giving rise to obscure pain in the back, occasional rigor, feverishness, and high-coloured or muddy urine, which when examined microscopically, may be seen to contain blood and pus corpuscles. If the disorganizing process con- tinue, and an opening form externally, inflammation, followed by sup- puration of the cellular tissue behind the peritoneum, occurs, causing fever of a low tvpe, and oedema more or less general. Such an occur- rence usually proves fatal. In the present case, death was delayed 740 DISEASES OF THE GENITO-URIXARY SYSTEM. apparently from the abscess having been, to a certain extent, circum- scribed, and forming a large cyst, so as to present the form of a tumour, the nature of whichrduring life, it was very ditfienlt to determine, although the renal disease was clearly apparent. Case CLXIV.* — Scrofidom KcpJiriiis and Abscesses in the Kidneys — Extensive Deposition of Tubercle in the Lungs and Intestines. History. — George Paton, set. 20, sailor — admitted 19th July. 1854. States that he enjoyed good health until seven years ago, when he noticed his urine tinged with blood, after having undergone considerable exercise in sliding on ice. The hfema- turia o-ave him no uneasiness until three weeks afterwards, when he began to sutler pain in the epigastrium', and a deep-seated burning pain in the pelvis. He could get little rest in consequence, and his micturition became frequent, almost every hour. He continued to sutler more or less in this way for two years, the pain and hjematuria abating, and again recurring at intervals of a few weeks. He then went to sea, and remained tolerably free of the disease for three years. His ailment then returned again in aggravated form, after exposure to a storm. He obtained admis- sion on board the Dreadnought hospital ship at this time, and had his bladder repeatedly examined for stone, but no calculus could be detected. After being a few weeks in the Dreadnought, he left it and went to sea again, though in very imperfect health. About twelve months ago, whilst lying in the Downs, he had a very severe attack of deep-seated pelvic pain and hematuria. He now, for the first time, complained of pain in the back, which has never left him since, and the character of the urine underwent a change. It became white and turbid, and on standing, emitted a putrid odour. He recovered partially from this attack, and went shortly afterwards on a voyage up the Danube, where his disease became aggra- vated from the exposure he was subjected to. Since that time his general health has been declining more rapidly than formerly. SYiiPTOiiS ON Admission. — On admission, he is considerably emaciated, counte- nance pale, and his expression anxious ; skin dry ; urine white and turbid, sp. gr. 1010- on standing, a large sediment falls down, which under the microscope is found to consist of pus, and under heat and nitric acid a large coagulum forms. He complains of pain in the hypogastrium and right lumbar region, of a dragging character ; he has also pain in the point of the penis during and after micturition ; tono-ue moist and florid ; he complains of sore throat, and on examination the ton- sils are seen to be- enlarged and covered with pus. He has tenderness of the epiotvstrium, and is troubled with vomiting immediately after taking food. Bowels regular. On percussing the chest, dulness can be detected at the apex of the right luno-, anteriorly and posteriorly ; on auscultation there is slight sibilation under the rio-ht clavicle, with slight inci-ease of the vocal resonance. He has a slight cough, but no expectoration ; pulse 88, and of good strength. Cardiac sounds feeble : heard loudest over the sternum, and a little to its right side; otherwise they are healthv. B Infus. Lini }bj. To be taken ad libitum. Throat to be sponged xcith a solution of nitrate of silver. Good diet. Progress of the GxsE..—Jidy 2oth. — The sponge has been three times applied to the throat, and it is nearly well. The pain has left the hypogastric region, and he has now a feeling of weakness in the right lumbar region. Urine of a milky colour, contains less albumen, sp. gr. 1007. $ Tinct. lodinii 3 i. To be painted * Reported by Mr. Almeric "W. Seymour, Clinical Clerk. NEPHRITIS AND PYELITIS. 741 over the lumbar region. IJ Decoct. Uvce Ursi fbj. One ounce to he taken four times a day. August 8th. — During last week he lias been suffering from nausea, vomiting, and looseness of bowels. Aug. \1th. — These few days past he has had rigors, followed by heat of skin and sweating. The attacks last only for a couple of liours, and come on regularly at two o'clock. He has been ordered the following pills : — ^. Sulph. Quince 3ss; Conf. Hosar. quant, suff. ft. massa in pilul. xx. dividenda. Two to he taken every sixth hour during the intermissions. Diarrhoea has continued, and for it he has been using the following mixture : — B Tinct. Catechu Z^'i; Sol. Mur. Mor2)h. 3 ij ; Conf. Aromat. 3 i ; Mist. Cretce § v. M. One table-spoonful to he taken three times a day. Aug. lUh. — Diarrhoea relieved; urine less turbid: sp. gr. 1009; not coagulable by heat and nitric acid. Aug. 2\st. — Since last report has been gradually growing weaker. Mucous rale has been occasionally audible under the right clavicle ; expectoration insignificant He has been unable to retain any food on his stomach for several days, scarcely even wine and water. Diarrhoea has also returned. Latterly his strength has become very much exhausted, and during the last two days, he has lain in a state of great prostration; his pulse often scarcely to be felt at the wrist; his intellect, however, never became impaired. Tliis morning he died at four o'clock. Sectio Cailaveris. — Forty-eight hours after death. Body much emaciated; rigor mortis considerable. Thorax. — Pericardium normal ; contained about three drachms of clear straw- coloured serum. Heart small and soft; valves healthy; muscular substance pale: under the microscope, the muscular fibres appear deficient in stria;, and loaded with small fatty granules. Left pleura normal. Rigid pleura presents dense adhesions over the whole of the lung, more marked, however, at the apex and base. The right lung itself was small, collapsed, and excessively emphysematous, along its anterior free margin. The apex presented numerous hard cicatrices, and on being cut into, showed numerous tubercular masses in all stages, some of them commenc- ing to break down and disintegrate, others undergoing the process of hardening and repair. In one spot, about an inch below the apex, a small vomica, about the size of a hazel nut, existed. Left toig- voluminous ; highly emphysematous ; cicatrized around the apex, the cicatrices, as in the other lung, being very firm and dense. On being cut into, masses of tubercular matter were found, but in a more latent state than in right lung. Abdomex — Liver normal in size, undergoing the fatty degeneration : jjale- coloured and friable ; under the microscope, the hepatic cells appeared loaded with fat. Spleen normal. Small intestines healthy, slightly congested towards the lower part. Large intestines. The mucous membrane, throughout the whole extent, but particularly in the descending colon, sigmoid flexure and rectum, apjjeared thickened, congested, and in many places ulcerated : the ulcers were small, their edges very slightly elevated, and their surface undergoing the process of separation. Bight kidney was much enlarged; quite smooth; the capsule densely adherent. On dividing the ureter, pus escaped in considerable quantity from the pelvis of the kidney ; and on cutting into the substance of the gland itself, several ulcers, varying in size from a horse-bean to that of a small walnut, were found ; their contents varied in consistence; in some, the pus was thin and diffluent; in others, it had the consistence and appearance of white paint. The ureter on this side was greatly thickened, of the size of an ordinary little finger; the thickening extended bej-ond the orifice of the ureter along the trigone of the bladder; the ureter was quite per- vious, and contained a quantity of pus Left kidney was small and lobulated; the substance of the gland was found to have disappeared, leaving a large cavity, which 742 DISEASES OF THE GENITO-URIXARY SYSTEM. was enclosed by a covering of the proper substance of the kidney, not exceeding four lines in thickness, and filled with cheesy matter of the consistence of putty; the ureter was closed, except for two inches above tlie bladder; externally, it was oi normal size: muscular wall of bladder somewhat thickened, especially around the orifice of the right ureter; mucous coat congested and much softened; the bladder contained about 6 oz. ot thick, turbid, semi-purulent matter. Commentary. — In tins case, the renal absce.sses formed in a young man of scrofulous constitution, and exhibited a moi'e lino-erino; tendency than in the foi-mer one. Indeed, notwitlistanding the g-reat disorganiza- tion found in the kidnevs after death, the fatal result was chietly brought about by the intestinal disease, and the exhaustion caused by colliquative diarrhoea. The left kidney evidently presented the incipient changes which commonly precede the spontaneous cnre of scrofulous abscesses in this, as in other internal organs. The purulent matter was of the con- sistence of putty, the animal portion liaving for the most part been broken down and absorbed, while the mineral portion was comparatively increased. In this manner, not unfrequently encysted cretaceous masses form in the kidney and remain latent, the rest of the renal substance performing its normal function. Sometimes an entire kidney may, in this manner, be completely destroyed, and the whole converted into a calcareous mass, of which I possess a remarkable example, from an indi- vidual who had quite recovered from the disease, and wliose remaining kidney, though enlarged, was in its texture healthy. Indeed, the spon- taneous cure of tubercular depositions in the kidney, pr-esents the same patholoo-ical history as that we have described of similar lesions occur- rino- in the lungs, p. 680, and the puckerings, cicatrices, cretaceous and calcareous concretions resulting from them, have a similar significance. It follows that onr general principles of treatment should also be the same, namely, supporting the constitution by analeptics and especially by coddiver oil, so as to enable nature to bring about a cure. This should always be the primary object of treatment ; whilst remedies dii'ected to the renal symptoms should, although by no means neglected, be subordinate to that great end. In the present case this indication could not be fulfilled on account of the great irritability of the alimen- tary canal, especially of the stomach. For another example of this disease, see Case CXLVI. Case CLXV.* — Calculous Ne^yJiritis and Gangrenous Abscess of Eight Kidney — Wo.o:y Liver — Eecio- Vesical Fistula. History. — James Allen, aet. 25, a tin and copper smith — admitted Augti.st 18, 1848. At three years of age was cut for stone by Mr. Liston. Thereafter he enjoyed good health until three years ago, when, after straining himself at a trial of strength, he was suddenly seized with a sharp pain in the right flank, just below the ribs. At the same time tlie urine became turbid, and was of a high colour. The pain left him at the end of three months, but the turbidity of the urine con- tinued. After six months' interval he had a similar attack — this time, he says, induced by drinking a glass of spirits — which also lasted three months. After * Reported by Mr. Frederick Hunter, Clinical Clerk. NEPHRITIS AND PYELITIS. 743 another interval of about six months, the pain and urinarj^ sjnnptoms again returned, and have continued more or less severe ever since. He was in tlie surgical hospital for three months, wliere he was frequently examined for stone, but none was found. At this time he was observed on several occasions to pass air by the uretlu-a, the urine being of a gangrenous odour. He left the surgical hospital last Maj-, and has been somewhat better since, the urine for some time having been clear and healthy. But having bathed in the sea a fortnight ago, he was seized with rigors, followed by fever, together witli the former local symptoms, which have continued ever since. Symptoms on Admission. — Tlie countenance is pale and sallow, expression dejected ; body not emaciated, but with a general look of chronic disease. He com- plains of great pain and tenderness in the riglit lumbar region, which on examina- tion presents a fulness, witliout great deformity, but well marked when compared with tlie opposite side. The hepatic duloess on percussion measures five inches ver- tically, the lower margin anteriorly being on a line with the umbilicus, and stretch- ing across the abdomen into the left hypochondrium. He has never suffered from pains sliooting down to the bladder, nor in the bladder itself But there is occasional pain after micturition, and always frequent desire to pass urine— indeed every hour — although little is voided. The urine is turbid, of dirty yellow colour ; acid, of sp. gr. 1017, very foetid, highly coagulable, and contains a considerable sediment of pus and mucus. The pulse is 108, soft. Tongue covered with a whitish fur. Appetite good. Other functions well performed. ^ Tart. Anlim. gr. ij: Aquce 1 viij ; Solve. Sumat ? ss teriid qudque hord. Aj)j)Ucent. hirudines viii lateri doknti, et postea foveatur. Progress of the Case —September 2Gth. — The local pain has been relieved by the treatment, but it returns with severity at intervals. For some time the urine has been clear. Ho has had a slight diarrlioea, which has been checked by a chalk and aromatic mixture; and has occasionally taken at night Pulv. Dove.ri gr. viij. October ?>d. — Two days ago was again seized with rigors, fever, and acute pains in the right flank. The urine is again loaded with pus and mucus, and of foetid odour. The appetite is gone; there is thirst and frequent vomiting. Pulse 120, soft. A saline antimonial mixture. Oct. Gth. — Anxious countenance; pain continues, pre- venting sleep. Can take no nourishment. Much exhausted. Vomiting diminished. IJ Pidv. Doveri gr. x. liora somni. Nutrients. Wine four ounces daily. Wann fomentations to the side. Oct. lOth. — Local pain somewhat diminished. Complains of diarrlioea. IJ Acid. Gallic. 3 ss ; Ojni, gr. xij ; Oonf. Rosar. q s. ; ft. pil. xij. Sumat unam sextd qudque hord. Oct. lUth. — Since last report has gradually sunk, and died this morning. Sectio Caclaveris. — Forty-eight hours after death. • TiiOR.Ax. — Pericardium contained about a draclim of turbid serum, with a few floating flakes of lymph. Lungs and heart healthy. Abdomen — The liver was considerably enlarged, and had undergone the waxy degeneration; its substance being pale and dense, with a smooth surface on section. On attempting to remove it, the right lobe was found to be adherent to the colon ; and on separating this adhesion with the fingers, a quantity of pus escaped. This originated from a large abscess in the right kidney, containing about half a pint of pu,s, mixed with curdy matter. The superior wall was composed of the substance of the liver, a portion of the lower and posterior border of which organ was absorbed- The posterior wall rested on the quadratus lumborum muscle, and anteriorly it was in contact witli the transverse colon and the pyloric end of the stomach. "When opened from behind, the walls of the abscess were found to be covered with shreds of gangrenous tissue, of a dark greenish colour, of gangrenous odour. Renal sub- 7-1-i DISEASES OF THE GENITO-URINARY SYSTEM. stance could only be delected at the lower part ; the rest of the kidney was con- verted into a fibro-cystic structure, in some places of great density. Two of the cysts contained uric acid calculi ; one resembling in size and form two walnuts united together by a neck, the other of a somewhat angular form, with rounded edges, the size of a hazel nut. These calculi were imbedded in pus, and partly projected into what might have been the pelvis of the kidney, but which was converted into a fibrous sac communicating with the ureter. Tlie bladder presented at its neck the cicatrix of an incision made in the usual situation for lithotomy. About two inches above this were three mucous excrescences the size of peas. In the centre of these was a depressed spot, tlirough which a director readily passed backwards and upwards through the cellular tissue into the rectum. The mucous surfece of the rectum at this point was highly vascular, and covered with lymph in patches to the extent of four inches in depth round the gut. Left kidney weighed 13^ oz., and appeared healthy in structure Otlier organs normal. Microscopic Examination. — The structure of the left kidney was quite natural. The liver presented the usual atrophied and translucent appearance in the cells, characteristic of the waxy degeneration, a few only containing a small number of fat granules. Conimentari/. — The local and p-eneral symptoms in tliis case were so clear as to leave me in no doubt from the first, that this man Iiad a cal- culus imbedded in his right kidney, causing an abscess in that organ. The recurring rigors and fever, with pains shooting down the right groin to the bladder, and occasional vomiting ; the turbid, bloody, purulent, and gangrenous urine ; the remarkable fulness in the right lumbar region, ■with tenderness on pressure; and the past history of the case, constituted an nnmistakeable group of phenomena diagnostic of calculous nephritis. Indeed, so certain was the fact, that more than once nephrotomy was spoken of as a possible means of relieving him, every other organ Avith the exception of the liver being at one time apparently healthy. It was with great interest, therefore, that the dissection after death was watched, which fully confirmed the diagnosis. It also pointed out that the other kidney was enlarged and healthy, peiforming double duty without diffi- culty ; that the liver was enlarged and waxy, and that a recto-vesical fistula existed, causing disease of the intestinal mucous membrane to ■which the diarrhoea latterly might be attributed. In reference to an operation, it appeared to me at the time that it might easily have been etfected after the method of Marchetti,* as the two calculi were loose within cysts, and surrounded by pus. The enlargement of the liver prevented the performance of such an operation being seriously enter- tained in this case. But here, as in ovariotomy, the great difliculty is to establish in the living subject an e.xact diagnosis, and this I had no diffi- cultv in doing six weeks before his death, and when his general liealth was tolerably good. For such a disease nothing but palliatives are to be thought of. As the size of the stone cannot be known, dikients are indicated with the possibility of favouring its descent along the ureters to the bladder, a practice which, should it fail in that respect, is also useful in carrying off' the pus which may accumulate in the pelvis of the kidney, should perchance any healthy secreting texture still remain in it. * An account of a gentleman being cut for the stone in the kidney, with a brief inquiry into tlie antiquity and practice of nephrotomy, by C. Bernard. — PJdl. Trans. October 1696. NEPHRITIS AND PYELITIS. Case CLXVI.* — Chronic Pyelitis, and Cystic Kidneys — Dikitaiion of Ureters — Fungoid Ulceration of Urinary Bladder. History. — Jane Watson, ?et. 74, widow — admitted November 15tli, 1852. As far as can be ascertained from the patient, wliose mental faculties are very much impaired, she has been labouring under her present complaint for the last eight months About that time, she was exposed to cold from sleeping on damp straw, and was seized with rigors, pain in the back, and in the larger joints. The urine at the same time decreased considerablj^ in quantity, with frequent micturition, accom- panied by pain. Tliese sj'mptoms lasted for about a month, after which the amount of water passed became greatly increased in quantity, and dysuria disappeared. For the last three months, the urine has been occasionally mixed with blood, continuing for a few days, and then becoming natural. Since the date of her first attack, she has complained of pain in the region of the right kidue}-, much increased at those periods when blood was observed in the urine. Symptoms on" Admission. — On admission, she has a peculiar cachectic appearance, and is much emaciated. Tongue moist, cracked in the centre, great thirst, appetite impaired, bowels costive. She has considerable pain and tenderness on pressure in the right lumbar region, where there is also some fulness. The urine is passed in considerable quantit}-, specific gravity 1010, alkaline, highlj' coagulable on the addi- tion of heat and nitric acid. It is quite turbid when passed, and deposits on standing a copious yellowish gelatinous-like sediment, which, under the microscope, is seen to contain numerous pus corpuscles, granule cells, and casts of the tubes, crowded with granules. When the bladder is about half empty, there is frequently a sudden stop- page of the flow of urine, when she suffers from severe pain in the hypogastrium, stretching down the thighs, especially on the right side. Pulse 90, of moderate strength. Heart's sounds feeble, otherwise normal. Other functions natural. The bladder was examined by Mr. Syme, and a large ulcer was detected, occupying the base and neck of the bladder. IJ Tinct. Hyoscyami 3 vi ; Tinct. Opii'Zx]] Mucila- ginis d Aquce aa. § vi. M. Sumat | j ter indies. Progress of the Case. — November I8th. — Continues much in the same state. Urine presents the same characters as before. Omittalur mistura Hyoscyami. 5 Potassce Acetatis ^ss; Sp. ^Etheris Xitrici 3 iij ; Miicilaginis et Aquce -0.0, 3 iij. M- Sumat t^ i quai'id qudque hard. 5 Sol.Mur. Mor^Mce 3j; Mist. Carnphora ^.i- M. Sumat dimidium liora somni et alierum j)ost lioras tres si opus sit. Warm fomentations to be applied to the loins. Nov. 2lst. — The warm fomentations were applied as ordered, and afforded considerable relief; she sleeps well at night after taking the draught ; the casts have now disappeared from the urine, but a few granule cells are still visible, mixed with pus corpuscles, blood globules, and some crystals of triple phosphate. Urine still of specific gravity 1010, highly albuminous, and of a very putrid smell immediately after being pH.ssed. Nov. 24^/t. — The quantity of urine is now greatly diminished; presents the same characters as on the 2lst. There is still pain and tenderness in right lumbar region ; frequent desire to pass water, the first half of which flows with comparative facility, but the remainder comes away slowly, requir- ing external pressure to empty the bladder, at the same time there are sharp shoot- ing pains in the vulva, and the inner side of the thighs, extending down to the knees. She appears much exhausted; pulse weak, 96. To have four ounces of wine. Nov. 28th. — Is much in tlie same state; the urine is still highly coagulable ; the sediment examined by the microscope presents a large number, 1st, of finely molecular exuda- tion casts ; 2dly, groups of broken down pus cells ; 3dly, crystals of triple phosphate ; * Reported by Mr. Robert Francis M. Russell, Clinical Clerk. 746 DISEASES OF THE GENITO-URIXARY SYSTEM. Aildy, granular cells ; bihly, blood corpuscles. December 4J/(.— Is now passing her foeces and urine inv^oluntarily; appetite rather improved; pulse 85, weak. The warm fomentations have been continued since the ISth ult. To have six ounces of wine. Dec. 8(h — Still passes everything in bed ; complains of great pain and tender- ness in right lumbar region ; still takes food well ; pulse 90, of better strength. Dec. Igth. — Appetite very much impaired within the last two or tiiree days; still complains of pain over right kidney, and passes dejections involuntarily. Only an ounce of urine could be obtained for examination. It is still coagulable : the sedi- ment presenting, under the microscope, tlie same characters as on the 28th ult., with an increase in the number of blood corpuscles ; pulse 100, very weak. Dec. 23d. — Since last report the patient has been gradually sinking, and she died this morning. Sectio Cadaveris. — Fifty hours after death. Body emaciated. Thorax. — Pericardium contains about two ounces of serum. Heart small, presents a large amount of fat on its surface ; valves and endocardium perfectly normal. Left lung slightly adherent at apex ; middle and lower lobes of right lung strongly adherent posteriorly; both lungs were crepitant throughout with the exception of some hardened deposits at apex of the left, which look like old tubercle. Bronchi contain much frothy mucus. The aortu througli the whole of its course (and both iliac arteries) contained a large amount of calcareous deposit, principally seated in the arch of the aorta, and the thoracic portion of that ves.sel. Abbohes.— Stomach and intestinal canal normal; pancreas pale: f^j^leen very small ; liver small congested, firm, and dense. Lumhar glands considerably enlarged, and contain a very great amount ef yellowish opaque juice, evidently purulent, but no distinct abscesses Both kidneys of normal size when viewed externally ; the ureters dilated to the size of swan quills ; pelvis of both kidneys dilated to three or four times the normal size ; cortical and tubular substance correspondingly small in volume ; several of the pyramids distorted and crooked in direction, but their basic line always distinct : cortical substance pale ; malpigliian bodies and stria? destitute of blood ; surface smooth, but more adherent to capsule than usual. On careful examination with tlie naked eye, a considerable number of cysts from the smallest visible size up to i inch diameter are obsei-ved in the cortical substance, especially near the surface. The Madder of normal size ; all its walls much thickened ; the raucous membrane presents a soft fungoid-looking ulcerated mass, in which no peculiar or characteristic structure could be observed. All parts of the mucous membrane were equally diseased. Microscopic Ex.^mixatiox — The cysts in the kidney can be traced down to very minute sizes (the smallest observed was about the 600th of an inch in diameter), having the usual appearance of such cyst formations. The malpighian bodies slirunk, bloodless and opaque, without apparent morbid deposit, but with thickening of their membrane and nuclei. In some of the tubes similar thickening and epithelial engorgement, producing an appearance of opacity in the tubuli without any recog- nisable granular deposit. When the tubules are washed out and examined sepa- rately, they appear (most of them) smooth. Epithelium small and compressed, but, generally, regularly disposed and normally developed. In a few places, traces of granular and molecular exudation, but to an insignificant extent. Comrnentari/. — The complication of renal and vesical disease here met with, is bv no means an uncommon one in aged persons. Its existence leads to obstruction of the ureter, at its entrance into the bladder, distension of the ureter above, accumulation of urine in the NEPHRITIS AND PYELITIS. 747 pelvis of tlic kidney, and, as a consequence, inflammation and distension of its mucous lining ■walls, pressure on the secreting portion, and atrojthy of its substance. Such a lesion, if it exist in both kidneys, must neces- sarily at last so interfere with their functions, as to be incompatible with life. The chronic disease of the bladder, on which the renal disease for the most part depends, oidy admits of palliative measures for its relief. Ci/sfic disease of the kidney may originate in various ways, — 1st, From greater or less obstruction in the tubuli uriniferi, and consequent accumu- lation of the fluid above, forming cystic collections. 2d, It may originate in the sacs surrounding the malpighian bodies, the fluid accumulating in them producing distension, and so causing cysts. 3d, In the enlarge- ment of the secreting cells of the organ, which here, as in the ovary, become distended with fluid, and bv pressing upon, compress one another. 1. The obstructions found in the tubuli uriniferi are of various kinds, and may consist of coagulated exudation, of pus, of blood, of altered epithelium cells, or of diflerent salts, such as mates, carbonates, phos- phates, etc. etc. The bloody points so frequently observed on the surface of diseased kidneys, most frequently arise from extravasation of blood into the convoluted extremities of the tubes. Small calculi may be formed fioin mineral deposits, but more commoidy the tubular cones present a diff"used white appearance from their occurrence. That such a condition is a frequent somce of cysts, may be easily proved by exami- nation. Tlie cysts so foimed may be of dift'erent sizes, vaiying fi-om that of a millet seed to that of an orange, and the destruction of the secreting portion of the kidney will, of course, be proportionate to their volume and number. The contents of such cysts are also of various kinds, such as serum, blood, pus, fibrous exudation, colloid and fatty matter, fluid hold- ing various crvstals in suspension, whether fattv (cholesterine or marga- rine), or saline (phosphates, urates, etc.). I have frequently seen all the forms in the following figure (Fig. 444), and occasit)nally the I'adiated bodies represented Fig. 297. 2. That numerous cvsts mav form from distension of the minute sacs surrounding the malpighian bodv, I have satisfied mvself of bv careful examination, and possess prepai'ations demonstrating the fact. In this case, the cysts are generally numerous and scattered through the cortical substance. It would appear to arise from some obstruction at the com- mencement of the excreting duct, although I have never been able to detect any. Fluid collects outside the membrane in immediate contact with the tuft of vessels constituting the malpighian bodv, and inside another membrane continuous with the basement membrane of the latter. Indeed, it is in cases of this kind that we may satisfy oui'selves that the membrane investing the tuft of vessels is really double, forming a shut serous sac, in the cavity of which the fluid accumulates. This fluid is invariably clear, varies in quantity, but each cyst seldom exceeds a sniall pea in size. As it forms, it gradually presses on the vascidar tutt, and causes its atrophy, and so impedes the secretory power of the organ. 3. The third form of cystic formation in the kidney evidently origi- nates in the secreting cells themselves, as they may be seen, on a microscopic examination, to exist in clusters, vai-ying in size from the 748 DISEASES OF THE GENITO-URINARY SYSTEM. 600th to the 16th of an inch in diameter. In such a case, the paren- chyma of the organ seems to be infiltrated with them, and strongly 444. remind: vesicles the observer of a section of the ovary, loaded witli Graafian Many still retain their nucleus, whilst in others it has dis- appeared. Mr. Simon, of London, who first described this form of cystic formation, says, as explanatory of its formation, " that certain diseases of the kidney (whereof subacute inflammation is by far the most frequent) tend to produce a blocking of the tubes; that this obstruction, directly or indirectly, pi-odiices rupture of the limitary membrane; and that then, what should have been the intra-tnbnlav cell-growth continues, with certain modifications, as a parenchytic deve- lopment."* One or all of these forms of cystic growth in the kidney may be associated with the next lesion to be treated of, viz., Bright's disease. PERSISTENT ALBUMINURIA, OR BRIGHT'S DISEASE. That albumen in urine was a symptom of certain dropsies, was first noticed l)y Dr. Wells of St. Thomas's Hospital,t and Dr. Blackball of Exeter ; that it indicated especially venal dropsies, was the discovery of Dr. Bright, who has given us a careful account of the phenomena * Medico-Chirurgical Transactions, vol. xxx. p. 152. f Trans, of a Society for promoting Medical and Surgical Knowledge, vol. iii. pp. 147, 167. Fig. 444. Structures occasionally seen in cysts of the kidaey ; a and Z*, Structure- less transparent colloid masses; c to g, Colloid bodies, composed of one or more nuclei, imbedded in albuminous matter ; h to i, Colloid masses, surrounded by con- centric laminaj; k, A colloid mass, with fatty granules arranged in an areolar manner. —{Wtdl) 3o0 diam. bright's disease, 749 -which characterize the disease that has since borne his name, as Avell as of the changes observed in the kidney after death. The subsequent observations of Christison, Martin Solon, Raver and others, as well as the more recent investigations of Gluge, Johnson, Simon, Frerichs and others, have rendered it certain that the lesions of the kidney accompanying albuminuria are various. Some are dependent on what mav be considered an acute or chi'onic form of inflammation (see Nephritis), whilst others mast be referred to what we now call the fattv and waxy degenerations. In selecting the following cases as illustrative of the disease, 1 have kept in view its natui-al piogress, and endeavoured to show how, by judicious treatment, it sometimes terminates in recovery ; how at other times it frequently becomes obsti- nate, and in what manner it may ultimately cause death. Of the pathology and treatment I shall speak separately, after describing the facts we have studied at the bedside. Case CLXVU.*—Albumi)mria—Ge7ieral Anasarca— (Edema of Lung—Recorery. History.— Elizabeth Brady, fet. 30, cook, married— admitted March 19tli, 1854. She states that her health was good until four weeks ago, when, after exposure to cold and wet, she was seized with pains in the chest and cough, but without shiver- ing. Three days afterwards her feet began to swell, and gradually the swelling extended upwards, involving her whole body. Symptoms os Admission. — On admission, chest well formed; breathing slightly laboured. On percussion, unusual resonance is perceived over the upper portion of both sides anteriorly. There is marked dulness on the left side below the nipple and lower angle of scapula. On applying the stethoscope over the portion marked as dull, fine crepitation is perceived. Elsewhere on the left side, the inspiration is harsh and the expiration prolonged; pulse 100, small and hard; cardiac sounds normal; tongue covered with a brown fur; complains of nausea and disinclination for food. The abdomen is distended with fluid, and she has pain in the epigastric region; bowels constipated; urine rather scanty, sp gr. 1028, is turbid when voided, and on standing deposits a copious sediment, which, when placed under the micro- scope, presents chiefly amorphous urate of ammonia, with a few tube-casts. On the application of heat and nitric acid a large coagulum is thrown down. Catamenia regular. Her skin is hot : her face flushed and swollen ; she suffers from general anasarca; her lower extremities, however, being especially affected and pitluig easily on pressure. Progress of the C.\se. — March 2\st. — Ordered to be bled at the arm to the extent of twelve ounces. ^ Pulv. Doveri Ql Taksvi. One to be taken at bed-time. March 22d. — Fifteen ounces of blood were withdrawn from the arm, and the pulse shortly fell to 70. She expressed herself as greatly relieved. After takhig the Dover's powder she had a short sleep, but no diaphoresis -was produced. The blood with- drawn presents no buffy coat ; her urine is voided in larger quantity, but still depo- sits a considerable sediment ; pulse 90, soft and weak. 1^ Potass. Acet. 3 i ; Sp. ^iEth. Xit. 3vi; Syrup. Aurantii |i; Aqiue 3 iv. M. One ounce to be taken three times a day. 5 Pulv. Gambogice gr. v ; Potass. Bitart. 3 ij. M. To be taken at bed-time. March 2.3d.— Her bowels have been well opened, and her general appear- ance is greatly improved, her face being much less swollen; urine less turbid, and * Reported by Mr. W. W. Clark, Clmical Clerk. 750 DISEASES OF THE GEXITO-URIXARY SYSTEiL in larger quantity. Tatermitkdur mist. 5 P^^- Scilkz et Digital, xii. One to be taken every sixth hour. March 24:th. — Her cougli lias abated greatly, and she feels herself much better. Repttat. Pulv. Gamb. et Potass. Bitart. vespere. March 2Gih. — Urine deposits ver}' little sediment on standing ; and under the microscope, no tube casts can be detected; sp. gr. 1018. A slight coagulum is produced on applying heat and nitric acid. Her appetite is greath' improved. March 29th — On examin- ing her chest to-day, the dulness on percussion, which previously existed on the left side, cannot now be detected, and on auscultation over that portion the respiratory murmur is heard normal. Under the right clavicle the inspiration appears unusually harsh. Her urine presents the same character as at last report. Repetantur Pil. ScHlcb et Digital, et Pulv. Potass. Pltart. 3ss ter indies. April 3d. — She is now nearly convalescent, and has taken no medicine for two days. To have steak diet. May Sth. — Complains to-day of pain in the epigastrium and of vomiting ; bowels constipated ; pulse natural ; urine yields no coagulum to the usual re-agents ; sp. gr. 1008 ; contains no tube-Ciists on microscopic examination. Menstruation rather frequent, and in the intervals of the catamenial periods, she is subject to a leucor- rhoeal discharge. 5 Naphthce Medicinal. 3 i ; Tinct. Cardam. Co. | i ; Aquce 3 v. M. A table spoonful to be taken ivhen tlie vomiting is troublesome. 5 Magnesice Carb. 3ss; Aq. Cinnam. §i; Infus. Semue. Co. 3 ij. M. Ft. haust. hora somni sumendus. Inter mittantur alia. July liith. — Since last report her urine has remained entirely free of albumen. The csdema has now for the most part entirely disap- peared, but still returns slightly after she has been some time in the erect position. General health good. Dismissed. Commentnnj. — On succeeding Dr. Ciiristison in the charge of the clinical wards on tlie 1st of May 18.54, I was informed that this was a case of Bright's disease. On the Sth of the month, however, as stated in the report, on examining her urine, I found it to contain no albumen on the addition of heat or nitric acid, while the sediment, carefullv col- lected, exhibited no tube-casts under the microscope. On lookin<>" into the history of the case, however, as recorded in the ward-book, and which is given above, it became clear that the woman had undoubtedly been labouring under albuminuria and chronic renal disease, which, well pronounced March 21st, had entirely disappeared at the beginnino- of May. But the oedema of the feet continued, with stomachic derano-e- lULMits ; the former symptom exhibiting a tendency to return, on assum- ing the erect position for any time ; and, in consequence, she was not dismissed until the 20th of Jnly. Before saying anything with regard to the treatment, it will be well to attend to the facts exhibited bv some other cases. Case CLXVIII.* — Albuminuria — (Eiem/i of both feet and legs, left arm and hand — Recovery. HiSTOKY.— Bobert Lindsay, at. 02, carder of wool— admitted 21st March, 18.54. States that, twenty-three years ago, he had a violent attack of rheumatism, which laid him up for ten months. After his recovery, his health continued good, until ten years ago, when he began to suffer from symptoms of stone in the bladder. He underwent the operation of lithotomy, but made a tardy recovery, being unable to ♦ Reported by Mr. Robert Bird, Clinical Clerk. bright's disease. 751 resume his work until upwards of twelve months afterwards, and for two or three years subsequently he was subject to attacks of rigors, which compelled him to keep within doors for several days at a time. He then became tolerably healthy, and continued so until three weeks ago, when he noticed his left wrist somewhat swol- len, and in the course of two days, his lower extremities became likewise cedeniatous- He sutTered from a dull heavy pain in the lumbar region; which has been present more or less ever since he underwent the operation ten years ago. His urine, at the time tlie swelling commenced, was scanty and high coloured, and he was troubled with a slight cough. He says that about tlie time when his illness began, he was engaged in cleaning machinery, and may have caught cold. He is not aware of any other cause which might have brought on his ailment. He acknowledges that for- merly he was a free liver, but since the operation he has been very temperate. Symptoms on Admission. — On admission, both feet and legs are oedematous, pit- ting on pressure There is also shght swelling of the left arm and hand. He com- plains of a dull pain in the lumbar region on both sides, but that on the left is most severe. Micturition frequent; he is obliged to rise several times in the course of the night for that purpose. It is not attended with pain or difficulty. Sp. gr. of urine 1011; coagulable by lieat and nitric acid. He complains of frontal headaciie. Sleeps badl}^ being much disturbed by dreams and sudden startings. Tongue moist and clean; complains of great thirst; appetite impaired; bowels regular; has a sliglit cough, with very little expectoration; chest every wliere resonant on perctis- sion. At the apices of both lungs anterioriy, and at the apex of the left posterioriy, sibilant rales are heard. He has suffered from palpitation for the last three weeks, but the cardiac sounds are normal. ]J Tinct. Ftrri Mur. | i. Ten drops to he taken three times a day. I^ Pulv. Doveri gr. x. MMant. tales, vi. One to he taken morn- ing and night. Progress of the Case.— J/arc7i 23d.— This morning he had violent vomiting, but it has now abated, and he complains of great thirst. March 26ril lid. — Urine not increased in quantity, varies from 9 to 1.5 oz. per diem ; abdomen measures 37| inches. The Inf. Digitalis has produced a rash of a papular character over the surface of the abdomen. IJ Sp. jEth. Xitrici 3vj; Aq. Cinnamomi § vss. M. Haheat ^j ter in die. Ap)ril2oth. — Saj's that the last mixture has given him great relief; has passed 26 oz. of urine after it. The spongio-piline to be removed, owing to irritation which it has caused in the skin of abdomen. May 2d. — Base of left lung dull on percussion posteriorly ; no rale ; a good deal of pain in abdomen ; bowels costive ; skin dry ; has passed 25 oz. of urine to-day. May 3d — Urine 24 oz. ; Habeat Potass. Bitart. 3j ter in die. Omittantur alia. May oth. — Urine 18 oz. ; swelling of abdomen much increased, thighs and legs greatly distended. Abdomen measures forty inches in circumference. Had Pil. Rhei Co. gr. x. last night. To take Gin § j daily. May 7th. — Urine 20 oz. ; sp. gr. 1018; his condition at present seems almost hopeless. The abdomen is enor- mously distended, with a peculiar diftuse indurated feel over the region of the epigastrium, which, however, is tympanitic on percussion. The scrotum, thighs, and legs are greatly enlarged ; appetite impaired ; tlie pulse 86, weak. To be dry cupped over the loins. To have Gin § ij daily. 2Iay 9th. — No change. Ilabeat Potass. Bitart. 3ss ter in die. May 11 th. — Urine 34 oz. ; sp. gr. 1015; still highly coagulable ; numerous casts of tubes are seen in the urine under the microscope. May lath. — Urine 38 oz. ; sp. gr. 1014; is less coagulable; complains of severe frontal headache. To continue tvith the Bitartrate of Potass. May IQih. — Urine 64 oz. ; sp. gr. 1010. May 11th. — Urine 58 oz. ; sp. gr. 1013; no headache; bedsore on sacrum ; right side more swollen than left (he lies on this side) ; bowels costive. bright's disease. 755 Haheat Pil. Cobcynth. Co. gv. x. hord somni. Afay 18th. — Urine 67 oz. ; oedema of limbs very much diminished; swelling of abdomen less. Mai/ 2lsL — Urine 68 oz. ; sp. gr. 1010; appetite good ; pulse 96, full and strong. May 22d. — Urine 120 oz. May 23d. — Urine 128 oz. ; sp. gr. 1014; it still contains albumen in considerable quantity : the abdomen has greatly diminished in size, and the thighs and legs are of natural appearance, tliough tiiere is some pitting on pressure at tlie ankles ; every second day of late he has been attacked about noon witli a severe frontal headache. ^ Quinoi SulphaUs gr. iij ter die sumend. 3Iay 2-lth. — Urine 107 oz ; sp. gr. 1018; still contains much albumen; no headache. May 2oth. — Urine 126 oz. ; sp gr. 1016; very slight headache to-day; has taken four of the quinine powders. Still takes the Bitartrate of Potash. 3fay 2Sth —Urine 100 oz, ; sp. gr. 1020. May SOih. — Urine 50 oz. 2Iay Slst. — Urine 80 oz. ; sp. gr. 1014; perfectly free from all trace of albumen ; oedema of legs and ascites have completely disappeared ; no headache; appetite good. June 8th. — No return of albumen in urine; quantity varies from 60 to 114 oz. daily. June 9t]t. — A slight trace of albumen in the urine toda}^, and feet sliglitly (edematous. June 15th. — Still a faint trace of albumen in the urine; his ankles become oedematous if he sits up long. June 19ih. — Urine 100 oz. in twenty-four hours; sp. gr. 1010; contains an exceedingh'- faint trace of albumen. June 27th. — The quantity of urine passed in twenty-four hours averages 100 oz. ; sp. gr. varies from 1010 to 1015 ; his ankles after he has been long up pit slightly on pressure. July 2d — Albumen has quite disappeared ; bandaging prevents his ankles from swelling. He sits up the entire day. Tlie appetite is good. Urine passed daih' about 40 oz. In fact he is quite well. July '3d. — Dismissed cured. Commentnry . — Tn this case the man describeowder after the bowels have been loell opened. Jan. 20th. — Was a good deal better last night, felt himself Avarm and comfortable after the Dover's powder, but he did not sweat ; he has had three loose stools since ; the quantity of urine is now 50 oz. ; sp. gr. 1020 ; still highly coagulable; his thirst is considerably diminished. Jan. 22d. — The urine examined under the microscope yesterday exhibited a few pale casts of the urinary tubes, which are also present to-day ; during the last two days he has passed about 58 oz. of urine in the twenty -four hours, and he states that altogether he feels much better. March 5th. — Since last report has gradually improved in health. To-day, wishes to go out, as he now has no complaint but weakness; voids from 50 to 60 oz. of urine daily. It is of rather pale colour ; sp.gr. 1020; about one-sixth coagulable. A few sibilant rales are heard occasionally over the cliest, but otherwise the systems are healthy. Is dismissed accordingly much relieved. Commentary. — In tins case tlie diaphoretic plan of treatment was tried at first, but with inconsiderable success. It is true the oedema disappeared from the legs, a result probably as mucli owing to the recumbent position and general comforts of the hospital, as to the medicines employed. When the bitartrate of potash was administeied, afterwards combined with purgatives, the effects were more lapid, and the anasarca soon disappearad. The coagulability of the urine, however, still continued, though in a diminished degree, when he left the house. Case CLXXIII.* — Third Attack of Albuminuria icith Anasarca — Dismissed relieved. History. — James Smith, set. 38 — admitted 25th November, 1852. States that he enjoyed good health till about three and a half years ago, when, after exposure to a di-aught of cold air, his ankles began to swell, which swelling in four days extended up to the thighs, and induced him to apply for admission to the hospital, where he remained three weeks, and was dismissed cured. The same symptoms reappeared in twelve months, and he was again admitted a patient, remained for a few weeks, and went out, feeling quite well. He continued in excellent health till four months ago, when he began to complain of shortness of breath and palpitation when at work; the palpitation was reduced by cupping, but the dyspnosa continued upon taking exertion. Four weeks ago the swelling at the ankles returned, and he was again admitted into the hospital, ward 6, where he has been under treatment till tlie date of his admission into the clinical ward. His habits were rather intempeiate previous to his first attack, but since then he has never indulged in any kind of intoxicating liquors. Symptoms on Admission. — On admission there is some oedema of the limbs and trunk, which pit slightly on pressure; the skin generally is very dry, but of the usual temperature. The quantity of urine voided in the twenty-four hours is 66 oz. ; it is * Reported by Mr. Alexander T. Macarthur, Clinical Clerk. bright's disease. 759 of a pale stra'w colour, slightly turbid, and highly coagulable ; sp. gr. 1014. depositing a slight sediment like thin whey. Viewed under the microscope, it presents nume- rous fragments of desquamative casts; some very long, some containing nuclei and granular cells more or less fatty, and some tilled with minute fatty molecules. There are numerous pus cells ; some epithelium cells, isolated and in groups, from the ureter or bladder. There are numerous columnar crystals of uric acid, and some mineral salts aggregated in masses of minute angular crystals. Tongue clean and moist ; appetite good; bowels regular; pulse 68, of moderate strength. There is slight irregularity of the heart's action : first sound prolonged, and accompanied with a soft blowing murmur heard loudest at the apex. Other functions normal. Progress of the Case. — He was dismissed at his own desire on the 29/7t of November, but returned with all his former symptoms aggravated on the '27th of December. He states that after leaving the hospital he returned to his usual em- ployment for about a week, when he caught cold, and he has been confined to the house ever since. The cough became very severe, with dyspnoea and great debility after passing his urine. On examination, the quantity of urine excreted is 50 oz. ; it is passed without pain ; is of pale colour resembling whey, is slightly turbid, and deposits, on standing, a small quantity of white sediment, whicli, on examination by the microscope, presents numerous casts, as before noticed, but no crystals ; sp. gr. 1013, highly coagulable. On auscultation, sibilant rales are heard all over the chest, expiration prolonged, but no dulness on percussion. He has a frequent cough, with frothy mucous expectoration. ^. Sol. Antim. 3 ii ; J/«t Camph. 3 iv ; Misce. Sumat 3 ss quarto, quaque hord. Descendaf in baineum calidura secunda qudque node. Dec. 29{h. — Still rather feverish, complains of intense thirst, constant craviiag for drink, which is unrelieved by water. To have as drink 5 ^ij of milk mixed with § vj. of lime water. January Yd. — Cough much the same as on admission ; oedema of legs much diminished, but the skin is still dry, diaphoresis never having been induced. About 90 oz. of urine are passed in the twenty-four hours, still very coagulable with heat and nitric acid; slight deposit, still containing granular casts of the urinary tubes. Jan Qth. — Cough much relieved ; pulse 68, of good strength ; swelling of the legs now quite gone; urine passed in large quantity; still complains of great thirst. Continueniur medicament. Jan. 13e same part At the lower part of right side anteriorly there is a fine friction sound. Sputum in very small quantity; muco-puruleut, untinged with blood. Pulse 124, small and feeble; heart sounds normal; urine sp. gr. 1012, becomes slightly clouded with heat and nitric acid, but no distinct coagulum is formed; other functions normal. 5 ^c^- Mur. Morph. 3 ij ; Tinct. Catechu 3 vj ; Mist. Crttoe, 5^-j.M. Sumat ^j tertia qudque hord. To have 6 oz. of wine and steak diet. Progress of the Case. — yovember 20lh. — TTandered a good deal during the night ; is exceedingly weak to-day, but tlie diarrhoea is less severe. Nov. 22d. — Complains more of cough and pain in right side, striking across the chest to the left; no dulness on percussion; still friction on right side with fine moist rales; marked increase of vocal resonance; urine diminished in quantity; of natural colour, with slight flocculent precipitate on the application of heat and nitric acid. Diarrhoea stopped; pulse 112, small and weak. Xov. IWi. — Was much weaker yesterday, and evidently sinking ; too weak for examination of the chest ; bowels were once opened; no urine voided since last report. Died this morning at four o'clock, comatose. Sectio Cadaveris. — Fifty-six hours after death. Body somewliat emaciated ; very little subcutaneous fat ; muscles well nourished. Thorax. — Heart normal; adhesions of both pleuras over limited space of upper lobes. Both lungs contained many scattered groups of tubercle, chiefly miliary ; some few of them softened, and with small dry excavations at the apices ; the pulmonary tissue around the tubercles mostly indurated and dark coloured from carbonaceous infiltration ; the bronchial glands dark and enlarged. Abdomex. — Stomach and jejunum and upper two-thirds of ileum normal. In lower third several scattered ulcers, not exceeding eight or twelve in number, from one-quarter to three-quarters of an inch in diameter; some of them slightly con- gested at edges; their characters in all respects those of tubercular ulcers. Colon contracted at lower part. In the ascending portion, there are four or five small tubercular ulcers ; the largest half an inch in diameter, edges pale and slate-coloured, the floor somewhat indurated. Spleen, pale, peritoneal capsule thickened, the organ rather small, no distinct morbid appearances. Liver slightly enlarged, presenting very distinctly, and in a considerable degree, the fatty degeneration. Kidneys unusuallj' small (dimension of right three and a half inches long, one and three- quarter inches broad, three-quarters of an inch thick ; left kidney of nearly the same size, weiglit not ascertained) ; capsule easily stripped off; surface slightly bright's disease. 765 uneven, not distinctl}' tuberculated ; venous vascularity of surflxce considerable but irregular; on section, cortical substance much diminished (average three-eighths of an inch in diameter from base of pyramids); limiting line of pyramids tolerably distinct; faint appearance of opaque granulations. On examination with a lens, many very minute cysts were discovered in cortical substance ; most of them required a power of half an inch focal distance to bring them into view. A similar power, or even the naked eye, distinguished easily a number of opaque light gam- boge yellow points in the cortical substance ; the largest was about one-tiftieth of an inch in diameter, accurately limited, and 3'ielding, on being punctured, a fluid of the same colour. In the cortical substances there were also some minute hemorrhagic petecbiie, having the usual appearance of extravasation. Microscopic Examination. — With high magnifying powers, the tubuli uriniferl were seen in some places to be of normal character, with the exception of a very few granules in the epithelium ; on the contrary, in others, the tubes were crowded with fatty granules. The epithelium generally was normal in form and appearance in the tubes which had fewest granules. In many places the cortical substance of the kidney was studded with minute cysts, constituting the third form which they present (see p. 747). In the fluid squeezed from the yellow points, in the cortical substance, there was an immense number of fatty granules, partly loose, partlj^ agglomerated into amorphous collections, partly composing distinct rounded granular masses up to the one-ninetieth of an inch in diameter, and partly contained in cells of a very fine delicate transparent character, presenting much of the appearance of a tesselated epithelium. The cells of this epithelium were more transparent, and generally one-third smaller than those usuall}* found in the renal tubules. Commentary. — In tliis, as in tlie two previous cases, the renal disease was associated with phthisis, but was move chi'onio, fnrtiier advanced, and exhibited the uUiinate effects of the fatty rather than of the wa.KV degeneration. The report states that the nrine was not highly coagah^ble, presenting only a slight cloud on the addition of heat and nitric acid. The tiuids of the body, however, seemed to Lave been discharged to a great extent by means of stool. Before death, the urine was suppressed, causing coma. In the three fatal cases now given, wo have seen — 1st, Extreme waxy degeneration of the kidneys in a child. 2d, Incipient waxy degeneration coming on in the ward in an adult. 3d, The last stage of the fatty de- generation, with atrojihy. It would be easy to multiply cases, where, on dissection, all kinds of intermediate conditions of the kidneys had been observed ; but those now recorded, together with the six which recovered or were relieved, present the leading characters illustrative of the patho- logy, diagnosis, and treatment of Bright's disease. A few words on each of these topics may now be added with propriety. Patholoyy of Br'igMs Disease. se em Many names have been proposed by various pathologists for the diseas called after Dr. Bright. tJp to the present time, however, none of ther has been sufficiently good to comprehend all those lesions which occasion renal dropsy, with persistent albuminuria. Hence we still retain the de- signation it has so appropriately borne, to express a disorder characterized 766 DISEASES OF THE GEXITO-URINARY SYSTEM. by more or less dropsy, caused b}' obstruction to the renal functions, and accompanied by the presence of albumen in the urine. The nature of the obstruction to the renal function differs under a great variety of circumstances, but such as occasion dropsy, with persistent albuminuria, it appears to nie may now be classified under three heads — 1st. Intiamination, acute or chronic; 2d, Waxy degeneration; 3d, Fatty degeneration. 1. The Iiiflammatory Form. — This may be acute or chronic; the first is generally induced by all those causes which excite inflammation in other internal organs, and is ushered in bv rigors and febrile symptoms, and accompanied by pains in the lumbar region, and the phenomena generally described as those peculiar to nephritis. (See Nephritis.) The chronic disease may follow tlie acute, may come on more slowly, as the result of the same causes, or proceed so imperceptibly from causes which have escaped oV)servation, that the occurrence of dropsy, more or less extensive, may be the first symptom which excites att'.'ntion. On testing the urine chemically, it is found to be albuminous, and on examining the sediments microscopically, various kinds of casts with epithelial cells, blood corpuscles, dift'erent salts, and other morbid products, may be seen. These casts of the uriniferous tubes are finally molecular and fibrinous {exudative caMs)^ or mingled with the fibrinous matter, there are epi- thelial cells and free nuclei of the tubes [desquamative casts). Other products, which vary according to the period of the disorder and the tissues involved, may also be present, to which we shall allude under the head of diagnosis. On examining the kidneys of individuals who have laboured under this form of the disease, we find that in the acute stage they are more or less congested and tinged of various colours, from a bright red to a dusky brown. The suiiace is not unfrequently covered over with minute ecchymolic spots, dependent on the extravasation of blood into the tubes, in tlieir convoluted portions. The excessive congestion and extravasation of blood, by obstructing the tubes and interfering with the secreting function of the organ, form the chief source of danger in these cases. There may also be frequently observed a fibrinous exudation filling the tubes, in which are intermixed the epithelial cells, and here again the extent of the obstruction so occasioned is, sometimes without much congestion (Case CLX.), commensurate with the danger of the case. As the disease becomes more chronic, the intense uniform coloration diminishes, leaving irregular arborizations, which mottle the surface — the blood extravasated is absorbed — the exudation, if not dislodged and passed in fragments by the urine, gradually disintegrates, and may or may not undeigo the purulent or fatty transfoi-mation. This, by long- continued pressure, causes permanent obsti'uction of the tubes and atrophy of the renal structure, so that at last the organ becomes smaller and smaller, less and less able to perform its functions, and ultimately causes death (Case CLXXVI). 2. The Wax;/ Form. — This form of the disease is generally chi'onic, and for the most part accompanies scrofulous or tubercular complications. Dropsy, and a peculiarly cachectic and emaciated look, constitute its chief symptoms ; and the urine, as the disease slowly progresses, becomes BEIGHT S DISEASE. 767 more and more suppressed, death taking place by coma. The sediment is usually small, and presents pale casts of the tubes {wuxi/ casts), with a few epithelial cells, unusually colourless and transparent. Xot unfre- quently, however, at an early period, desquamative casts, with little fibrin, and composed of closely aggregated cells, of the tubes, may be seen. This form of the disease is so mixed up with the various other lesions which usually accompany it, as not to admit of any distinctive description, referable to the more renal disorder. On examining kidneys which have undergone the waxy deo-eneration, we generally find that they are more dense to the feel tlum natural, sometimes smallei-, at others larger than usual, and of a colour resembHng various shades of dirty bees' wax, or of a liglit fawn tint. On section the surface is smooth, and the edges more or less translucent ; a circumstance dependent on the diminished vascularity which everywhere prevails, and a peculiar transparency which all the structures of the organs have under- gone. A thin slice, when magnified under a power of 250 diani. linear, exhibits the vessels of the malpighian bodies more transparent and re- fractive than usual (Fig. 445). The tubules are colourless, often destitute of epithelium, and of a peculiar whiteness. Such cells as are t. 22, a somewhat stout servant girl, with fair skin, and scrofulous aspect, was admitted into tlie clinical ward of the Royal Infir- mary, Mav 6, 1849. She states that there has been au eruption on her head for the last twelve years. Four months ago the catamenia ceased, since whicli time she has been subject to occasional headache, constipation, and slight dyspepsia. Symptoms on Admissiox. — Nearly the whole of the scalp is covered with a thick yellow friable crust, of uneven surface, and irregular margin, emitting a highly offensive odour, like cat's urine, and causing great itching and irritation. Up to the middle of July she was treated with various internal remedies, which subdued the constipation and dyspepsia, and caused return of the catamenia. The crusts on the scalp Avere removed by poultices, and au ointment, composed of ammon. mur. 3 j ; and umj. sulphuris § j, applied locally. Dr. Bennett first took charge of the ease ou the 14th of June. The head was then again covered with favus crusts, some isolated, others compressed together, and forming au elevated scab. A small portion examined under the microscope, presented the branches and sporules of the crypto- gamic plant so characteristic of the disease. Tlie crusts vjere again removed by 2)ouUices of linseed meal, the head shaved, and cod-liver oil ordered to be applied to the scalp morning and evening — the whole to be covered with an oilrsilk cap. This treat- ment was continued for six weeks, but on suspending it the favus crusts returned. During the mouths of August and September, iodine and pitch ointments were applied ; portions of the scalp were even blistered, but without eflect. Progress of the Case. — At the commencement of October, the scalp being at the time perfectly clean and closely shaved, all local treatment was suspended, and the reappearance of the disease carefully watched. In three da3-s the eutue surface presented a scaly eruption, the epidermis being raised, cracked, and broken up over the whole scalp, which was exceedingly dry and harsh. The furfuraceous con- dition of the scalp continued, becoming more and more dense, until the fourteenth day, when there were first perceived minute bright sulphur-coloured spots in it. These, on being examined microscopically, were seen to be composed of fine mole- cular matter, mingled with epidermic scales, from which delicate branched tubes were apparenth' growing. The crusts were now once more removed by repeated poulticing, and cod-liver oil applied as formerly. The scalp continued fi-ee from eruption until the 20th of November, when she was seized with febrile symptoms, which ushered in a very severe attack of typhus, that ran its usual course. She was not considered fully convalescent until the %ih of December. During this * Reported by Mr. "William Johnson, Clinical Clerk. DERMATOPHYTA. 795 period, no local application was made to the scalp, with the exception of tlie cold douche to alleviate the head sj-niptoms, delirium and coma having been severe. The surface latterly once more became covered with furfuraceous scales ; and on the nth December the bright yellow minute spots again made their appearance. As her strength improved, tlie favus crusts increased in size and number, and the pro- gress of this very singular disease was again very carefully watched. Each individual crust, at Urst the size of a small pin's head, gradually flattened out and became circular. Its centre was cupped and umbilicated, and many, which were more isolated than the rest, grew until they measured a quarter of an inch in diameter. More generally, however, they came in contact with others, and groups of twos, or threes, and sometimes a dozen, became compressed together and presented the hexagonal form of the honey-comb. Gradually the concavity disappeared. Each crust presented an external dark ring, and an internal lighter centre, which became considerably elevated. The various groups became aggregated together, and she complained of great itching and irritation, and it was evident that, if allowed to proceed further, the condition she presented on admission would be soon produced. The crusts were, therefore, again removed by poultices, cod-liver oil once more applied, and the scalp remained clean and free from irritation until \1ih January, when the cure appearing to be hopeless she was dismissed. She was enjoined to continue the use of the oil, which, whilst applied, and covered with the oil-sOk cap, had the power of preventing the formation of fresh crusts on the scalp. Case CLXXTIII.* — Favus of the Scal2) of three years' standing — Cured. History. — Margaret Bryer, a?t. 12, of scrofulous and cachectic appearance, was admitted June 19tb, 1849, with favus crusts on the scalp. The crusts are most numerous and dense on the crown of the head; but others, isolated or in small groups, are scattered over the temples, forehead, and occiput. The scalp is bald here and there in patches, varying in diameter from half an inch to an inch. Oa examining the crusts microscopically, they are seen to contain the cryptogamic branches and sporules pathognomonic of favus. The disease is of three years' .stand- ing, and is attributed to the use of a comb, belonging to another girl who had a sore head. The crusts have been several times removed by means of pitch plasters and a variety of ointments, but have always returned. Progress of the Case — At first, the crusts were removed and the scalp kept moist by means of an alkaline lotion, which succeeded in removing the irritation. Early in July she was ordered 3 ss of cod-liver oil three times a day. Tlie oil was also directed to be applied to the shaved scalp ttvice daily, tvhich v:as to be kept constantly covered tvifh an oil-silk cap. This treatment was persevered in until August 10<7j. when she was dismissed cured. This girl was re-admitted September- 5th, and remained in the Infirmary five days, under observation. Up to this time the disease had not re appeared, so that, wlien dismissed on the lOih, a permanent cure was undoubtedly produced. Case CLXXIX.f — Favus caught in the Ward from Case CLXXTII. — Cured. History. — Margaret Cameron, set. 5, an ill-nourished cachectic-looking child — admitted July 23d, 1849, on account of an eruption on the scalp. In some places * Reported by Dr. J. Smith, Clinical Clerk. ■]• Reported by Mr. Alexander Struthers, Clinical Clerk. 796 DISEASES OF THE INTEGUMENTARY SYSTEM, the hair was matted together b}"- a recent pustular eruption ; groups of impetiginous pustules and eczematous vesicles being scattered here and there. In others, where, tlie disease was more chronic, hard, nodulated, elevated masses, and friable crusts existed. The disease was eczema impetiginodes. No favus was present, as was proved by careful examination, and micro.scopic demonstrations of the scabs. Poul- tices loere ordered to the scalp, to remove the crusts ; and afterwards an alkaline wash, with cod- liver oil internally. Progress of the Case. — My colleagues taking charge of the ward during the months of August and September, I lost sight of this patient; but on resuming duty in the beginning of October, I was surprised to find the child's head covered with favus crusts, with the branches and sporules fully developed, as proved by the micro- scope. It appeared that the girl was a great favourite with Isabella Fergusson (Case CLXXVII ), and frequently slept in her bed, and there can be little doubt she had caught favus from her. The child's general health, however, had greatly improved ; and the crusts vjere ordered to he reinoved by poultices, the head shaved, and cod-liver oil applied locally twice daily, and an oil-silk cap to be worn constantly. This treatment was continued for seven weeks. At the end of that time all treatment was suspended, and the scalp watched daily. In fifteen days the head was covered with a slight furfuraceous desquamation; but the hair was abundant. Another week elapsed without any return of favus ; and, her health being now good, she was discharged, December Gth. Case CLXXX.* — Favus of the Scalp of four years' standing, cured hy a Sulphuric Acid Lotion. History.— Helen Goodall, vet 15 — admitted November 3d, 1853. She has been affected with favus of the scalp for four years, and frequently been in the Infirmarj', and subjected to various kinds of treatment, under different physicians, without any permanent benefit. On admission, a great portion of the scalp was bald, from destruction of the hair bulbs, but the other portions were covered with a prominent yellow friable crust, of mousy odour, crowded with pediculi. On the Ith of November a lotion composed of one part of sulphurous acid and three parts of water, was con- stantly applied by means of lint saturated in it, and covered with an oil-skin cap. It was suspended December 23d, leaving the scalp parti}' bald, but quite clean. On the 15th of January, 1854, the disease had not returned. The scalp was then rubbed over with the oil of cade, twice daily, to remove the squamous eruption, and she was dismissed apparently quite cured, February oth. Case CLXXXI.f — Limited Favus of the Cheek, cured by Cauterization with Nitrate of Silver. History. — James Scott, aat. 15, a painter, applied for advice, January 27. 1850. He states that, a week ago, without any known cause, he observed a small spot about the size of a pin's head, over the external angle of the left malar bone. On examination, a circular reddened spot, about the size of a shilling, is seen over the external angle of the left malar bone, in the centre of which were several favus crusts, aggregated together. These examined under the microscope, presented the branches and sporules pathognomonic of the disease. TJie whole was then luell cauterized with nitrate of silver, and was cured at once. * Reported by Mr. P. "^. Wallace, Clinical Clerk. f Reported by Mr. Hugh Balfour, Clinical Clerk. DERMATOPHYTA, 797 Commentary. — Of the five cases of favus now given, tlie first was that of an adult, and was of twelve years' standing. By means of poultices and excluding the air with oily applications, the scalp could easily be freed from the eruption and kept so; but as soon as these means were discontinued, the disease returned. The second and third cases were permanently cured by the constant application of oil to the scalp for six or seven weeks. They were children of the ages of twelve and five years respectively In the former the disease was of three years' standing; in the latter, it was altogether recent, and caught from another case in the ward. The fouith case was cured by using a sulphurous acid lotion instead of oil— a practice recommended by Dr. Jenner, in consequence of the powerful efiect possessed by this acid, in destroying vegetable growths. In the fifth case, the disease was limited, and was at once destroyed by means of caustic. It is rare that favus can be watched through its entire progress in tlie wards of a hospital — first, because the disease commonly lasts months — often years, and charitable institutions cannot support individuals so long ; and, secondly, because it always happens, that when urgent cases demand admission, and beds are required, these are just the parties who are discharged to make room for them. At the same time, the disease is so common in Edinburgh, that the wards are seldom free of one or more examples of it in various stages. Besides, by poulticing off the crusts, and allowing the eruption to come back, its commencement and progress may be studied in any individual case. Case CLXXXII.* — Parasitic Pityriasis — Incuralik. History.— Charlotte Clerk, xt. 18— admitted June 20, 1857— a Hiudoo girl from Bombay. She has had an eruption on her head ever since she can remember. On admission the hair was found clipped short ; the scalp was bald in patches, especially over the crown of the head. The hair is filled with scales, easily detached, resem- bling desquamated epidermis. Towards the back of the head these scales are embedded in a dittused friable yellowish matter, which, on examination under the microscope, presents the thalli and sporules of favus. July Qth. — To determine more certainly the character of the disease, poultices have been applied to the head, the hair has been shaved, and the disease allowed to return. To-day, being the seventh since the head was clean, two bright yellow favus spots, each perforated by a hair, were observed. These rapidly increased and amalgamated with others, never form- ing distinct favus crusts, but causing a scaly eruption over the surface, together with a few pustules of impetigo. On removing the scales a friable yellow mass can be generally seen below, presenting on examination the vegetable structure of the Achorion Schoenleini. The sporules and thalli were unusually large and well developed. This girl was treated by constant oleaginous and other applications ; was dismissed and re-entered the house; but when I last saw her in December, 1857, the disease still existed as bad as ever. Commentary. — This eruption presented to the naked eye all the appearance of pityriasis of the scalp. The only suspicious circumstance was the baldness. I had previously seen two similar cases, and was in * Eeported by Mr. W. Guy, Clinical Clerk. 798 DISEASES OF THE IXTEGUirEXTARY SYSTEM. no way surprised to find that the disease was a parasitic one. All chronic scalp eruptions, especially if there be Alopaecia, should be examined microscopically, in order to arrive at an exact diagnosis. E>seiitially the fungus is the same as that of favns, although it may present occasional modifications as to the size of the sporules and thalli. In the present case they were remarkably well developed and larger than usual ; in one case I found all the sporules perfectly globular, and only half the size of the usual oval corpuscles. In tliis, as in Case CLXXVIL, all the remedies tried were of no avail. History of Fai'us as a Vegetable Parasite. — [Achorion Schanleini of Link.) The demonstration by Bassi* of the vegetable nature of the disease named muscardine in silk worms, which causes so great a mortality amongst those animals, opened up to pathologists a new field for observa- tion, and led to the discovery, that certain disorders in the hio;her animals, and even in man himself^ were connected with the growth of parasitic plants of a low type. SchonIein,f of Berlin, was the first to detect them in favus crusts — an observation confirmed by Remak,;}; Fuchs, and Langenbeck.§ Gruhy|| gave a very perfect description of these vegetations in 1841, and made numerous researches as to their seat, origin, and mode of propagation. These were repeated by mvselt^ and further extended in 1842.«r In 1845 I succeeded in inoculating the disease in the human subject. Since then tiiey have been made the subject of further investigation by Lebert,*' Remak,!" Robin,J^ and numerous other inquirers, to whose observations I shall have occasion to allude subsequently. Mode of Development and Symptoms of Favus. By most writers, amongst whom may be cited Willan, Bateman, Biett, and fiayer, favus is described as commencing in a pustule, which breaks and forms the peculiar scab. Others, such as Baudelocque, Alibert, and Gibert, deny its pustular nature, and state that it commences in a crust. But numerous observations have satisfied me that the formation of pus- tules is not essential to the disease, although they are often present. Hence the mistake of those pathologists who classified favus amongst the pustulse. M. Gruby says that they are never present, which is equally erroneous, although they appear to be a secondary result, attri- * Del. MaL del Segno Calcinaccio o Muscardino. MUano, 1837. f MuUers Archives. 1836. \ Mediciniscbe Zeitung. 1S40. y Comptes Readus de la Polyclinique de Gottingen. I Comptes Rendus, torn. xiii. pp. 72 and .309. 1841. •[ On Parasitic Vegetable Structures found Growing in Living Animals. Edin- burgh PhUosophical Transactions, vol. xv. p. 277. 1S42. Monthlv Journal, June 1842. *^ Physiologie Pathologique, torn, iu 1845. \" Diagnostische und Pathogenische Untersuchungen. 1845. X^ Des Vegetaux qui croissent sur THomme, eta 1847. DERilATOPHYTA. 799 billable to the irritation the disease produces in some individuals.* On the other hand, I have never seen this atlection produced, without hav- ing; been preceded by desquamation of the cuticle, an observation which appears to me of some importance in explaining the origin of the disease, as we shall subsequently see. Occasionally, also, the scales form a thick mass, and the favus matter is more disseminated, and does not form the distinct umbilicated crusts. This constitutes the parasitic pity- riasis of some writers. After removing the favus crusts by poulticing, and then watching from day to day how^ the disease returns, it will be seen that the first morbid change is increased vascularity of the skin, accompanied with a desqua- mation of the cuticle ; and that in a period varying from twelve to four- teen days, small spots of a bright yellow colour, like that of sulphur, may be detected. These gradually augment in size, but even at the earliest period may be observed, Avith a lens, to have a centi'al depres- sion, through which a hair may generally be observed to pass. The crust or capsule may enlarge to about the size of a shilling, and if it be isolated, still retain its rounded form. Usually, however, its edges come in contact with other capsules, and then it loses its rounded shape, and assumes the hexagonal and honey-combed appearances described by authors. I consider, then, that the so-called Porrigo Inpinosa, and Por- rigo favosa, constituting distinct forms or varieties of some writers, are merely different stages of the same disease, and dependent upon the greater or less aggregation of the crusts. On the first appearance of the capsule, its edges are somewhat depressed below the surface of the cuticle ; but as it increases in size, the margins become more and more elevated and prominent, whilst a series of concentric rings or grooves may be observed in them. At first, also, the whole capsule appears of a homogeneous bright yellow, but when further developed, its centre assumes a whiter colour. This arises from the aggregation of the spo- rules of the plant, which are more abundant in this situation. As the development proceeds, this central whitish yelloAv mass assumes a mealy, powdery consistence, and encroaches upon the edges of the capsule, which gradually disappear, whilst its upper concave form becomes con- vex, as Gruby pointed out. In general, an inflammatory ring is seen round tlie crust, which, as the capsule becomes elevated above the skin, enlarges, and assumes a deeper colour, indicative of the increased local irritation. At length the whole cracks or splits np ; all regular form is lost ; a dense thick crust covers the scalp ; an odour, like the urine of cats or mice, is evolved ; and in chronic cases, vermin deposit their eggs in the inteistices, and ci'awl in lai'ge numbers over the suriace. I have satisfied myself that occasionally the disease, instead of pre- senting distinct capsules round hair bulbs, becomes diflused under the epidermis, which then assumes the appearance of pityriasis, and not unfrequently of chronic eczema. A microscopic examination, however, will in such cases always detect groups of sporules and thalli more or less developed. In one instance I found the sporules smaller than usual, * This explanation of the origin of pustules and purulent matter, wheu present, has been adopted by Lebert, Remak, and Simon. 800 DISEASES OF THE IXTEGUMEXTARY SYSTEM. and perfectly globular instead of oval. In others I have seen tlie sporiiles three or four times laro-er than those of ordinary favns, with included nuclei, muUiplying fissiparously. Hence the so-called para- sitic pityriasis of the scalp, I believe to be a modification of favus, and consider it a good rule, in all chronic eruptions on the head, to examine the crusts microscopically. The other local symptoms are merely those which result from the greater or less degree of irritation produced in difterent persons by the changes above referred to. At first, scarcely any uneasiness is felt; perhaps occasional slight itching of the part. As the disease progresses, however, the itching becomes more intolerable, and induces the patient to rub and scratch the scalp. By these means, several of the crusts are forcibly torn from their attachments, and considerable effusion of serous fluid and blood is produced. Sometimes inflammation is thus occasioned. Impetiginous pustules are frequently formed, or suppuration produced, terminating in ulceration, and the discharge of an ichorous fluid from beneath the crusts. At an advanced stage of the disease, the peculiarly offensive odour exhaled is insupportable to those who surround the individual, and the ichorous discharge, vermin, and crusts, which cover the aftected parts, present a most disgusting appearance. e^ d Fig. 463. Although the disease most commonly attacks the hairy scalp, it may occur on the forehead, temples, cheeks, nose, chin, ears, shoulders, Fig. 463. a. Isolated crusts of Favus, presenting the lupine seed-like depression in different stages of growth (so-called Porrkfo lupinosa) ; some are arranged in groups of twos and threes, h, A larger group of these crusts, somewhat compressed at the sides, like a honeycomb {Porrigo favosa), c, Another group, which occurred on the shoulder of a young girl. Xo hairs passed through the centre of these crusts. rf. Large isolated crusts in an advanced stage of growth, "the external ring is cracked, and the friable centre is enlarged and elevated, e. Xumerous crusts'^ aggregated together, so as to form an irregular elevated mass. Traces of the original form°may be observed iu the cracked rings round the margin. {Natural size.). DERMATOPHYTA. 801 arms, abdomen, lumbar region, sacrum, knees, and legs. Alibert gives a plate in ^Yhicll it is figured in all these situations. I have myself seen it on the cheek, shoulders, back, arms, and interior extremities, and in some of these situations I could detect no hairs perforating the capsules. (Fig. 463, c.) The constitutional symptoms are of the utmost importance, but, general Iv speaking, receive little attention from practitioners. In most of the iiidividualsatiected, who have come nuder my notice, the general health has been greatly deranged, and a scrofulous or cachectic con- stitution more or less evident. In some the fades scrofulosa of authors has been well marked; in others there were engorgements of the lymphatic glands of the neck ; and in the only fatal case which has come" under my observation, there were found tubercular depositions in the lungs, mesenteric glands, and other textures. Indeed, the o-enerality of individuals who die labouring under favus, perish from phthisis, "or other forms of tubercular disease. The beautiful plates pub- lished bv Alibert, are in this respect far from being true to nature; for whilst tiie capsules and crusts are accurately drawn, the individuals atfected seem to be ideal personages, enjoying the most robust health, and possessing even the utmost beauty of form and feature. In the o-eneralitv of cases, on the contrary, the patient is thin, the countenance is of a dirtv yellow colour, and the whole aspect betrays depression of the vital powers. The appetite is often impaired, the alvine evacuations irregular, and the functions of digestion and nutrition are impeded. Xuruerous writei-s have observed the physical and mental development of the individual to be retarded ; and Alibert gives instances where the epoch of puberty was considerably delayed. Bv those not well accustomed to the diagnosis of skin diseases, favus has often been confounded with other eruptions of the scalp, more espe- cially eczema and impetigo, or the combination of these diseases known as the eczema impetiginodes. In none of these eruptions, however, do the yellow crusts or scales present traces of vegetations when examined microscopically. This, therefore, furnishes the real diagnostic and pathognomonic character of the disease.* Occasionally, as has been stated, favus presents a scaly character. It has then been called Pityriasis. On examination of the scurf, however, the epidermic scales will be found associated with the Achorion Schcenleini, in various stages of develop- ment. Causes. Alibert considered the disease hereditary, and gives cases confirmatory of this view. As regards age, it is by far most common in children between the ages of three and twelve years. In infancy, and after * I am not aware that this peculiar disease has ever been observed in any of tlie lower animals. I may therefore mention, that I have seen it on the face of a common house moused in which animal the same cryptogamic vegetations were to be detected as in man. ' Dr. Carter has confirmed tliis observation in a communication he brought before the Eoyal Mediaxl Society of this city, during the session 18.56-57. Prof Gluge of Brussels has also described and fiirured the same fact (Bulletins de TAcademie Royale de Belgique. 2me. serie. Tom. iiL, Xo. 12). 61 802 DISEASES OF THE INTEGUMEN'TARY SYSTEM. pvibertj', it is more rare, although sometimes present; and in a few instances it has been observed in persons advanced in years. In ahnost all the cases which have come under my notice, the individuals have been exposed to causes which depress the vital powers, and are well known excitants of tuberculous disease. Close questioning will usually elicit that they are of a scrofulous family; have been exposed for some time to infected or corrupted air; inhabited small rooms, or confined streets, or dwellings situated in unhealthy situations; that the aliment has not been verynutritive, etc., etc. Hence why the disease is common in workhouses and jails, and most prevalent amongst the poorer classes of the population, and individuals wlio obtain a precarious subsistence. Almost every writer on the disease considers it to be contagious. Batenian, Guersent, and others, speak of its spreading amongst school- boys, from the employment of the same towels, combs, caps, etc. Gibert has seen it propagated in the wards of St. Louis from tlie same cause. It has been observed, he says, two or three times to be communicated by young people kissing each other, when it has appeared in the chin or neighbourhood of the mouth. Mahon even pretends to have contracted favus incrustations on his fingers, from having neglected to wash them after dressing the heads of those affected. Alibert, in his early writings, also thought" it to be contagious. In his later works, however, he evi- dently doubts it, says that much exaggeration has been made use of on this subiect, and states that the amour j^ropre of parents usually induces them to ascribe the origin of so disgusting a disease to external com- munication, lie further observes, " Mes eleves ont souvent tente d'inocu- ler en notre presence, le produit de I'incrustation faveuse, sous plusieurs formes, et en variant le procedes. Le plus souvent il n'est rien resulte, dans d'autres cas est survenue une infiammation passagere, qui s'est bientot evanouie — pai-fois une suppuration semblable qui pourrait s'eta- blir par tout irritant mecanique, ou par I'insertion d'une substance ctrano-ere dans le tegument."* Gruby also, on discovering its vegetable nature, inoculated tliirty phanerogamous plants, twenty-four silk-worms, six reptiles, four birds, and eight mammifera, but only produced the dis- ease once, and then in a plant. The human arm was inoculated five times, but, independent of a slight infiammation and suppuration, no eff'ect was produced. Sixteen years ago I inoculated myself and others many times with a view of determining whether favus was or was not contagious. But in none of these experiments, performed in various ways, and frequently repeated so as to avoid fallacy, could I succeed in causing the plant to germinate on parts different from those on which it was originally pro- duced. In other words, I could not communicate the disease to other individuals, or from one part of the same individual to another. At the time I did not consider these experiments (performed in 1841- 42) as decisive of the question, although they show that it is with great difficulty inoculation succeeds. Shortly after, Dr. Kemak, of Berlin, comnmnicated the disease to his own arm in the following way : — He fastened portions of the crust upon the unbroken skin, by means of plaster. In fourteen days, a red spot, covered with epidermis, appeared, and in a few days more a dry yellow favus scab formed itself upon the * Traite des Maladies de la Peau, foL p. 443. DERMATOFHYTA. 803 spot, which, examined microscopically, presented the mycodermatous veijetations characteristic of favus.* Mentioning this fact to my polyclini- caf class, at the Roval Dispensary, in the snmmer of 1845, one of the ixentlemen in attendance volunteered to permit his arm to be inoculated. A bov, called John Bangh, a?t. 8, labouring under the disease, was at the time the subject of lecture, and a portion of the crust, taken directly from this bov's head, was rubbed upon Mr. M.'s arm, so as to produce erythe- matous redness, and to raise the epidermis. Portions of the crust were then fastened on the pait by strips of adhesive plaster. The results were reii'ularlv examined at the meetings of the class every Tuesday and Friday. The friction produced considerable soreness, and, in a few places, super- ficial suppuration. Three weeks, however, elapsed, and there was no appearance of favus. At this time, there still remained on the arm a superficial open sore about the size of a pea, and Mr. M. suggested that a portion of the crust should be fastened directly on the sore. This was done, and the whole covered by a circular piece of adhesive plaster about the size of a crown piece. In a few days, the skin surrounding the inocu- lated part appeared red, indurated, and covered with epidermic scales. In ten davs there were first perceived upon it minute bright yellow- coloured spots, which, on examination with a lens, were at once recog- nised to be spots of favus. On examination with the microscope, they were found to be composed of a minute granular matter, in which a few of the crvptogamic jointed tubes could be perceived. In three days more, the vellow spots assumed a distinct cupped shape, perforated by a hair; and in addition to tubes, numerous sporules could be detected. The arm was shown to Dr. Alison ; and all who witnessed the experiment being satisfied of its success, I advised Mr. M. to destroy each favus spot Avith nitrate of silver. With a view of making some fuilher obser\ations, however, he retained them for some time. The capsules were then squeezed out, and have not since returned. Mr. M. had light hair, blue eves, a white and very delicate skin. There is every reason to believe that the strips of plaster employed in the first attempt shifted their posi- tion, and that the crust was only properly retained by the circular piece of plaster employed in the second experiment. That the disease, therefore, is inoculable, and capable of being com- municated by contagion, there can be no doubt, a result which accords with the observations of most practitioners, and with numerous recorded facts. (Case CLXXIX.) It must also be evident that it does not readilv spread to healthy persons, and that there must be either a pre- disposition to its existence, or that the peculiar matter of favus must be kept a long time in contact with the skin previously in a morbid condi- tion. Patholoyy. "We have seen, when describing the symptoms and mode of develop- ment of the disease, that it is not essentially pustular, and that the pustules occasionally present are accidental. On the other hand, it has been shown that the peculiar favus crust is composed of a capsule of epidermic scales, lined by a finely granular mass ; that from this mass * ilediciniscbe Zeitung, August 3, 1S42. 804 DISEASES OF THE INTEGUMENTARY SYSTEM. millions of cryptogamic plants spring np and fructify; and that the presence of these vegetations constitutes the pathognomonic character of the disease. In order to examine the natural position of these vegetations micro- scopically, it is necessary to make a thin section of the capsule, com- pletely through, embracing the outer layer of epidermis, amorphous mass, and light friable matter found in the centre. IlAvill then be found, on pressing this slightly between glasses, and examining it with a magni- fying power of 300 diameters, that the cylindrical tubes (thalli) spring from the sides of the capsule, proceed inwards, give off branches dicho- tomously, which, when fully developed, contain, at their terminations {inyceUa), a greater or smaller number of round or oval globules [sjyo- ridia). These tubes are from the ji^ to g^o of a millimetre in thick- ness, jointed at irregular intervals, and often contain molecules, varying from yo.Voo to ToVo of a millimetre in diameter. The longitudinal diameter of the sporulesis generally from ^\-^ to yio, and the transvei-se from 3!-^ to y4^ of a millimetre in diameter (Gruby). I have seen some of these, oval and round, twice the size of the others. The long diameter of the former measured ^W of a millimetre. The mycelia and sporules M^S-sh^ Fig. 465. agglomerated in masses are always more abundant and highly developed in the centre of the crust. The thalli, on the other hand, are most numerous near the external layer. There may frequently be seen swell- ings on the sides of the jointed tubes, which are apparently commencing ramifications. On examining the hairs which pass through the favus crusts, it will often be found that they present their healthy structure. At other times, however, they evidently contain long, jointed branches, similar to those in the crust, running in the long axis of the hair, which is exceed- ingly brittle. I have generally found these abundant in very chronic cases ; and on adding w ater, the fluid may be seen running into these Fig. 464. Branches oi the Achorion Schcmkini, in an early stage of development, growing from a molecular matter, and mingled with epidermic scales, from a very minute Favus crust. Fig. 465. Fragments of the branches more highly developed, with numerous sporules and molecular matter, from the centre of an advanced Favus crust. 300 diam. DERMATOPHYTA. 805 tubes bv imbibition, leaving here and there bubbles of air, more or less long. There can be ver}- little doubt that the tubes and sporules, after a --^^ «- b time, completely fill up the hair follicle, and from thence enter the hair, causing atrophy of its bulb, and the baldness which follows the disease. The various steps of this process, however, I have been unable to follow, never having had an opportunity of observing favus in the dead scalp, and of making proper sections of the skin. Several writers on favus have treated its vegetable nature as a mere hypothesis. At first it was considered, as by Mr. Erichsen,* to be "founded merely upon the outward appearance, sufficiently strong, cer- tainly, which the cup-shaped crust of favus offers to lichens, or vegetations of a similar description." Subsequently favus was supposed to consist of a mass of cells ; and it was argued by Dr. Carpenterf that the vesicular oro-anization is common to animals as well as plants; and hence "to speak of Porrirjo favosa, or any similar disease, as produced by the growth of a vegetable within the animal body, appears to the author a very arbitrary assumption." Mr. Erasmus Wilson, in his work on "Diseases of the Skin" (p. 430), as well as in a special "Treatise on Rino-worm," is also opposed to the idea of favus owing its essential characters to a vegetable growth. He considers that the peculiar branches and oval bodies previously described are mere modifications of epidermic cells, which in some cases he is of opinion may be transformed into pus cells — in others, into those observed in favus. The branches of the plant he calls "cellated stems," and the sporules, secondary cells; and argues, that mere resemblance to a vegetable formation is not sufficient to constitute a plant. He says, " The statement of the origin of the vegetable formations by roots implanted in the cortex of the crust is un- founded ; the secondary cells bear no analogy to sporules or seeds ; and it is somewhat unreasonable to assign to an organism so simple as a cell the production of seeds, and reproduction thereby, when each cell is endowed with a separate life, and separate power of reproduction.'''^ * Medical Gazette, December 1851, p. 415. ■)• Principles of Physiology, p. 453. X Ou Riugworm, i847, p. 23. Fio-. 4G6. a. A light hair containing branches of the Achorion Schoenkini (magnified 300 diameters linear). The wood-cutter has made the branches too beaded, b, A darker coloured hair, containing branches of the plant. 800 diam. 806 DISEASES OF THE INTEGUMENTARY SYSTEM. Lastly, M. Cazenave,* altliongh he acknowledges liimself to be no histologist, says lie has sought for the spornles many times, and believes himself authorised to conchule that their detection is not always so easy as is supposed (p. 225). Finally, he denies that favus is a vegetable parasite, and maintains it to be a peculiar secretion, originating in the sebaceous glands (p. 236). With the exception of Mr. Wilson, who ajtpears carefully to have examined the favus crust, the opposition to the vegetable nature of this production seems to have originated in very imperfect notions as to its intimate structure on the one hand, and that of certain cryptogamic plants on the other. For if long hollow filaments, with partitions at intervals, containing molecules within their cells, springing from an unoro'anized gi'anular mass, and giving off towards their extremities round oval bodies, or spoiules, arranged in bead-like rows, be not vegetables, what are they ? The animal tissues present nothing similar, while numerous plants, long known to botanists, present the same identical structure. But not only must they be referi'ed to the vegetable kingdom, but to a considerably elevated position among the cryptogamic plants. The 'protoroccus viralis and iorula cei-evisia; universally considered as plants, together with the nuixina voifriculi, described by Goodsir, are immeasurably beneath them in complexity of structure ; and many of the mucores or mouMs growing in damp places are, as I have satisfied myself by repeated examination, much more simple in their organism. Any one who looks over the cryptogamia of Greville will at once detect the strong analogy between the structures found in favus and the jjcnicilium glaucum of Link, the uspergillns penicillatus, acrosporiura monilioides, sporoiorium minuticm, nostoc cierideum, and other plants therein figured. Indeed, it seems to me surprising how the vegetable nature of these structures can for a moment be doubted by any one who has personally examined them, especially under powers of from six to eight hundred diameters linear. In considering whether the structures described, and now by every one acknowledged to exist in the favus crusts, really belong to the vegetable kino;dom, we should remember that they are not the onlv formations of this kind which have been found to grow parasitically in living animals. In my original paper,t I described others growing in phthisical cavities, in the sordes on the gums and teeth of typhus patients; and pointed out that they had been observed in the living tissues of mollusca, insects, reptiles, fishes, birds, and mammiferous animals. These observations have subsequently been confirmed by numerous pathologists and natur- alists. Lastly, we cannot overlook the opinion of botanists themselves concerning this question. The most eminent mycologists, so far as I am aware, have no doubt of the vegetable nature of favus. Dr. Greville, to whom I exhibited them, was quite satisfied of the fact. Brongniart, according to Gruby, and Messrs. Link and Klotzsch, to whom they were shown by Remak, expressed a similar opinion. Brongniart considers them to belong to the genus Mycoderraa of Persoon. J. Miiller places them among the genus Oidium ; but both Link and Klotzsch consider that they ought to constitute a distinct genus. The former, in consequence, has given it the name of Achorion (from achor, the old term for favus), * Traite des Maladies du Ciiir Clievelu, 1S50. f Ediu. Philosophical Trans. 1842. DERMATOPHYTA. 807 and added to it the designation of the discoverer, Scboulein. The fol- lowing is his description of the plant : — ^* Achorion Schanleirti 7iobis orbicuIare,f.avum^coriaceum, cuti Jiiimanae praeserdm capitis insidens ; rhizopodion moUe, pellucidum, Jioceosum Jloccis tenuissimis, vix articulatis, rumosis.'iimis, anastomoticis {?) ;* myce- lium Jloccis crassioribus, subiatnosis, distincte articulatis, articulis inaequa- libus irregularibus in sporidia abeuntibus ; sporidia rotunda, ovalia vel irrer/ularia. in uno vel pluribus latcribus r/erminaniia." The mode of development from sporiiles has now been determined with considerable exactitude. Remak made small grooves on the cut surface of a fresh apple ; placed portions of the favus crust in them ; then laid the apple, with the cut surface turned upwards, in moist sand ; and covered the Avhole with a glass bell. Under these circumstances, he found that the sporules developed themselves, and he examined them frequently up to the sixth day, when the surface of the apple became of a brown colour, and was covered with a rapid growth of Penicilium glaucum, or other kind of mould, among which the structure peculiar to favus could no longer be traced. These observations, however, showed that the sporules of the Achorion undergo development in the same manner as those in other cryptogamic plants. That is, the membrane Avhich surrounds them throws out one or more prolongations, which are converted into tubes; and these, in turn, present, generally towards their extremities, a number of sporules, which at length arc pushed out, ef- Fis. 467. Fi£r. 468. Fig. 409. or are disintegrated, and so become free. Figs. 467 and 468 represent the changes observed in the sporules germinating on the surface of the apple; and Fig. 469 shows the thalli, mycelia, and sporules, seen in the crusts, produced by inoculation, on Remak's arm. Tlie method of reproduction and formation of sporules mav be observed with great facility in any well-developed favus crust, especiallv under powers varying from 500 to 800 diameters linear. Thalli, with variable- sized cells, may be observed branching at the extremities, with sporules * I have never seen anv anastomosis. Fig. 467. Sporules developing on the surface of an apple, after three days. Fig. 468. The same, after four days. Fig. 469. The same, more fully developed on the human arm, after inoculation. a, Thalli, with pale walls; h, containing sporules (mvcelia); c, mycelium separated from the thaUus ; d, sporules separated from the mycelium — (after Remak). 300 diam. 808 DISEASES OF THE INTEGUMENTARY SYSTEM. forming Avithin them. These are coTijoined with separated mycelia, con- taining well-developed sporules, many of which are also free, as in the fiffure below. It follows, therefore, that all the circumstances connected with the development and mode of reproduction of the Achorion Scboenleini have been fully ascertained. The seat of fuvus has been much dif^puted by authors. By some it has been located in the piliferous bulbs or follicles (Duncan, Baude- locque, Rayer), by others in the sebaceous glands (Sauvages, L'nderwood, Murray, Mahon, and lately by Cazenave), and a third party in the reti- cular tissue of the skin ( Bateman, Gallot, Thomson). According to Gruby the plants grow in the cells of the epidermis, the true skin is com- pressed, not destroyed, and the bulbs and roots of the hairs and sebace- ous follicles are only secondarily aft'ected. I have made observations to determine the correctness of this state- ment, and have found that the whole inferior surface of the capsule is formed of epidermic scales, thickly matted together. These are lined by finely molecular matter from which the plants appear to spring, and which unites the branches and sporules together in a mass. Superiorly, however, the epideimic scales are not so dense ; and I have always found them more or less broken up, and not continuous. This observation is valuable, as indicating the probable mode in which these plants, or the sporules producing them, are deposited on the scalp. It will be seen that the appearance of the peculiar porrigo capsule was invariably pre- ceded by a desquamation of the cuticle, that is, a separation or splitting up of the numerous external epidermic scales which constitute its outer- most layer. Hence it is more probable that the sporules or matters from which the vegetations are developed, insinuate themselves between the * Fig. 470. Thalli, mycelia, and sporidia, of the Achorion Schcenkini, showing the mode of reproduction. 800 diam. DERMATOPHYTA. 809 crevices, and under the portion of epidermis tlnis partially separated, than that thev spring up oriyinallv below, or in the thickness of the cuticle. The chemical constitution of the matter originally exuded is supposed by M. Cazenave to be allied to fat, but it appears to me to be more pro- bablv albuminous, and allied to the molecular character of all broken down or disintegrated organic material in which fungi grow. We have seen that, prev'ious to the return of favus crusts, the head is always covered with broken-up epidermis, more or less disintegrated. Experi- ments have shown that the plants will not grow on the healthy skin, and that inoculation succeeds only in places where pustules have pre- viously been formed. It is also exceedingly probable that, when favus is communicated from one person to another, the part affected (generally the scalp) has been the seat of some other eruption (Case CLXXIX.), or is not particularly clean. Mr. I^richsen considers, "That the matter of favus is a modification of tubercle — that it is a tnbercular disease of the skin. By tubercular I do not mean a disease like lupus, characterised by small firm tumours, but a disease, the nature of which consists in the deposition of that heterolo- gous formation called tubercle." This view of the nature of favus I have long held ; and it was distinctly stated by me, when treating of the pathology of scrofula, in a work published in 1S41.* The favus crust, however,' is not constituted wholly of tubercular matter. The peculiar exudation only constitutes the soil from which the mycodermatous vege- tations spring, as I shall now endeavour to show. Grubv describes the mycodermata of favus as springing from an amor- phous mass, of which the periphery of the capsule is composed. This mass undoubtedly exists, and, according to my observations, is composed of a finelv molecular matter, identical in structure with certain forms of tubercle, or recently coagulated exudation. The cheesy matter, for instance, so frequently found on the secreting surface of serous mem- branes, and in tubercidar cavities and other structuix-s in chronic cases of tuberculosis, or general tendency to tubercidar deposition, presents this character. Every pathologist who has minutely examined tubercle recognises a granular form in which there is no trace of nucleus or cell, and which, therefore, we are warranted in considering as unorganised. I have mvself repeatedly examined this tubercular matter, and been una- ble to detect any difference between it and the mass in which the vege- tations of favus appear to grow. Chemical analysis of this form of tuber- cle demonstrates it to be composed principally of albumen, with a minute proportion of earth v salts; sometimes there is combined with it a small quantity of fibrin or gelatine. If this general result be compared with the analysis, by Thenard, of favus matter, the identity between it and tubercle must appear highly probable, lie found in 100 parts — coagu- lated albumen, 70; gelatine, 17 ; phosphate of lime, 5 ; water and loss, 8 parts. Thus the "evidence furnished by morphology and chemistry agrees in determining the molecular matter found in the crusts of favus and in tubercle to be analogous. * Treatise on the Oleum Jecoris Aselli, p. 9-4. 810 DISEASES OF THE INTEGUMENTAEY SYSTEM. Remak found that, althongli the sporules underwent developmental changes on the cut surface of an apple, as well as in animal tluids to which sugar had been added, no such changes took place in spring or distilled water, in the serum of blood, solution of albumen, pus, muscle, substance of brain, cut pieces of skin, or animal fat. In these cases the animal tissues, as well as the portions of favus crust, became gi'adually disintegrated, and infusorial formations commenced. Hence the Acho- rion grows under the same circumstances only as all other moulds. Putrefaction of animal or vegetable substances is unfavourable to its pro- duction ; but that peculiar acid change which occurs in milk or paste, exposed to the air for some days, and in which growths of mould and confervge are fjxvoured, is also beneficial to the development of favus. Hence why inoculation in healthy tissues fails, and why certain exuda- tions in peculiar states of the constitution, or disintegrated matters which have undergone particular chemical changes, probably from acid secre- tions of the skin, are necessary to the production of Uie disease. I believe, therefoi'c, that the pathology of favus is best understood by considL'ring it essentially to be a form of abnormal nutrition, with exu- dation of a matter analogous to, if not identical with, that of tubercle, which constitutes a soil for the germination of cryptogamic plants, the presence of which is pathognomonic of the disease. Hence is explained the frecpieiicy of its occurrence in scrofulous persons, and among cachec- tic or ill-fed children: the impossibility of inoculating the disease in healthy tissues, or the necessity for there being scaly, pustular, or vesi- cular eruptions on the integuments, previous to contagion. But as ex- periments have proved the possibility of inoculation in healthy persons, it follows that the material in which the vegetations grow, may at the co'.umencement, in a molecular exudation, be formed primarily or secondarily. That is, there may be want of vital power from the first, as occurs in scrofulous cases, or there may have been production of cell forms, such as those of pus or epidermis, which, when disintegrated and reduced to a like molecular and granular material secondarily, constitute the necessary ground from whicii the parasite derives its nourishment, and in whicli it grows. Treatment, Almost every species of treatment has been had recourse to, in order to remove this disagreeable and intractable disease ; and there can be no doubt, that cases have recovered under the use of all and each of the methods recommended. In some instances, favus wears itself out, or rather, as the development of the frame proceeds, and the constitutional strength improves, the conditions necessary for its production and main- tenance are removed, and it consequently disappeai's. In every case, however, it nrust be our object to get rid of the disease permanently as soon as possible, and this is only to be done by removing the patho- logical conditions on which it depends. The notion that it originates in the bulbs of the hair caused an attempt to remove the disease by eradicating the structures with which it was supposed to be connected. Hence the barbarous and cruel treat- DERMATOPIIYTA. 811 ment by means of the Calotte. This consisted in spreading a very ad- hesive plaster inside a cap, which closely fitted the shaven scalp. The hair was then allowed to grow and insinuate itself amongst the sub- stance of the plaster — wlien the whole was forcibly torn off. In this wav, portions of the scalp were sometimes separated — at others, pieces of the plaster remained firmly attached, and gave great trouble. A modification of this plan consisted in covering the head with the plaster in strips, which were removed separately from before backwards, and from behind forwards, so as to tear out the hairs. Even this plan failed. The practice I snw adopted in Berlin, in 1841, consisted in plucking out the hairs individually with a pair of pincers ; but this tedious and painful method, also, was found to be of little service. In Paris, the above kinds of practice have generally been pat aside for the milder empiric treatment of the freres Mahon. Between the years 1807 and 1813, 439 girls and 469 boys, aftected with favus, were cured by them at the Bureau Central des Ilopitaux, and the mean duration of the treatment was 56 applications. These applications are generally made every other day, so that the average length of treatment by this much boas'ted and successful method is three months and a-half. I have endeavoured to show, however, that in many cases it is a con- stitutional disease, and dependent upon the causes which induce scrofu- lous diseases in general. The treatment, therefore, in such ought to be constitutional, and directed to removing the tendency to tubercular exu- dation, on which the malady depends, Xo doubt, liowever, a local treatment in this, as in all other disorders which are at the same time general and local, is of the utmost service. I consider, then, that the chief indications of treatment are — 1st, To remove the constitutional derangement ; and, 2dly, To employ such topical applications as tend to prevent the development of vegetable life. This line of practice may be thought similar to that recommended long ago by Lorry, who advises, 1st, A modification of the fluids and solids of the economy by a general treatment ; 2<,lly, A vigorous attack upon the local disease by topical applications, capable of removing the crusts, causing the skin to suppurate deeply and substituting a solid cicatrix for the morbid ulceration of the hairy scalp. For the most part, however, the general treatment of physicians has been confined to diluent drinks, blood-letting, purging, and remedies which depress the vital powers, whereas it must "be "evident, that ifthe views of its pathology I have brought forward be correct, and it is in its nature allied to tubercular aft'ections, a treatment exactly opposite ought to be pursued. The de- velopment of vegetable life may also be prevented by the application of much milder remedies than the escharotics, or irritating ointments usually employed. We have previously seen that tuberculosis is caused and kept up by some fault in the digestive process ; that the blood is secondarily aftected, and its albuminous constituents proportionally increased ; that the albumen at length becomes eftased into the different structures of the economy, causing the various forms of tubercular disease ; and lastly, as the albumen in the blood becomes excessive, and its eft'usion into the textures increases, the fatty constituents of the frame diminish. It has been shown, by numerous facts, that under such circumstances the inter- 812 DISEASES OF THE "I^'TEGUME^'TARY SYSTEM. nal and external exliibition of cod-liver oil has been attended witli the most marked advantage, and often been made tbe means of cure when all other remedies have failed. Tlie action of the oil appears to be the same in favus as in other forms of scrofulous disease, and its use should be combined with appropriate diet and exercise, and with reference to the same indications and contra-indications. The local treatment I have employed for several years, is directed, in conformity with the patholoo-ical views previously detailed, to the exclu- sion of atmospheric air, so as to prevent vegetable growth. For this purpose, I direct, in the first instance, that the affected scalp should be poulticed for several days, until the favus crusts are thoroughly softened, and fall off. Then the head is to be carefully shaved, after which it will be found to present a shining clear surface. Lastly, cod-liver oil should be applied with a soft brush, or dossil of lint, over the affected surface morning and night, and the head covered with an oil-silk cap to prevent evaporation, and further exclude the atmospheric air. Everv now and then, as the oil accumulates and becomes inspissated, it should be removed by gently washing it with soft soap and water. It is very pos- sible common lard, or any other oil, would do as well as cod-liver oil. In one case I found a sulphurous acid lotion succeed. I have found the average duration of this treatment to be six weeks, which contrasts very favourably with the results of MM. Mahon's prac- tice at the Hopital St. Louis. Some cases seem to be incurable, and these are most frequent among adults ; but even in them, so lonsj as the scalp is kept moist with oil, and the air is excluded, the eruption will not return (Case CLXXVIL). In young subjects, in whom general as well as local treatment is admissible, and in whom a scrofulous disposi- tion is manifest, the prognosis is more favourable, and the disease mav be permanently eradicated (Cases CLXXVIII. to CLXXX.). AVhenever favus is recent and of limited extcTit, it may at once be destroyed bv cauterization with nitrate of silver (Case CLXXXL). Lebert is of opinion that poultices and oily applications soften the favi, and distribute the sporules over the skin. He, therefore, insists on removing the crusts drv, by means of a small spatula, sewing needles, or other instruments. He savs that nothing is more easy than to detach them entire; for, although pushed into the skin, they are not held there by any adhesion. But I think it will be found that, however dexterous a pei-son may be in removing the crusts, that the majoritv are held firmly to the scalp, by means of the hair which perforates them, and that tearing these out is very painful. Besides, the crusts are easily broken, and the time and trouble required, even when they are thinly scattered, renders this plan impracticable in hospitals. When densely matted together, it, of course, cannot be done. I believe, then, that repeated poulticing is l:)y far the best and most efficient method of freeing the skin from the eruption, whilst it has the extra advantage of doing so without irritation, and thereby diminishing the tendency to the formation of im- petiginous pustules. SECTION X. DISEASES OF THE BLOOD. The diseases of the blood have strongl}- engaged the attention of modern pathologists, who, putting aside the vague speculations which the ancients heki regarding this important fluid, have sought to inves- tigate the subject by the aid of facts derived from chemical, micro- scopical, and clinicai researches. The general results of these have been sketched, pp. 102 to 105. The alterations of the blood give rise to many of the most important disorders which aifect the body, besides being necessarily associated more or less with every morbid change connected with "alterations of nutrition. It is the principal idiopathic or essential forms of blood disease which will be treated of in this place. LEUCOCYTHEMIA. On the 19th of March, IS-to. I examined the body of a man, who died under the care of Professor Christison, in the Royal Infirmary, labouring under hypertrophy of the spleen and liver, and whose blood was crowded with corpuscles which exactly resembled those of pus. This case was the first of the kind in which a careful histological examination of the blood was made, and in which the remarkable morbid condition then discovered, was separated from ordinary pyaemia, and shown to be unconnected with any form of inflammation. It was published in the Ediuburijh Med. and Surg, Journal, October Ist, 1845, vol. Ixiv., p. 413. Dr. Craii-ie, who was present at the dissection, recognised its similarity to one he had had under his care four yeai-s previously, the blood of which had been examined microscopically by Dr. John Reid, who found '• tliat it contained globules of purulent matter and lymph." An account of it appeared in the same number of the Edinburgh Journal for October 1845. Six weeks after these cases had been published. Professor Vir- chow of Berlin gave the history of another, in the second number for 814 DISEASES OF THE BLOOD. November 1845, of Froriep's "Xotizen" (Xo. TSO), under the name of " Leukhemia," or white blood. On the 31st of December 1845, a man was received into St. George's Hospital, London, in whom Dr. Fuller detected, both before and after death, the increased number of colourless corpuscles in the blood. This man, like the other individuals, had great hypertrophy of the spleen. A notice of the case is inserted in the " Lancet,'' for July 1840. Since then several similar cases have been met with, in which this morbid condition of the blood has been deter- mined to exist, by an accurate exaniinatiou with the microscope ; and a reference to the I'ccords of medicine has shown the previous occurrence of like cases. Li these last, the blood, with two exceptions, was not ])hysically proved to contain an unusual number of colourless corpuscles, althongh now on looking back upon the facts which are mentioned in regard to them, we can have little doubt that such was the case. The exceptional cases occurred to M. Barth in 1839, and Dr. Cragie in 1841. In the first, M. Donne found one-half the corpuscles in the blood to be " mucous globules," and in the second. Dr. John Keid found that the blood "contained globules of purulent matter and lymph.'"'' The term "Leukhemia," or white blood, given to this disease by Yirchow, is faulty, because, in the first place, as was correctly stated by Dr. Parkes, the blood is not white, but presents its usual red tinge when drawn from the aim. The colourless clots occasionally observed after death will certainly not warrant the application of this term to the blood generally, as they are frequently present without the moibid condition under consideration. Besides the same name (white blood) has b(!en given with more propriety to the fatty blood, examined bv Drs. Traill, Christison, and others, which presents a milkv, opalescent appearance. x\t the meeting of the Academy of Medicine in Paris, on January 29th, 1856, the members were naturally enough led into great confusion in consequence of not keeping this distinction in view. What ought to be expressed is, that the blood abounds in colourless corpuscles, and this is done by the term Leucocythemia — from Xsvxoc:, white ; xurog-, cell ; and aljxrx, blood — literally, white cell blood, which expresses the simple fact, or pathological state, and involves no theory. Thixmghout England and France this name has been universally adopted. Case CLXXXIIT.f — Leucocythemia discovered after death — Ilypertroj^hy of the Spleen, Liver, and Lymphatic Glands — Abseiice of PI ilebitis and of Purulent Collections in any p)art of tlie Body. History. — John Monteitli, aged 28, a slater— admitted into the clinical ward of * Gazette Hebdomadaire, March 21, 1856, and Edin. Med. and Surg. Journal, October, 1845. f Thi.s case occurred in the clinical ward of Professor Christison, who treated it. The body after death was most carefully inspected by me as pathologist to the Royal Infirmary, and parts were removed for careful subsequent examination, and for pre- servation, the appearances being altogether of a kind quite new to me. Tiie case, for reasons which will appear in the sequel, is here given verbatim, as it was origi- nall}' published in the Edinburgh Journal for 1st October 1845. LEUCOCYTHEMIA. 815 the Royal Infirmary, February 27, 18-45, under the care of Dr Cbristison. He is of dark couiplexion, usually healthy and temperate ; states that twenty months ago he was aftected with great listlessness on exertion, which has continued to this time. In June last he noticed a tumour in the left side of the abdomen, which gradually increased in size till four months since, when it became stationary. It was never painful till last week, after the application of three blisters to it ; since then, several other small tumours have appeared in his neck, axillse, and groins, at first attended with a sharp pain, which has now, however, disappeared from all of them. Before he noticed the tumour, he had frequently vomiting in the morning. The bowels are usually constipated, appetite good, is not subject to indigestion, has had no vomiting since he noticed the tumour ; he has used chiefly purgative medicines, especially croton oil; employed friction with a liniment, and had the tumour blistered. Stmptom,s ox Admission'. — On admission, tliere is a large tumour, extending from the ribs to the groiu, and from the spinal column to the umbilicus, lying on the left side. It is painful on pressure near its upper part only. Percussion is dull over the tumour ; pulse 90 ; states that for three months past he has not lost in strength. There is slight oedema of the legs. To have two pills of iodide of iron morning and evening. Progress of the Case. — March \st. — Urine of ye.sterday somewhat turbid when just passed, natural in colour, acid to litmus; sp. gr. 1013. Sediment presents cubic crystals under the microscope, disappears almost entirely on the addition of aqua potass«, but is unaSected by nitric acid. The filtered urine is not affected by aqua potassa;, and yields only a slight white haze when boiled. 2Iarch Wi. — (Edema of legs increased They have been bandaged with flannel rollers. IJ. Pota-ssce Carbo- natis, 3 i ; Spiritus .£therix Kitrici, 3 iv ; Aquce Mentha, 5 "j ; Aquce foniis, % ij- M. Sumat unciam ier in die. March lOih. — Tormina and considerable diarrhoea ; urine not increased. Habeat hausium ex Olei Ricini | ss statim ; et exaciis quaiuor horis Opii, gr. ii. March 13^^.— Attacked this morning with lieat of skiu ; thu-st ; pulse, 110, full, very compressible. The diarrhoea, which had been checked, returned yesterday: none this morning after taking an opium pill. Urine 100 ounces. Omit- ianlur medicamenta. Sumat statim Pulveris JpecaciuinltoR et Opii, gr. x, et repetatur dosis singulis seinihoris ad tertiam vicem. March l-ith. — Xo sweating from the pow- ders; diarrhoea still rather troublesome ; pulse 100, softer; tongue dry and brown; febrile expression of countenance, resembling tliat of typhus. IJ Aq^MX Acetatis Ammonice 3vi; Solutionis Morphia, 3i; Aquce fontis, §iij; Syrupi, 3J. Sumat xinciam quartd qudque hord. Habeat decoctum hordei pro potu. March Ibth. — Died suddenly in the morning. Sectio Cadaverh. — March 19 [four days after death). Externally, the body presented a considerable prominence of the ensiform cartilage and false ribs on both sides. The abdomen was contracted ; considerable dulness on percussion on left side, which had previously been marked out by a line formed with nitrate of silver. Xo ascites nor oedema of the limbs. Blood. — Tlie blood throughout the body was much changed. In the right cavi- ties of the heart, pulmonary artery, venae cavae, vena azygos, external and internal iliac veins, and many of the smaller veins leading into them, it was firmly coagu- lated, and formed a mould of their size and form internally. In the cavities of the heart and venje cavte, the blood, when removed, was seen to have separated into a red or inferior, and a yellow or superior, portion. Tlie red portion was of a brick- red colour ; it did not present the dark purple smooth and glossy appearance of a 816 DISEASES OF THE BLOOD. healthy coaguhim, but was dull and somewhat granular on section, and when squeezed readily broke down into a grunious pulp. The yellow portion was of a light yellow colour, opaque and dull, in no way resembling the gelatinous ap- pearance of a healthy decolorised clof. When squeezed out of the veins, as was sometimes accident- ally done where they were divided, it resembled tliick creamy pus. In some portions of the veins, the clot was wholly formed of red coagu- lum. In others it was divided Fig. 471. into red and yellow. In a few places the yellow formed only a streak or super- ficial layer upon the red, or covered the latter with spots of various sizes. "Whether this coagulum ex- isted in all the veins, could only have been ascer- tained by a complete dissection of the body. It was seen, however, that the femoral veins, after passing under Poupart's ligament, were empty and perfectly healthy, as far down as the Sartorius muscle. The external and internal iliac veins, as well as the pelvic veins, were full and distended. The azygos, both axillary and jugular veins, were Fig. 472. full, also the longitudinal, the lateral, and other sinuses at the base of the cranium, and veins ramifying on the surface of the brain. In this last situation some of the veins appeared as if full of pus, whilst others were gorged with a dark coagulum — (See Fig. 473). In the aorta and external arteries were a few small clots, resem- bling those found in the veins. These vessels, however, were comparatively empty. The basilar artery at the base of the brain was distended with a yellow clot. Vessels. — The arteries and veins themselves were perfectly healthy. Although carefully looked for, in no place could thickening or increased vascularity be observed. Nowhere was the clot adherent to the vessels, but, on the contrary, it readOy slipt out when an accidental puncture was made in them. Head. — On removing the dura mater, the veins which empty themselves into the longitudinal sinus were considerably engorged, especially posteriorly. Some were filled with the red, and others -with the yellow clot previously described. Others, again, were half filled with red and half with yellow coagulum, the passage of the one into the other being clearly perceived. Both hemispheres, with the longitu- dinal sinus and faho in situ, were removed by a section across the brain, as low down as tlie division of the cranium would permit. The brain was then discovered to be very soft uniibrmly, — a circumstance accounted for by the time which had elapsed since death. The part removed was put aside, in order to be preserved and hardened in spirit. The lateral ventricles were found healtliy, contained no serum, and the choroid plexus was perfectly normal. At the base of the brain the Fig. 471. Portion of clot from the vena cava, showing the divisions into red and white coagula. Half the real size. Fig. 472. Posterior surface of the aorta and vena cava. An incision has been made in the latter, to show that it is not thickened or diseased, as well as to expose colour- less coagula even in the most depending portions of the clot. Half (he 'real size. LEUCOCYTHEMIA. 817 basilar artery was seen distended with the yellow coagulum, as were also a few of the arteries, but to a very slight extent. The substance of the brain itself was throughout iiealthy. All the sinuses at the base of the cranium gorged with the red coagulum. Fig. 4T3. Chest. — A few chronic adhesions united the pleurae on both sides, which were easily torn through. Both lungs were slightly engorged posteriorly and inferiorly. The anterior margin of the left lung emphysematous, but to no great extent. On section, tlie yellow coagulum of the blood was observed to occupy all the ramifica- tions of the pulmonary artery. In some places it was so consistent as to be drawn out, exhibiting an arborescent form ; in others, it was more soft, and exuded from the cut surface like thick pus. Heart somewhat enlarged; weighed, when freed from coagulum, eleven and a half ounces. Its texture was healthy; the valves normal. The right auricle much distended, and gorged with a firm coagulum, the upper third of which was found composed of the yellow, and the two inferior thirds of the red clot formerly described. The right ventricle and pulmonary artery were similarly distended ; portions of the clot closely embraced the columnai carneae, but were in no place adherent. The coronary arteries and veins were normal. Abdomen. — On the inferior surface of the diaphragm there existed a firm, almost cartilaginous, deposit, about a line in thickness, of a white colour, oval form, two inches long by one and a half broad, with irregular margins, which were composed of several rounded tubercular bodies, the size of a small pea, and of a fibrous struc- ture. The liver enormously enlarged from simple hypertrophy. Its structure throughout healthy. Gall-bladder enlarged, and distended with a clear pale yellow Fig. 473. Appearance of the upper surface of the hemispheres after removing the dura mater, showing the remarkably white appearance of the coagula in the veins and longitudinal sinus. Ilalf the real size. 52 818 DISEASES OF THE BLOOD. bile. The whole weighed ten pounds twelve ounces. The spleen also enormously enlarged from simple hypertrophy. It was of a spindle shape, largest in the centre, tapering towards the extremities. It weighed seven pounds twelve ounces. It measured in length fourteen inches; in breadth, at its widest part, seven inches; and in thickness, four and a half inches. Towards its anterior surface was a yellow firm exudation, about an inch deep, and three inches long. The peritoneum, also covering a portion of its anterior surface, was thickened, opaque, and dense over a space about the size of the hand. Both kidneys healthy. The stomach and intes- tines healthy throughout. About four inches from the anus the superior hemor- rhoidal veins were distended on both sides external to the rectum. They formed two chains of tumours about three inches long, consisting, on the one side, of three swellings as large as a walnut ; on the other, of one swelling somewhat larger. They were filled with a red coagulum, broken down into a grumous mass. The lymphatic glands were everywhere much enlarged. In the groin they formed a large cluster, some being nearly the size of a small hen's-egg, and several being that of a walnut. The axillary glands were similarly affected. The bronchial glands were not only enlarged, but of a dark purple colour, and in some places black from pigmentary deposit. The mesenteric glands were of a whitish colour, some as large as an almond nut. A cluster of these surrounded and pressed upon the ductus communis choledochus. The lumbar glands were of a greenish-yellow colour, also enlarged; forming a chain on each side, and in front of the abdominal aorta, more especially at its bifurcation into the iliacs. No collection of pus could be found in any of the tissues. Fig. 474. Fig. 476. Tiff. 477. Fig. 47S. Microscopic Examination. — The yellow coagulum of the blood was composed of coagulated fibrin in filaments, intermixed with numerous colourless corpuscles, Fig. 474. Colourless corpuscles, mingled with a few coloured ones, from the white clot of the blood in Case CLXXXIII. Fig 475. The same bodies, mingled with a larger number of yellow blood cor- puscles in the red clot. Fig. 476. Change produced on the colourless corpuscles on the addition of acetic acid, the yellow corpuscles being dissolved. Fig. 477. Cells in the fluid squeezed from the lymphatic glands, after the addition of acetic acid. Fig. 478. Bloodvessels giving off a capillary from the pia mater; the latter is seen filled with colourless corpuscles; the former partly with colourless, mingled with coloured corpuscles. 250 diam. LEUCOCYTHEMIA. 819 which could be readily squeezed out from it when pressed between glasses. Where the yellow coagulum was unusually soft, the corpuscles were more numerous, and the librin was broken down into a diffluent mass, partly molecular and granular, partly composed of the debris of the filaments broken into pieces of various lengths. The corpuscles varied in size from the 80th to the 120th of a mill, in diameter; thev were round, their cell-wall granular, and presented all the appearance of pus corpuscles. (Fig. 474 ) Water caused them to swell and lose their grarmlar appear- ance, and acetic acid dissolved the cell-wall and caused a distinct nucleus to appear. Tliis nucleus was compo.sed sometimes of one large granule about the 200th of a millimetre in diameter, at others of two or three smaller granules, as is seen in cor- puscles of laudable purulent matter. (Fig. 476.) The red portion of the coagulum contained a smaller number of these colourless corpuscles, mixed with a multitude of normal yellow corpuscles. (Fig. 475.) The colourless corpuscles now described were found in the blood throughout the system. They were seen in the veins and arteries ramifying on the brain, in the coronary veins, hemorrhoidal tumours, and wherever the blood was examined. On stripping off a portion of the pia mater, and examining the capillary vessels of that membrane, all that were not too minute to contain them were found crowded with the same corpuscles. (Fig. 478.) This fact was confirmed by Dr. Allen Thomson, to whom I sent a portion of the brain for that purpose. The cartilaginous deposit on the inferior surface of the diaphragm was composed of dense fibrous tissue, in which numerous granules and molecules were observed. The exudation in the spleen was composed of amorphous fibrin mixed with nume- rous molecules, granular and imperfect cells. These Avere intermingled with bundles of filamentous tissue. The enlarged lumbar glands, on being pressed, exuded a fluid that was crowded with corpuscles: some resembhng the colourless corpu.scles already alluded to; others oval and round, containing a distinct nucleus. (Fig. 477.) The ultimate textures of the muscles, brain, nerves, etc., were carefully examined, and found normal. Commentary. — I have reprinted this case verbatim fi-oni the original paper published by me in the Edinburgh Medical and Surgical Journal for October 1st, 1845, in order to show that it contains a careful and minute description of the facts which I discovered on examining the body, March 19th. Figs, 471 to 473 are copied from some of the preparations still in my possession, taken from the body. A cast of the spleen is in the University Museum. Numerous drawings were also made from microscopic demonstrations ; some of which are represented Figs. 474 to 478. In the remarks originally appended I observed : — " The points con- nected with this case that require discussion are, 1st, The connection between the symptoms and morbid appearances; 2d, Were the cor- puscles contained in the blood really those of pus? and 3d, If so, how were they produced ? The discussion of these theoretical points, it appears to me, has nothing whatever to do with the correctness or incorrectness of the facts above detailed, which, it will be observed, are studiously separated from everything of a hypothetical character. But in connection with the first point I observed, " It is important to remember that there was no phlebitis, abscess, or purulent collection to which the appearances within the vessels could be ascribed. In all cases of phlebitis there are changes in the vessels themselves, and the clot is more or less adherent to the vascular walls. Nothing of the 820 DISEASES OF THE BLOOD. kind could be detected, although particular attention was paid to this point. How far the hypertrophy of the liver and spleen may be connected with the coao-ulation of the blood, and the formation of pus, it is difficult to say. Whether the hypertrophy of these organs exer- cises a peculiar influence on the blood, or whether the change in that fluid be caused in connection with chronic diseases in general, as has been lately pointed out by M. Bouchut, further observations alone can determine." Concerning the second point, I said, " The only bodies with which they can be confounded are the colourless corpuscles of the blood itself, the corpuscles described by Gulliver as existing in softened fibrin and those found in lymph. With regard to the colourless corpuscles of the blood, we know of no instance where they existed in the amount or even presented the appearance described." I then, after considering the structure of softened fibrin, came to the conclusion tljat the physical characters of the corpuscles found in the case of Menteith, would leave little doubt that they were identical with those of pus. In reference to the third question, I pointed out that the corpuscles must originate in the blood system itself, in the same manner as they had been shown by M. Bouchut to occur in various forms of cachexia and chronic diseases. I distinctly separated it from what was then understood by pysemia, or purulent absorption, saying, " Pus has long been considered as one, if not the most characteristic proof of preceding acute inflammation. But in the case before us, what part was recently inflamed ? There was none. Piorry and others have spoken of an inflammation of the blood, a true hematitis ; and certainly if we can ima- gine such a lesion, the present nmst be an instance of it. But it would require no laboured argument to show, that such a view is entirely opposed to all we know" of the phenomena of inflammation. Without entering into this discussion, however, I shall assume it to have been satisfactorih^ demonstrated that we can form no idea of this process without the occurrence of exudation from the blood-vessels, and that, consequently, the expression, inflammation of the blood, is an error in terms. A "moment's reflection will make it evident that all our ideas of, and facts connected with, inflammation are associated with some local chano-e in the economy. The constitutional disturbances connected with it are invariably ascribed to phlegmasia or fever, which pathologists hitherto have always separated from inflammation. Unless, therefore, it could be shown that inflammation and fever were like processes, we must conclude that the alteration of the blood in this case was inde- pendent of inflammation properly so called." These observations appended to the facts of the case must at least be allowed to be sufficiently suggestive, so that when, six weeks afterwards. Professor Yirchow published a similar case, and said they tcere the colourless corpuscles of the blood, he merely adopted another opinion reo-arding them from what I had done. But, I submit, this does not entitle bun to claim for himself the discovery of this morbid condition,* or to represent, notwithstanding my distinct separation of the lesion from all known pre-existing conditions of the blood, that in my opinion it was an ordinary case of pyaemia. He was fortunate enough, however, * See note on the discovery of Leucocythemia at the end of this article. LEUCOCYTHEMIA. 821 to meet witli two other cases, before I was enabled to resume the inquiry by meeting with the following one : — Case CLXXXlY.*—Leucocijthemia detected during Life— Hypertrophy of the Spleen — Ascites. History.— Barney Tiulay, a;t 17, farm-servant — admitted into the clinical ward of the Royal Infirmary, January 25, 1850. "With the exception of an attack of scarlet fever, which he experienced about three years ago, he enjoyed perfect health until twelve months since, when he first noticed a tumour in the abdomen, accompanied by some pain. The tumour since this period has gradually increased in size, and latterly lie has been unable to walk fast on account of dyspnoea. For the last two or three years he has been employed in farm service, and during three months last summer he resided in the fenny district of Lincolnshire, but never had intermittent fever. Symptoms ox Adjiissiox. — Ou admission, his complexion is pale, the conjunc- tivEe are unusually blanclied, and his whole appearance is very cachectic. On examin- ing the abdomen, a hard tumour can be felt occupying the whole left side. Supe- riorly, it can be felt emerging from the folse ribs about two inches to the left of the ensiform cartilage. It then passes downwards an inch and a half to the right of the umbilicus, and curves round inferiorly to a point about an inch and a half above the symphysis pubis, from which it may be traced directly backwards to within three inches of the spinous processes of the lumbar vertebrse. Its anterior margin presents a semicircular convexity, which is smooth, with a distinct notch in its upper third, and is apparently about half an inch tliick, as with the fingers a fold of integument may be pressed somewhat below it. The tumour is completely dull on percussion throughout, and is in several parts painful ou pressure. It measures about ten inches in the long diameter, and thirteen and a half transversely. The rest of the abdomen has the usual tympanitic percussion, and there is no fluctuation. Liver, on percus- sion, found to be of tlie natural size. Tongue clean ; appetite good. There is profuse diarrhoea, the bowels being open eight or ten times a day ; this symptom has existed for the last three or four weeks. Pulse 80, weak. Complains of giddiness on assuming the erect posture. Heart sounds natural. He has occasional epistaxis and hemorrhage from tlie gums. Eespiratory and urinary systems healthy. Tlie appearance of the blood drawn from the extremity of the fingei, when magnified 250 diametti^ linear, is represented Fig. 47'> Tlie coloured corpuscles for the most part have collected togetlier in rolls, the numerous colour Ics corpuscles filling up the inter- vening space. Acetic acid dis- solved the coloured bodies, and rendered the cell wall of the colourless ones very transparent Fi?. 4T9. Fig. 450. brino-ino- into view the nucleus, consisting of a single round or oval body in some, but in the majority presenting two, three, or even four granules, each having a * Reported by Mr. Hugh M. Balfour, Clinical Clerk. Fig. 479. Appearance of a drop of blood in this case. Fig. 480. The same after the addition of acetic acid. 250 diani. 822 DISEASES OF THE BLOOD. depression in their centre. Here and there the nucleus was crescentic, or iu the form of a horse-shoe. (Fig. 480.) Progress of the Case. — January 21th.— Rq lias had eight leeches applied to the epigastrium, and has taken the lead and opium pills — one three times a day. The diarrhoea is much diminished, and there is less pain. IJ Ferri Citraiis, 3i; Tind. Card. Comp. 5 i ; Infus. Calmnhce, § vii. M. Fiat mistura ; sumat 5 i ter in die. 5 Sulph. Quinte, gr. iij ; Pulv. Catechu extr. gr. iv ; 01. Carui m. i M. Fiani pil. ij. Mittantur tales xij, et Sig. sumat ij, mane et vespere. Jan. ?iOth. — Diar- rhoea now entirely ceased. ^. Pulv. Qninm Sulph. gr. iij ; Ferri Carb. Sacch. gr. vij. M. I^ant pil. iy, Mittantur tales, \i; sumat unam, ter in die. Intermiitantur alia. Yesterday three ounces of blood were taken from the arm, which Dr. W. Robertson was so good as to analyse. The results are as follows : Sp. Grav. ofthe Blood 1041-5 Sp. Grav. ofthe Serum 10265 Composition of 1000 parts — Fibrin 6 Serous Solids *?2 Globules 67 5 Total Solids 145-5 Water 854-5 The analysis was conducted on nearly the same plan as that recommended by Dr. Christison, and subsequently adopted by Andral and Gavarret: but it is believed that the fibrin is more exactly estimated than by the process of the latter authori- ties. The sp. grav. of the blood and serum was very accurately taken, and the errors of manipulation cannot exceed 5 per 1000 in each constituent. The blood allowed to remain iu a vessel for twenty-four hours presented a large and firm clot. Examined microscopically, it exhibited the same appearance as in Fig. 479, the rolls of coloured bodies not being so large. On adding acetic acid, the same kind of nuclei were observed ; but they were now tinted of a deep yellow colour, having apparently imbibed colouring matter dissolved in the serum. Some of the crescentic nuclei had become nearly straight. (Fig. 481.) February 2d. — Urine is observed to be loaded with lithates, and diarrhoea has returned. Sumat pil plumbi opiat. unam ter in die, et Syrupi lodidi Ferri guttas quindecem ter in die ex aqud. lUlnatur Tind. lodinii parti dolenti. Intermittantur alia. March 2Uh. — During fZ^ the last few weeks the hemorrhage from the nose and ^??!5\ ^^ K j gums has continued to recur, and the ascites has not vy^ K§) r ^v^ abated. He was ordered an astringent lotion for his '^^' 1^"^^ ^^ gums. Since the 11th, Spongio-pihne, with Tr. of Digi- \iBj f^ 'kS/ I % j ff^ talis, has been applied to the abdomen, which apparently, G^ ■<^'''i^ sW^} in consequence, is less tense, while the pain has undoubt- }j p ^-^^ |; ^ \ edly diminished. April 8ih. — Diarrhoea again violent. [\ f % ; "^-^ Stools very fluid. He suffers also from cough, and there is harshness of the respirator}' murmurs, and prolouged ^'S- 481- expiration to be heard at the apices of both lungs. No dulness on percussion. Sumat pil. pilumhi opiat. unam ter in die. April I3th. — Pain in abdomen, and diarrhoea nearly gone. Sweats profusely at night. IJ Quince. Sulph. gr. xij; Acidi Sul2oh. dil. 3j ; Syrupi Aurant. 3 j; Aquae font. § v. M. Fig. 481. The same after the blood has stood for twenty-four hours. 250 diam. LEUCOCYTHEMIA. ' 823 Ft. mistura ; sumat % ss ter in die. Repeiantur pil. plumbi opiat. April 1M. — The diarrhoea has ceased for the last eight days, but to-day has returned with considera- ble pain. Inter miUatur mist. QiiincR Sulph. ; Applicetur emplastrum Opii 4x4 ahdomini ; Sumat pil. plumb, ojjiat. ij ter in die ; Utatur enem. amyli cum Sol. Morph. sta.tim, et supposiforio opii quotidie hord somai. May oth. — Has complained a good deal lately of nausea and vomiting, for which he has been ordered a draught every evening, with naphtlia. He has also taken the squill and digitalis pill three times a day, and the tumour has been fomented with infusion of digitalis. Girth of abdo- men at this period was thirty-seven inches. 5 Sp. JEth. Nitrici, |iss; Aqute PolassoE ; Sol Mur. Morph. aa, 3 ij. M Sig sumat 3 j ex aqua ter in die. May 7 which the blood was examined by ^'S- 484. Fig. 485. Drs. Holland and Neale, a similar condition was observed. Dr. Addison has also shown, in two of his cases of disease of the supra-renal capsules, that the blood was leucocytheniic. Other lesions which have been occasionally found in cases of leucocythemia are evidently accidental, and in no way connected with that morbid state of the blood which we are now considering. Relation existing betiveen the Colourless and Coloured Cor2mscles of the Blood. — Many physiologists have maintained that the coloured cor- puscles are formed from the colourless ones ; and among those who hold this opinion, some have supposed that the latter bodies are directly transformed into the former (Pagetf). Others, again, contend that, whilst sucli may be the case in fishes, reptiles, and birds, in mammals the coloured disc is merely the liberated nucleus of the colourless cell (Wharton JonesJ). From the observations I have made on the blood * Glasgow Journal. April 1 855. f Kirke's Physiology, pp. 68, 69. % Lend. PliU. Trans., 1846. Pig. 484. Colourless corpuscles increased in number, and of small size. Fig. 485. The same after the addition of acetic acid. i:50 diam. 830 DISEASES OF THE BLOOD. corpuscles in cases of leucocythemia, tlie latter appears to me to be the moi-e correct opinion. The mode ot" transformation of the nucleus of the colourless cell into the flattened, biconcave, coloured disc, has not yet been described ; but, from the appearances I have observed, it woukl seem to take place in the following manner : — The colourless cell may frequently be seen, on the addition of acetic acid, to have a single round nucleus. But more commonly the nucleus is divided into two, each half having a distinct depression, presenting a shadowed spot in its centre. Occasionally, before the division takes place, the nucleus becomes oval, and sometimes is elongateil, more or less bent, and even of a horse-shoe form. Not unfrequently the nucleus is divided into three or four granules, each having the central shadowed spot. All the appearances here figured have been frequently observed, and I have placed them in the presumed order of development. ,^^. .^1 \^l[^ FijT. 436. On one occasion the colourless bodies in the blood were of two distinct sizes. The smaller were evidently free nuclei, such as could be observed -within the larger. (See Figs. 492* and 493.) On examining these latter, after the addition of acetic" acid, all the appearances represented in the accompanying figure were observable, and these I have again placed in Fis. 4s:. the presumed order of development. On examining the lymphatic glands in this case, they were observed to contain the first body figured («) in great numbers, associated with a few of the second one [h). On several occasions the blood, when crowded with colourless cor- puscles, was removed from the arm by venesection ; and it was observed, that after standing twenty-four hours these variously-shaped nuclei had become of a straw colour, and exactly resembled the coloured discs in tint. It was immediately apparent that they had imbibed the colouring matter of the blood, leaving the cell which surrounded them perfectly transparent. (See Fig. 481, p. 822.) With a view of still further determining the transitional changes in the colourless cells, I performed the following experiment ; — A rabbit was killed three hours after having eaten a meal. The thorax was ra- pidly opened, and a ligature placed round the pulmonary artery, to pre- Fig. 486. Colourless blood-cells observed in leucocythemia, showing the different appearances of the nuclei, placed in the presumed order of iheir development. Fig. 487. Pre.sumed development of the nucleus in colourless blood-cells, iu another case of leucocj'themia. 500 diam. LEUCOCYTHEMIA. 831 vent the corpuscles coining from the tlioracic duct passing into the lungs. The abilomen was then pressed gently for a few moments, to favour the flow of chvle, and then a ligature placed round the large vessels, and the heart removed bv cutting above it. On examining the blood in the right ventricle, it presented an unusually large number of colourless cells, the nuclei of which, on the addition of acetic acid, exhibited all the tran- sition stages figured Fig. 486. On examining the blood in the left ven- tricle, thecolourless cells were found normal in amount. This experiment was repeated with the same results. I am therefore of opinion, with Valentin, Wharton Jones, and others, that the coloured blood corpuscles in mammals are free nuclei. But I do not consider, with the latter observer, that these nuclei in mammals should necessarilv proceed so far in development as to be surrounded with a cell-wall, — in other words, the coloured disc is not always a fur- ther phase in the evolution of the colourless cell. " On the contrary, I believe that the vast majority of the coloured blood discs simply reach the nuclear stage of growth before they join the circulation. Many of them, however, do proceed beyond this point in development, and may be seen to have cell-walls around them. Under such circumstances, the nuclei increase endogenously by a process of fissiparous division, in the manner formerlv described, circulate in the blood within colourless cells, and on the solution of the cell-wall, also become coloured blood discs. I have further examined the blood of birds, reptiles, and fishes, and have been enabled to observe transitional forms between the colourless and coloured cell, with even greater facility than 1 could in man. Indeed, the attention once directed to this point, scarcely a demonstration of blood can be made in these animals without seeing abundant evidence that the latter is a transformation from the former. In them, however, the colourless cell, at first round, enlarges gradually, becoming oval, and colour is addedto it. The nuclei, also, after the addition of acetic acid, may be observed in these animals to be undergoing fissiparous multiplication within the cells. Thus all the appearances, o ft I? ** Fig. 48'.), mav readily be seen. Hence the ^ ° same mode of endogenous development © © @ ^ q may take place in the blood-cells of all the /sv a i, b « vertebrated tribes of animals, the difi"erence ® © I g sSo being, that whilst in birds, reptiles, and Fig. 489. fishes, the corpuscles retain the form of nucleated cells, in mammals we find the majority of them to be free nuclei. FifT. 4SS. Haddock. Turker. Fros. Figr. 488. Cells of various sizes, colourless and coloured, observed in the blood of a haddock, fro^. and turkey, placed in the order of their supposed development. The three first bodies flsured in each line are colourless. Fig. 489. The nuclei of the blood-cells of the haddock, frog, and turkey, as seen after the addition of acetic acid. 450 diam. 832 DISEASES OF THE BLOOD. Origin of the Blood Corjyuscles. — Ilewson was the first "\v ho distinctly stated that the blood corpuscles were derived from the lymphatic glands, yet few have adopted his opinions. Even Crnickshank, who wrote on the lymphatic system immediately after him, and was one of his contem- poraries, says of the lymphatic fluid in which these corpuscles swim, "that we do not know the use of this fluid."* The correctness of Ilew- son's views is not even clearly admitted by his recent commentator, Mr. Gulliver,f and has been denied by most physiologists in this country; and although Nasse, Wagner, Miiller, and a few others, liave contetided that the lymph corpuscles in the blood are the same as those found in the lymphatic vessels, the mode of their origin and their functional importance is not even alluded to. On examining the chyle in the lacteals ramifying below the serous coat of the intestine, it is found to consist of a multitude of minute fatty molecules, floating in a fluid (see Fig. 438, p. 686). These diminish in number as the chyle progresses towards the thoracic duct, in which it is found to contain a number of free nuclei, mingled with a few others which are surrounded by a delicate cell-wall. The free nuclei may fre- quentlv be observed in mammals to present the same size and bi-concave discoid form of the coloured blood coi'puscles. (Fig. 438, a.) ^lore- over, on the addition of water, they in like manner become globular, and, after the fluid has been allowed to evaporate a little, assume a j)uckered or crenated appearance. They only dift'er in their want of colour, and in not being par- r^ '- ■-> tially soluble on the addition of acetic acid. (Figs. 438, a ; 490 , C ^iid 491.) On cutting into a T" '.^ ■ well-formed lymphatic gland, ■^ 1 ° . • and examining the juice which (^^ c ' c5 • niay be squeezed from it, it will ' ■ O be found to contain numerous „ ^ ^gg ^ ^ ..J free nuclei and nucleated cells. These are evidently the same bodies as are found in the lymph and chyle, and those found in the latter closely resemble the colourless cells of the blood. The nucleus of these corpuscles also may frequently be observed to have undergone the fissiparous division formerly described, and to exhibit vaiious stages of this process, in chyle taken from the thoracic duct. The opinion, therefore, held by many physiologists, that the colourless cells of the blood, and those of chyle or lymph, are the same, and conse- quently that in the highest class of animals they are not formed in the blood itself, but before they are mixed with that fluid, seems to be well founded. * The Anatomy of the Absorbing Vessels of the Human Body. London, 4to, 1786. P. 73. f Tlie Works of William Hewson, F.R.S., edited by George Gulliver, F.R.S.L. Printed for the Sydenham Society. Note, p. 281. Fig. 490. Fluid chyle, mingled with water, taken from the thoracic duct of a cat three hours after it had been led on milk. Fig. 491. The same after the addition of acetic acid. 250 diam. LEUCOCYTHEMIA. 833 According to Henle, the molecules of the chyle unite together in order to form the nuclei, which are afterwards surrounded by an envelope.* These, he thinks, are delayed, and become more fully developed in the lymphatic glands.f Nasseij; also states, that he has seen aggregations of the chyle molecules and granular bodies, formed before they reach the lymphatic glands. Ou the other hand, it is certain that both nuclei and cells are most abundant in the glands themselves, and the cases of leucocythemia prove, that excess of colourless cells in the blood is not dependent upon an increase in the amount of chyle molecules, but is coincident with the enlargement of the spleen and other glandular organs. It is to these, therefore, we must attribute the principal influence in the formation of the colourless cells, and to them evidently we must look for the origin of the blood- corpuscles. llewson considered the lymphatic glandular system to consist of the spleen, thymus, and lympiiatic glands. He believed that particles were produced in these organs Avhich ultimately became the blood- corpuscles, and that the spleen especially served to secrete the colour- ing matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudi- ated by all British physiologists up to this time. Mr. Simon § declares it to be impossible that the globules of the thymus can enter the lymphatic or blood-vessels, on account of the limitary membrane within which they are enclosed. But that they do find their way into those vessels was shewn by llewson and Sir Astley Cooper,| who found them there ; and that the colourless corpuscles of the spleen and lymphatic glands enter the blood in large numbers, is proved by what occurs in leucocythemia, and by the great preponderance of these bodies at all times in splenic and portal blood. But there are other glands which must be associated with those just mentioned as part of the lymphatic system, such as the thyroid body and supra-renal capsules. The pituitary and pineal glands have also been referred to the same class of organs by Oesterlen.^ Without entering into lengthy anatomical details of each, it may be said that all these organs resemble one another in the following particulars :— 1. They consist of a fibrous stroma, enclosing spaces lined by a structureless membrane, which spaces are filled with colourless mole- cules, nuclei, and cells, in all stages of development. 2. The corpuscles of all these glands resemble one another, — the nuclei corresponding in size to the coloured blood-discs of mammals, and the cells corresponding to the colourless corpuscles of the blood. The very slight ditferences which do exist are at once explained by vari- ations in the degree of development. 3. They have no excretory ducts, so that if the corpuscles formed in * Anatomie Generate, par Jourdain. Tom. i. p. 455. f Anatomie Generate, par Jourdain. Tom. ii. p. 103. X Wagner's Handworterbucli. Arts. Cliylu.s and Lymplie. § On the Tliymiis Gland. P. 91. II Anatomy of the Thymus Gland. Pp. 15 and 43. •|[ Beitrage zur Physiologie des gesunden und kranken Organisraus. Jena, 1843. 53 834 DISEASES OF THE BLOOD. § them are to leave the organs in ^vhich they originate, it can only be by the lymfiliatios or veins. Now, it is certain that the blood of the splenic and portal veins, even in health, is ahvays richer in coloniless corpuscles than that of the sys- temic circulation!* It is also well known that in young animals the blood contains a larger number of these bodies than it does in their adult condition, — that is, when all these glands, including the thymus, thyroid, and supra-renal capsules, are fully developed and in a state of activity. In leucocythcmia, we observe that when those glands are hyper- trophied and their corpuscular elements are multiplied, the colourless cor- puscles of the blood are increased in number. Two very carefully made observations, however, apjiear to me sufficient in themselves to determine the connection of these lymphatic glands with the cells of the blood. Thus in Case CLII., where the thyi'oid body was enlarged, its cells and their included nuclei were considerably smaller than usual, and it was ascertained that the colour- less bodies in the blood and their nuclei were smaller also. (Figs. 439 and 440, p. 697, f) andFig. 484, p. 829.) In one '■^ ' © -" ^^^^ it ^'^'^^ *^^^^" t''^t t^^^ . _ • o ® colourless corpuscles in the ('|g^ blood were of two distinct "^ q"" & sizes, the smaller correspond- ing with the nuclei of the Pj ^gg larger ones, and the lympha- tic glands were found to be crowded with corpuscles also of two distinct sizes, exactly corresponding to those in the blood. (Figs. 492 and 4V3.) From these facts, we can have little doubt that the colourless corpuscles are formed in the lym- phatic o-lands, and from thence find their way into the blood. Bv what channel they effect this, whether by the lymphatics, the veins, or by both, it is very difficult to determine. The limitary mem- brane which surrounds the saccular glands is exceedingly delicate ; indeed, so much so, that its existence has been denied by some obsei'vers. When distended, therefore, it may easily break, and the contents be poured into the pulp, surrounding stroma, or blood-vessels. Dr. Sandersf lias shown that the Malpighian sacs of the spleen are traversed by very large vessels, and Mr. Gray has attempted to demonstrate an intimate relation between the former and the splenic veins.J But it must be acknowledged, that notwithstanding the certainty which exists as to the connection between the closed lymphatic glands and tlie blood-vessels, and the passage of corpuscles from one to the other, the method by Fig. 492. * Tlii.s well-known fact has been confirmed by the careful ob-servations of Funke. —Eenlts Zeilschrift, 1851, p. 172. f Report of Physiological Society of Edinburgh for January 31st, 1852. Monthly Journal lor February 1852. X On the Spleen, pp. 233-4. 1854. Fig. 492. Numerous naked nuclei of the colourless corpuscles of the blood. Fig. 493. The same after the addition of acetic acid. 250 diam. LEUCOCYTHEMIA. 835 whicli this is accomplislied has not yet been satisfactorily shown. I cannot help thinking, however, that there mnst be a direct venous com- munication. Of late vears physiologists have been in the habit of calling these glands the blood glands, although nothing more definite has been deter- mined with reo-ard to them than that they are in some way subservient to nutrition, especially during an early period of life. But if I have been successful in establishing that the corpuscular elements found in these oro-ans are transformed into those of the blood, it will follow that the Ivmphatic glands secrete the blood corpuscles in the same manner as the testes secrete the spermatozoa, the mammee the globules of the milk, or the salivary and g;vstric glands the cells of the saliva and gastric juice. With regard to the exact mode in which the corpuscles are formed in the glands, two theories exist, both of which are dependent upon numerous facts and observations closely connected with the origin of all vital structures, and indeed of organization itself. One is, that they are thrown off, in the form of epithelium, from the membrane which sur- rounds them ; the other, that they originate in an organic fluid, by the production of molecules, the successive development and aggregation of which constitute the higher formations.* I have long been of opinion that the latter theory is the more consistent wnth known facts, and cer- tainly all that I have seen during repeated investigations into the struc- ture of the various lymphatic glands, is in harmony with it. Nowhere have 1 seen the nuclei and cells of these glands attached to, or appa- rently given off from, a membrane, still less from supposed fixed germs, but everywhere pervading a molecular fluid within the closed sacs. But, however produced, whether from molecules or fixed germs, it is here they are formed, and are subsequently thrown into the torrent of the circula- tion, — there, colour is added to them, and they become blood corpuscles. Multitudes of free nuclei in this way join the blood, and are at once converted into coloured blood discs.f The cells, which in health are comparatively few in number, circulate for a time as colourless corpuscles, but after a certain period their walls dissolve, when their included nuclei also become coloured discs. In leucocythemia the colourless cells are increased, whilst the free nuclei are diminished in number. The conse- quence is, that the former are developed at the expense of the latter, and as they do not become coloured on reaching the lungs, the forma- tion of red blood is more or less checked. In the three inferior verte- brate tribes, the entire cell becomes oval, and assumes colour. All that is known of the development of the blood corpuscles, on the one hand, and of the blood glands on the other, supports the theory now brought forward. The primitive production of blood in the embryo * Report of Physiological Society of Edinburgh for January 3 1st, 1852. Monthly Journal for April 1852. f In making this statement. I am aware of the possibility of these nuclei being surrounded by a cell-wall so fine as not to be detected by the best iustrumenls. But having confirmed the observations made originally with Oberhccuser's microscope, by means of an excellent lens by Ross, of one-eighth of an inch focus, with the most careful attention to the management of the light, it is my conviction that the great majority of these bodies possess no cell- walls. 836 DISEASES OF THE BLOOD. occiu's in the interior of cells in the vascular layer of the germinal mem- brane, which cells are afterwards transformed into vessels. At tliis period the colourless cells are very abundant, and their nuclei may be seen to undei'go the fissiparous mode of multiplication formerly described ; the cells themselves also in this foetal condition, multiply by division.* In the invertebrate tribes, there are no lymphatic vessels or glands. In fact there is only one circulation, which has been shown by Milne Edwards to consist of a series of tubes, analogous to arteries or veins, which communicate by means of lacunaj that surround viscera. But the circulating fluid contains two distinct kinds of corpuscles, which Mr. Wharton Jones has shown to be different phases of each other, and to correspond with the colourless and coloured corpuscles of fishes, rep- tiles, and birds. In fishes a lymphatic system exists separately, and in them we first observe a pituitary body, supra-renal capsules, and a spleen. In reptiles there are added the thymus and thyroid glands, and in -both these classes of animals the communications between the blood-vessels and lymphatics arc numerous and direct. In birds we first observe, in addition, glands on the lymphatics of the neck, but not on the lacteals, and there are two thoracic duets. In the mammalia, the liighest develop- ment of the lymphatic glandular system exists, including mesenteric and lymphatic glands, a spleen, thymus, thyroid, pineal and pituitary bodies, and supra-renal capsules. Thus we observe a correspondence between the amount of corpuscular elements in the blood, and the extent and complexity of the lymphatic glandular system. The cor- puscles are comparatively few and colourless in most of the invertebrata, and in such animals, as stated by Wagner, should be considered analogous to those of lymph. They become more numerous and coloured, with the appearance of a spleen and supra-renal capsules, in fishes. Both in fishes and reptiles, however, the colourless cells are numerous. In birds the coloured cells are smaller, but still nucleated ; and in mammals the coloured bodies are free nuclei, and are even much more abundant. Again, it has been supposed that the coloured cannot be foi'med from the colourless bodies of the chyle, — 1st, Because the former can be seen of all sizes in the blood itself; 2d, Because, on examining the blood of foetal animals, no intermediate stages of growth can be seen between them; and 3d, Because, on the addition of acetic acid, while the coloured bodies are nearly dissolved, the naked nuclei of the chyle are not, and hence, it is said, they are of different chemical composition. With regard to the first argument, derived from variations in the size of the colom-ed particles, it may be said that, granting the fact, nuclei may also be observed both free and within cells, of all sizes, so that they cor- respond perfectly with the coloured corpuscles of the blood. Besides, in different cases of leucocythemia, although the colourless cells have been seen to be smaller, of the same size, somewhat larger, and even twice as large as the coloured bodies, their nuclei may always be observed to correspond exactly with the different phases of the latter. With regard to the second argument, advanced by those who have not suc- ceeded in detecting transition forms in embryonal blood, I am persuaded that this arises from the circumstance, that attention is directed to the * These changes are well figured by Fahmer. — De Globulorum Sanguinis, &c. Turici, 1845. LEUCOCYTHEMIA. 837 colourless cells, instead of to their nuclei. For ray own part, I have never failed to observe all the changes previously described, not only in foetal, but even in adult blood. As to the third objection, in reference to dissimilarity of chemical composition, it must be remembered that when the chyle corpuscles enter the circulation by the left jugular or sub-clavian vein, they pass immediately through the pulmonary artery into the lungs, come in contact with oxygen, and undergo chemical changes, with which we are as yet unacquainted. Some physiologists have supposed that colour is added to them before they join the pul- monary circulation, because yellow corpuscles have been seen in the upper extremity of the thoracic duct. In all such observations, how- ever, they have been necessarily exposed to the atmosphere ; and I have frequently confirmed the observation of Enimert, viz., that the coagulum of chyle, at first colourless, becomes pinkish-red in contact with air. On this point I ofter no opinion, believing that neither chemistry nor physioloijy has as yet communicated to us any exact information with regard to when or how lueinatin is produced. But whatever the clianges may be which occur in the lymph corpuscles on their passage into the lungs, to those organs we nuist attribute the alteration in their chemical constitution, as they are colourless and insoluble in* the lymphatic glands and in chyle, but coloured and partially soluble in the torrent of the circulation. Moleschott,* having found the colourless cells increase in the blood of the frog after excision of the liver, supposes that it is in the latter organ colour is added to the blood. In man we have seen that the structural diseases of the liver are frequently associated with enlargement of the spleen in leucocythemia, but in other cases the liver has been quite natural even in very severe examples of the blood disease. Besides, it is difficult to understand how chemically so important a function should be performed by this organ. Ultimate destination of the blood-corpuscles. — There may frequently be observed in the spleen of all animals, groups of blood-corpuscles, surrounded by an albuminous deposit closely resembling a cell-wall. This fact has been dift'erently interpreted. Gerlach is of opinion that they are new blood-corpuscles forming within a mother cellf — whilst KollikerJ and Ecker§ maintain that they are old ones, which, having fulfilled their functions in the circulation, go to the spleen, and are there dissolved. These large cells, con- taining several coloured nuclei, I believe to be cells of the lymphatic glands, which, under especial circumstances, assume power of increased development, with endogenous multiplication of nuclei. Thev are common not only in the spleen, but in the mesenteric and * Miiller's Archives. Hept. 1, 1853. f Handbuch der AUgemeine uiid Speciellen Gewebelehre, etc., s. 53. i Mikroskopisc'he Auatomie, etc. 2 Band, s. 282. § Wagaer's Haadworterbuch. Art. Blukgefassdriisen. Fig. 494. Cells with single and multiple nuclei ; many of the latter in colour and form exactly resemble blood globules. From the human spleen. 250 diam. 838 DISEASES OF THE BLOOD. other lymphatic glands, especially -when hypertrophied from neighbour- ing irritation, the result of inflammatory or canceious exudations, and especially in typhoid fever. A similar increased power of development may occasionally be observed in the epithelial cells of the pulmonaiT air vesicles in certain kinds of pneumonia ; in those covering the choroid plexus in hydrocephalus; in those of the epidermis in epithelial cancer; and in pus. On the other hand, that extravasated blood-corpuscles may assemble together in groups, and subsequently be surrounded by an albuminous deposit closely resembling a cell-wall, is a fact of great pathological importance.* It is true they closely resemble the lymph cells, Avith multiplying nuclei, but may, I think, be sepaiated from them by possessing more colour. I have seen them not only in the spleen, but in other glands, and especially in the brain, following spontaneous and artificial sanguineous extiavasations (see Figs. 292, 293, p. 214). But surely it will not be maintained that the normal function of the organs in which these accidental formations occur, is to dissolve the blood-corpuscles. l>esides, from the numerous facts -which have been referred to, I trust it has been made ap)>arent that the siileen is much more probably a blood-forming than a blood-destroying gland. The view \vf\ich seems to me most consistent with facts is, that the blood-corpuscles are dissolved in the liquor sanguinis, and with the ofl;ete matter absorbed from the tissues by the lymphatics, constitute blood fibrin. (Seep. 103.) From the various facts which have been stated, I think we may conclude : — 1. That the blood-corpuscles of vertebrate animals are originally formed in the lymphatic glandular system, and that the gi'cat majority of them, on joining the circulation, become coloured in a manner that is as yet unexplained. Hence the blood-corpuscles may be considered as a secretion from the lymphatic glands, although in the higher animals that secretion only becomes fully formed after it has received colour by exposure to oxygen in the lungs, 2. That, in mammalia, the lymphatic glandular system is composed of the spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lymjihatic glands. 3. That, in fishes, reptiles, and birds, the coloured blood-corpuscles are nucleated cells, originating in these glands; but that, in mammals, they are free nuclei, sometimes dei'ived as such from the glands ; at others, developed Avithin colourless cells. 4. That, in certain hypertrophies of the lymphatic glands in man, their cell elements are multiplied to an unusual extent, and under such circumstances find their way into the blood, and constitute an increase in the number of its colourless cells. A corresponding diminution in the formation of free nuclei, and consequently of coloured corpuscles, must also occur. This is leucocythemia. Since the above views were published by me in 1851, they have been confii'med by observations of various kinds. Thus Hollandf and * See Dr. Sanderson on the Metamorphosis of Coloured Blood Corpuscles, etc. Monthly Journal for September and December, 1851. •J- Journal of Microscopical Science, vol. i. p. 176. LEUCOCYTHEMIA. 839 Neale* have shown that in many cases of bronchocele the blood is leucocythemic. In the only two cases of supra-renal disease described by Addison in which the blood was examined, the colourless cells were increased in number. In a case of dysentery, with thickening of the mucous membrane of the small intestine, I found leucocythemia. (Case LXXV.)t Attempts have been made to divide leucocythemia into varieties. Thus, Virchow speaks of a splenic and a lymphatic variety. But in this manner we might make further distinctions of a thyroid, a supra- renal, an intestinal, and a mesenteric variety, according as disease in these organs occasioned the blood lesion. Nay more, we might speak of an hypertrophic, a tubercular, a cancerous, a dysenteric, and an anajmic form, according as we found tlie blood glands simply increased in size, loaded with tubercle or cancer, or associated with dysentery or anoemia. These distinctions I believe to be of no advantage, either in a scientific or practical point of view. The different blood glands contain elements which, when locally increased in number, find their way into the blood, to constitute leucocythemia. They form one system * Medical Times and Gazette, vol. viii. p. 430. •j- The first eleven of tlie following cases of Leucocythemia have been under my care since the publication of m}' work in 1852. To these Dr. Haldane has kindly added seven others, the bodies of which he has examined in the Patliological Theatre of the Royal Infirmary since November 1853 — making eighteen in' all. I might have swelled the list greatly by adding numerous cases obligingly communicated to me by professional friends : — Name. < 15 Degree. Liver. Spleen. Abdominal Glands. Eemarks. 1. Tho. Christie Advanced. Not examined after death. 2.tWin. Biiillie. 43 Advanced. 3 lb. 10 oz. 2 lb. 4. oz. Little enlarged. 3. Patrick Flo,,.] 13 Well mark'd Dls- missed from the house, and did not return. 4. Jn. (latt'iiey. 10 Moderate. 61b. 14 oz. 22 oz. Twice natl. size 1 5. Clias. Keimic. lit Well m.arkM 4 lb. 7 oz. 2 lb. 14 oz. Enlarged. | 6. J. M-Arthur. •25 Moderate. 31b. 5 oz. 6oz. Highly tubercu- Tubercular peri- lar. tonitis. 7. Eliz. Pollocli. 56 Advanced. Not examined after death. 8. Win. Dods. 23 Slight. 3 1b. 2oz. 5oz. Greatly enlarged Cancer in various 1 organs. 9. T. Crease. 28 Moderate. 2 1b. 8oz. 6oz. Mucous coat of Cancer in lung, ileum thickened.' 10. Eliz. Barker. 17 Slight. 2 1b. 7oz. Natural. Enlarged. Tubercular pen- tonitis. 11. Janet Young. 50 Moderate. 2 1b. Natural. Not mentioned. Aneurism- Waxy Kidnevs. 12. John Young. 27 Well mark'd Natural. 14 oz. dense. Not mentioned. iGlanders? Cere- bral hemor- rhage. 13. G. Harper. 60 Advanced. Do. 8 lb. with deposit Little enlarged. 1-4. Ber. Collins. 35 Well mark'd 51b. 10 oz. 27 oz. Not enlarged. Tubercle in lungs — Pneumonia. 15. D. Cockfield. 32 Slight. 6 1b. 8oz. 22 oz. deposit. Little enlarged. iBright's disease. 16. J. M-Gregor. S> Do. 5 1b. 11 oz. 16 oz. Much enlarged. Mehena. 17. Jer. Brown. 29 Advanced. 5 1b. 9oz. 3 lb. 13 oz. Enlarged. Acute tuberculo- 18. John Short. 50 Well mark'd 41b. 8 oz. dense. Not enlarged. sis. Brighfs disease. X The blood in this case, when subsequently under the care of Dr. Halliday Douglas, was analysed by Mr. Kemp, who found — water, 8C4'67; albumen, 71 25; fibrin, 5 35; corpuscles, 5S'97. 840 DISEASES OF THE BLOOD. of organs, and any kind of disease in them may strnctnrally affect the blood. What appears to me, however, now a desideratum in research, is to determine why, in some cases, the blood should, and in others should not, be leucocythemic, when these glands are diseased; and why smiple anaemia, as was first shown by Eemak, should increase {he number of colourless cells in the blood ? In one case examined by me in the autumn of ]8o2, and the characteristic blood in which I had the pleasure of showing to Dr. Hannover of Copenhagen and to Dr. Sharpey of London, I unexpectedly ascertained that the microscopic examination cleared up a doubtful diagnosis. It was the case of a woman concern- ing whom a difference of opinion existed between two distinguished obstetricians, the one declaring a tumour in the left flank to be s})lenic, and the other that it Avas ovarian. I showed it to be splenic, by demon- strating that the blood Avas crowded with colourless ceils. AVitli regard to treatment, nothing that I have yet ti-ied has appeared to be of the slightest service in well-marked cases of leucocytliemia associated with distinct glandular enlargements. Iron, quinine, chloride of potassium, hydiiodate of potash, and a variety of medicines given internally, with tincture of iodine applied externally, have been of no avail. The chief indications in advanced cases, however, will be found to be furnished by accidental complications, the most common of which are diarrhoea and epistaxis, which require astringents, combined with tonics, nutrients, and stimulants, to support the vital powers. Discovery of Leucocytliemia, Professor Kolliker of Wurtzburg (in Month. Jouin. of Med. Science, Oct. 1854), laid before the English medical public the history of the discovery of Leucocythemia as it is understood in Germany^ from the representations of Professor V irchow. The following is my reply: — It is said by Professor Kolhker that the first observations on this subject occur in the year 18-15, and take their origin from a case of disease by Dr. Craigie. Now, the fact is, tliat Dr. Craigie's case occurred in 1841 ; and it is admitted by Dr. Craigie himself that it would not have been published even four years aiterwards but for the occurrence of mine. He says, " I kept it unpublished from the period at which it took place ; and it is published at tliis time, chiefly because the occurrence of a case in many, if not in all, respects similar to another physician in the same hospital, led me to anticipate similar results, and went far to confirm my conclusions deduced from the first case." — Edin. Med. and Surg. Journ., vol. Ixiv. p. 402. Professor Kolliker takes great pains to show that Dr. Craigie and m}'self held the same opinions as to these cases, and that in mine, which followed his, "nothing further was elucidated." On the other hand, he says Professor Virchow was the first to point out that "no signs of inflammation in the veins were anywhere dis- coverable," etc. Now, exactly the contrary of this is the fact. Dr. Craigie put forth two possibilities as to the cause of the blood disorder. \st, He says, "It is barely possible that some inflammatory action had taken place in the tributary or constituent veins of the mesenteric trunks; and that the pimiknt matter and lymph thus formed had been conveyed into their interior with the blood, and thence into the vena cava, heart, and vessels of the brain." 2d, He says, "Another opinion occurred to me, however, as more probable, and which various circumstances in the case induced me to regard as the most correct. Considering that the spleen had been for some time, that is, for several weeks, in a state of chronic inflammation, and taking into account the large vessels with which this organ is connected to other organs, it appeared to me that this inflammatory jyrocess, which had been continuing LEUCOCYTHEMIA. 841 so long without abating, subsiding, or being subdued, was at length beginning to give rise to the fonuation of lymph and purulent matter, and that these substances, as they were formed, were immediately taken into the veins, and thus circulating with the blood, gave rise to the peculiar assemblage of symptoms which the patient presented during the few days preceding his death."' (P. 409.) From these extracts it must be clear that Dr. Craigie considered the blood disease as secondarj-, and dependent on the absorption of pus from an inflammatory lesion either iu the mesen- teric veins or spleen. The view talcen up by myself was wholly different, viz., that the blood disease was primary, originating in that Huid itself, altogether independent of local inflam- mation, and especially unconnected with inflammation of the veins. This will appear from tiie following extracts from my paper: — "In the present state of our knowledge, then, as regards this subject, the following case seems to me particularly valuable, as it will sen'e to demonstrate the existence of true pus formed universally within the vascular .system, independent of any local jjuruient colledian from which it could he derived."' (Pp. 413, 414.) And again, "Pus has long been considered as one. if not the most characteristic, proof of preceding acute inflammation. But in the case Isefore us, what part was recently inflamed f There was none. Piorri- and others have spoken of an inflammation of the blood, a true hematitis; and certainly if we can imagine such a lesion, the present must be an instance of it. But it would require no laboured argument to show, that such a vieiu is entirely op2)osed to all we knoic of the 2}henornena of inflammation." (P. 421.) From these passages it must be clear tl)at I tlien separated the state of the blood from pre-existing inflammation in any of the tissues, which had not been done by any preceding author. I espe- cially distinguished it from pya?mia as it was then generally understood. Thereby I established a new blood-disease — one of a primary "nature. ' I carefully described all the f-ACts which Virchow has only subsequently confirmed. I spent three entire days investigating the histological character of all the tissues in the body, and in demonstrating the important fact, that the colourless corpuscles in the blood, which I minutely described, were unconnected with inflammation. Notwithstanding all this. Professor Virchow has pertinaciously endeavoured to persuade his countrymen that I regarded the case as one of ordinary pyjemia or purtilent absorption ; and Professor Kolliker, in his communication, says of these laborious researches, that " nothing further was elucidated " beyond what had previously been determined by Craigie and Rei(L Here, it sliould be observed, that Dr. Craigie was no histologist, and had never employed the microscope in the investigation of disea.se. To argue, then, that the discovery of this condition of the blood — a discovery altogether dependent on histo- logical research — was made by him, seems absurd in the extreme. But it may be maintained tiiat this part of the inquiry was carried out by Dr. John Reid, because he .stated in the register, kept by him as pathologist of the' Infirmary, that the blood "contained globules of purulent matter and lymph." The few words now quoted constitute literally the whole of Dr. Reid's observations on the matter. They would have been buried in oblivion, if I myself had not found them in the register of dissec- tions, pointed them out to Dr. Craigie. and indicated their importance. I have frequently conversed with Dr. Reid himself on the subject, who had forgotten the circumstance of having examined the blood microscopically in Dr. Craigie's case, or of having made a note of it. Certainly he paid no more "attention to it. or in any way thought it more important than a host of other notes he made, which still exist in the pathological register, and in which some future controversialist may doubtless find many similar discoveries, as yet unknown. At all events, it is certain that neither Dr. Craigie nor Dr. Reid ever imagined to themselves that the " globules of purulent matter and lymph " seen by the latter, originated independent of purulent absorption, or ever dreamed of claiming for themselves the discovery of leucocythemia. Who then did make it ? Certainly not Virchow, who with Kolliker, in "order to depreciate the value of my observations, claims it for these gentlemen. And if none of the tiiree made it, tlie inference undoubtedly is, that the discovery belongs to me. What, then, it may be asked, does Professor Kolliker claim for his colleague ? It cannot be the discovery of the facts, or of the existence in large numbers, of colour- less corpuscles in the blood, independent of inflammation. All the histological facts —the white appearance of the blood (white blood), its independence of inflammation, and its separation from all previously known pathological conditions — were minutely described by me in the pajjer of the first of October 1845, and their accuracv has been 84:2 DISEASES OF THE BLOOD. everywhere confirmed (See Case CLXXXIII.) Surely tliis description of /acte never before published, and of their connection with a new blood-disease, consliiuies the discovery. On the other hand A'irchow's short and comparatively imperfect histo- logical description of a case of white blood (the white appearance of the biuod being the chief point he dwelt upon) was printed in the second number for the following Xovember, although from the admission of Professor Kolliker, as to the practice which prevails in (jerman}-, the actual period of its publication may have been much later. Hence all that can be claimed for Virchow amounts to this, that lie puts fortii an opinion regarding these facts difierent from muie. but the possibilit\' of wliich I clearly indicated. For having described the peculiarities of the blood — the white coagulum, its structural characters, the colourless corpuscles, the relation to the red ones, and tiie absence of the inflanuuatory appearances in every tissue, not except- ing the veins — tiie questions remained, What are these coipusclts? How are they produced ? In reply, I remarked, that " with regard to the colourless corpuscles of the blood ice know of no irieianct where they existed m tlie amount, or ever presented the appearance described." From this passage Professor Kolliker draws the inference that I denied that these bodies were the colourless corpuscles of the blood. But I need scarcely point out that the passage does not fairh' bear that construction. On the other hand, it clearly shows that the possibility of their being these colourless corpuscles was fully entertamed. At that time the whole subject was hislologieally new; and having shown that the cells observed closeh' resembled those of pus in their structural and chemical characters, I said so, and concluded they were pus corpuscles. But having also demonstrated that they could not have been derived from any inflamed tis-sue, it only remained to be concluded that these bodies were formed in the blood system itself^ constituting a primary suppuration of the blood. Here. I contend, was the real discovery, which was at that time quite new, and remains up to this hour, in mj' belief, a correct generalization. "Whilst Profes.sor Kolliker .seems to attach no importance whatever to my careful histological examination of the blood and of the tissues, and wliolly disregards the fact I was at so nmch pains to establisli, that the colourless corpu-des I described were not dependent on intlanunation, he thinks it of the greatest importance that Tirchow should have stated that these corpuscles were not tho.se of pus. To me it has always seemed of little importance by what name these bodies weie designated, so long as the facts regarding them were described with exactitude It cannot be denied that I first discovered and described them, and pointed out their origin in the blood itself TThat histological difterence tliere can be between pus cells independent of inflammation, originating spontaneously in the blood, and the colourless corpuscles of that fluid, I am at a loss to imagine. Yet this is the only distinction which Yir- chow made. But what are pus corpuscles but cells presenting certain pliysical characters originating in an exuded blood-plasma? and what are the colourless corpuscles of the blood but similar cells originating in a plasma contained in the blood glands? I have yet to learn that there is any true histological difi'erence between them ; I believe still that the only distinction is, that the same corpuscles originate in blood-plasma, sometimes outside, and sometimes within the blood-system. If so, the controversy raised by Tirchow, and maintained by Kolliker, is wholly one of words. Here I may mention, that, acting on the persuasion that tiie two kinds of corpuscles, hitherto separated, are reall\- identical, I opposed the generalization of Mr. Henry Lee, which set forth that pus brought in contact with living blood caased its coagulation. In conjunction with the late Professor Barlow of tlie Veterinary College. I injected considerable quantities of pus into the veins of an a.ss, in order to determine this point. I thus increased the colourless cells in the blood of the animal "without producing any coagulation or inflammation whatever. — {Monthly Journal, January and March 1853, pp. 80 and 272, 273). Moreover, it may be questioned, and indeed it has been questioned in a communication which I received from Pro- fessor Gluge of Brussels, and in an article by Dr. Radcliffe {Half- Yearly Abstract of Medical Sciences, vol xvi. p. 295). whether this distinction can have any real foun- dation. Rokitansky still maintains that the colourless corpuscles of the blood in leucocytliemia aretrulj' those of pus, and Tidal, after a series of observations directed to this very point, has come to the conclusion that the colourless corpuscles of the blood, those of pus and those of mucus, are the same {Gazdte Ethdimiadaire. Avril llth, 1856). If so, the pretended discovery of Tirchow sinks into nothing, as it is not founded on fact, but simply on opinion. As to the subsequent progress of this inquiry, I have only to express my astonish- LEUCOCYTHEMIA. 843 ment at the statement made hy Professor Ivolliker, that in 1851, in the Monthly Journal. Awii. that in 1852, in my separate work, I made no allusion to my former views, and did not take tlie sliglitest notice of the labours of Virchow. It is most untrue. My views regarding this disease have always been the same, but never such as Yirchow and Kolliker have represented them ; and so far from denying the labours of the former pathologist, I have fully set them forth, and quoted all his facts and observations. I always have and still continue to estimate highly the value of the facts he has contributed in connection with this important subject. But what he has accomplished does not entitle him to the original discovery of leucocytliemia, or to the merit of giving it a place in pathology. Careful investigation into this subject will, I am satisfied, convince the candid inquirer that the discovery of leucocytliemia and the subsequent progress of ideas regarding its nature may be divided into three epochs or stages as follows: — 1. Professor Bennett. — Discovery of a new morbid condition of the blood, October 1, 1845. consisting of multitudes of colourless corpuscles, re- sembling those of pus, associated with hypertrophy of the spleen and liver, and presenting after death pecu- liar white coagula. Shown to be unconnected with inflammation in any of the tissues, and especially un- connected with phlebitis. Attributed to tlie develop- ment of the corpuscles in the blood itself 2. Professor Virchow. — Confirmation of the preceding facts, but the corpuscles Series of papers from the said to be an increase in the colourless cells of the 2d or 3ii week of November blood. New cases, and especially one of great value, 1845 to 1847. ' in which a similar condition ot the blood was associ- ated with enlargement of the lymphatic glands with- out hypertrophy of the spleen Origin of the colour- less cells attributed to the Ij^mph glands ; proposed name of leukhemia or white blood. 3. — Professor Benxett. — Systematic view of the whole subject. Additional Series of Papers, 1851. facts and cases, with chemical analysis of the blood. and separate ivork, Doctrine that the lymphatic and other ductless glands 1852. Rl. 8vo, Edinr. secrete the blood ; proposed name of leucocytliemia or white-cell blood, and the relation of this disease to other pathological conditions, and to practical medi- cine, pointed out. From this view of the case, it will be seen that although I claim the discovery of leucocytliemia, and have given it the correct scientific name it bears, I am far fi'om undervaluing or wishing to hide Professor Virchow's contributions to its pathology — whereas he, in order to make it appear that the origin as well as development of the whole subject is due to himself has not hesitated to give, and circulate in Ger- man}-, the most erroneous and partial accounts of my facts and views. Since the above statement was published. Professor Virchow has continued not only to repeat his former errors, but to assert that his. case, published at lea.st six weeks after mine, was, in fact, the first one. Thus in his "Gezammelte Abhand- lungen," dated 1856, he says, p. 155 — "About the same time that my case was published, two other cases were made known in Edinburgh," etc. He then goes on to detail them, observing, ''Case 1, observed hij me; Case 2, by David Craigie; Case 3, by John Hughes Bennett." Thus distinctly claiming for himself priority in observation. In the same manner, Vogel, in giving a report in Canstatt's Jalir- biicher of the progress of Medical Science in 1852, part 3, on special and local pathology, puts 1st, Virchow's paper from the Archives, vol v. ; 2ndly, my papers in the Monthly Journal ; and 3rdly, my separate work. Yet what are the dates of these puljlications? My papers appeared in 1851, with the first chemical analyses of the blood made by Br. W. Robertson. My separate work is dated March 1*852, and Virchow's paper, with the chemical analyses by Professor Scherer, is dated August 1852 ! The French writers on this subject have declared the term leukhemia to be fiiulty, and adopted that of leucocytliemia. Leudet,* Vidal.f and Sclinepf| have followed the representations of Virchow, and, in a professed historical sketch, have stated that * Gazette Hebdoraadaire, 27 .Tuillet, 1855. f Idem, 15 Fevrier, 1856. I Gazette Medicale de Paris, 5 Avril, 1856. 8-i4 DISEASES OF THE BLOOD. his and my cases appeared about the same time. As if six weeks were not more tlian a sufficient period for the Edin. Med. and Surg. Journal to reach Berlin, and to be placed on the library table of the Royal Library there, where it mic^ht have been seen by such readers of English medical literature, as Virchow undoubtedly i.-^, long before the latter published his note, in the 2nd number for Xoyember of Froriep's Notizen. Schnepf (who is evidently unacquainted with my writings, and has only seen the short resume I presented to the Biological Society of Paris in 1851, at the request of my friend M. Lebert) represents Virchow's ca.se as occurring in March, and mine in October 18J:5. That is, he gives to Yirchow's case the date at whicli mine was investigated in Edinburgh, hve months before the latter occurred ! The real dates are as Ibllows : — Observed. Published. 1st Case Prof. Bennett March 19th, 1845 October 1st, 1845. 2d Case . . .Prof. Virchow August 1st, 1845. . . .Xovem. 2d week, 1845. 3d Case Dr. Fuller Decem. 31st, 1845 July, 1846. Dr. Craigie's case must obviously be placed amongst those that occurred long before the discoverj^ of leucocy themia was made, although on looking back upon it one can have no doubt that it was an example of the disease similar to a verj' excellent one published by Duplay, in the Archives Gen. de Mrdecine, 2d series, vol. xxxvi p. 223, 1834; or tiie one which occurred to M. Barth in 1836, but was only published in 1856 by Vidal, when the subject was fully known. In a recent work, '• Die Cellular Pathologic" 1858, Professor Virchow for the first time admits (p. 170) that mj- lirst case occurred, not about the same time, but " some months " bef()re his. He continues, however, to assert that my conclusion as to the cells being formed in and not outside the blood, and therefore being a suppuration of that fluid, was not original, but was based on the views of Piorrj- as to hcmatitis, although, in the words previously quoted. I expressly repudiated that doctrine. But Vh-chow himself now says (p. 140 op. cit.) that pus corpuscles and the colourless cells of the blood cannot be distinguished from one another. " If found outside the blood, we can with certainty conclude that tliey are pus ; if this is not tlie case, they belong to the elements of the blood." Further, as a jjroof of the impropriety of the word leukhemia, he now speaks of this morbid state under the name of leucocytosis ! Hence after twelve years' misrepresentation of mj discovery and views, he thus (indirectly) acknowledges my priority in observation, as well as the correctness of all the facts and opinions I originally put forth. CHLOROSIS AND AN.EMIA. Case CLXXXVL* — Chlorosis and Ancemia — Cured. History. — Lilias Eoss, set. 19, servant in a hotel — admitted October 13th, 1856. She states that menstruation commenced in her sixteenth year, and continued to recur regularly till about a year ago. It then ceased, and she experienced debility, palpitation with pain under the left breast, defective appetite, and discomfort after meals. On leaving ofl' work for six weeks, her health was restored, and the cata- menia returned. She again went into service, and in four months the symptoms came back. She dates the present indisposition from the last menstrual period, four weeks ago. Symptoms ox Admission. — She seems in every respect well formed, not ema- ciated, but the skin is blanched, and of a slight greenish waxy tint. Over the chest and mammfe are a few patches of pityriasis versicolor, of a faint yellowish tint. She complains of occasional palpitation. On examination, the heart's impulse is in its normal position, and is at present of natural force. There is a soft but distinct blow- ing murmur with the first sound, loud at the base of the organ, and audible in the * Reported by Mr. John Glen, Clinical Clerk. CHLOROSIS AXD AX.EMIA. 845 course of the aorta and large arteries. Over the carotids above the clavicle, a loud double blowing is audible, which, on pressure with the stethoscope, becomes a con- tinuous humming-top sound. Pulse 100, soft. Tongue pale and flabby, appetite defective, food causes a painful sense of weight with distension in the stomach, no vomiting or flatulence, occasional sense of constriction in the throat, bowels costive, having for some weeks been opened only by laxatives. She has frequent giddiness, rarely headache, often darkness before the eyes, no spinal irritation, but great weak- ness over the loins, and such a sense of fatigue, with heaviness in the limbs, that she has great difiSculty in walking. The catamenia have not appeared at the usual period on this last occasion. They have never been profuse or accompanied by pain. Urine healthy. Respiratory system normal B Pil. Bhcei Camp. xij. Two to be taken every third night. 5 Feiri Citralis, 3j; Syrupi Aurantii, et Tr. Aurantii, aa 3 j ; Tafm. Calumh. § iv. M. One table-spoonful to be taken three times a-day. Progress of the Case. — October 25th. — Is improved in strength, and can -walk about the ward. The heart's palpitations are easily excited. Sometimes the mur- mur over the carotids in the neck is of a hoarse double character, at others con- tinuous and very loud. To encourage a return of the catamenia, /owr leeches mclered to be applied to the vulva, followed by a warm hip-bath. November lOih. — Is gaining strength slowly on the whole, but experiences alternations in this respect — palpi- tations and pain under lefl mamma being sometimes severe, at others absent. The soft blowing murmur at base of heart has disappeared, but the humming-top sound over cervical vessels continues. November 2oth. — Blowing murmur at base of heart occasionally returns only alter exertion. Sounds in neck less intense. No cata- menia, although pediluvia, mustard poultices to the feet, and other means have been employed at the supposed menstrual period. December lOth. — Has continued to take the chalybeate mixture all this time, and is now strong and vigorous. A faint sound only is audible over the vessels in the neck, after exertion. Appearance healthv. appetite good, bowels regular, no headache, nor nervous pain. With the exception of amenorrhcea, may be said to be quite welL Advised to go to the country for a httle. Dismissed. Comnientanj. — This was a well-marked case of anaemia and cblorosis, cured by iron, tonics, and rest. Such cases, in yonng women, are exceedingly common in the female wards of the Infirmary, especially amono- the class of servants. Great discussion has occurred as to the cause of the murmurs in the heart and large blood-vessels, some maintaining their seat to be the arteries, others the veins. The argit- meuts of Dr. Ogier AVard, who first maintained the seat of the anaemic murmur to be in the jugular vein, are generally considered to be well founded. They are — Ist, The continuous murmur is often co-existent with distinct carotid impulse, which alternates with repose ; 2d, It may be interrupted bv pressing the vein above the stethoscope ; .3d, The two murmurs mav be occasionally heard by employing a small-ended stetho- scope, and shifting it slightly to the right or left ; 4th, It is increased by anv cause which accelerates the flow of blood through the jugular vein, as during the act of inspiration, and when in the upright posture — it is diminished when there is an impediment to the venous circulation, as during expiration, the recumbent posture, and when the veins are swollen or turgid. Andral endeavoured to show that the constancy of the murmur is proportionate to the diminution of corpuscles, and that it became continuous if the blood globules fell below 80 parts in 1000. But Dr. Davies has pointed out that the murmur is not 846 DISEASES OF THE BLOOD. peculiar to anoemic persons, but often exists in individuals of robust liealtli. He attributes it to friction on the inner surface of tlie veins, which is more or less audible according to the readiness with which tlieir parietes talce up vibrations, and the facility Avith which the latter are conducted to the outer surface of the body. Hence their frequency in children and young persons, and in the quick ventricular contraction ■with thin blood, of the chlorotic girl, and, on the other hand, their absence during the slower circulation, and thickened condition of the tissues in adult and aged persons. At the same time there can be little doubt that the interrupted blowing at the base of the heart, over the aorta and carotids, which .is synchronous with the impulse, is often arterial and not venous. Indeed, the sepai-ation of anamic arterial and venous murnuirs is frequently a matter of excessive difficulty. Some- times also, as has been well pointed out by Stokes, they are associated with organic disease, which adds to the complexity, and occasions still greater difficulty in forming a correct diagnosis. The coloured corpuscles of the blood may be increased" or diminished in quantity, constituting Polycijthiemia and Olifiocythcemia (\^ogel). These changes may be absolute or relative. In the former case, the corpuscles are uniformly increased or diminished throughout the body generally; in the latter, this depends upon the amount of water which, by being less or more, alters the proportion of the corpuscles to the other constituents of the blood. Becquerel drew a distinction between aniemia and chlorosis, which, on the whole, is well founded. Thus, anaemia is caused by a variety of circumstances which impoverish the blood, such as long-continued hemorrhage, exhaustive discharges, starva- tion, chronic diseases, certain poisons, etc.; chlorosis is induced by obscui'e causes connected with the nervous system, generally originating in disturbed uterine functions. In antemia, the alteration of the blood is constant and pathognomonic ; in chlorosis, it is only one of the pheno- mena, and not always present. In both diseases the physical signs may be alike, but in auajmia the functional sound is more often in the arteries, in chlorosis in the veins. In anaemia there is constant relation between intensity of symptoms and poverty of the blood. This is not the case in chlorosis. The duration and progress of ansemia is de- pendent on the causes Avhich produce it, but chlorosis is very variable, and no such evident connection is visible. The treatment of anajmia has two indications — 1st, To suppress the exhausting causes which occasion it ; and, 2dly, By means of wine, proper nutrients, and regu- lated exercise, to improve the quality of the blood. In chlorosis, iron is the chief remedy, which should be conjoined with efforts to regulate the menstrual function. ICHOK^MIA OR PYEMIA. 8-17 ICHOR^MIA OR (so-called) PY.EMIA. Case CLXXXVII.* — AcvAe Articular Rheumatism — Multiple Abscesses in the Joints^ in the JIurScles, within the Cranium, etc. History. — James Lockie, set. 17, a rope-spinner — admitted December 1, 1854. Ten days ago, when spinning ropes iu the open air, he was exposed to more than usual cold and wet. Next day rigors and other febrile symptoms appeared, followed by pain, redness and swelling of the riglit elbow joints. During the four following days the right wrist and ankle joints were also affected, together with both knee joints. Four days before admission the heart's action became very violent, and leeches were applied to the precordial region. The pain and swelling of the joints have continued since. Symptoms ox Admissiox. — On admission he complained of great pain in the right wrist, ankle, and left shoulder joints, which were swollen, immovable, doughy to the feel, tender to the touch, with the integuments over them erythematous. From the left shoulder joint, the swelling extended into the axilla and down the inside of the arm. Pulse 130, full and strong; heart's impulse violent, but no blowing murmur. The tongue coated with brown in the centre and white at the edges ; no appetite ; great thirst ; skin hot and dry ; urine turbid from excess of lithates ; bowels open ; no headache, and the other functions normal. Fiat vene- seciio ad § xiv. IJ Fotassce Xitratis 1 ss. Aqua § vj solve. § ss to 6e taken in half a tumblerful of water every four hours — warm saturnine lotions to the inflamed joints. Progress of the Case — December 2d. — Little change, pulse 120, more soft, blood not buffed, but it was drawn from a small orifice. Dec. 4th. — Pain in all the joints greatly diminished ; the swelling, however, continues. A blister has formed over the external malleolus of right ankle — complains of soreness in the heels. Pulse 100, of good strength. Xo blowing murmur with the heart's sounds. Took 3 j of castor oil last night (the bowels having been constipated), which has acted copiously. Tongue dry, and covered with a brown fur. Febrile symptoms continue, with pro- fuse diaplioresis. On the 6th December the blister over the malleolus of right ankle burst, and gave issue to a quantity of pus. Distinct fluctuation existed over the right wrist and dorsum of the hand, which was opened by an incision, and also gave exit to a considerable quantity of pus. To omit the nitrate of potash. On the 8?/i, com- plained of pain in the back of the neck, and a bed sore was seen to be forming over the sacrum. To be jAaced on the water bed. From this time the pulse, which ranged from 110 to 140, lost its fulness, and became much more weak; the skin assumed a dirty yellowish or tawny hue, the typhoid febrile symptoms continued, with dry tongue and sordes, and numerous abscesses formed in the joints and various parts of the body, several of which, as soon as they became soft, were opened. A very large abscess formed over the occiput, which was opened on the 18ih, and another over the manubrium of the sternum, extending up the left side of the neck, which was opened on the 24th. The skin over the heels, trochanter of the right hip, and the sacrum, sloughed, notwithstanding every care taken to prevent it. On the 26ih, the whole of the right lower extremity was swollen, oedematous, and while, resembhng in aspect phlegmasia dolens ; there was laborious breathing, and great prostration. Low muttering delirium, and involuntary evacuations supervened, and he sank on the morning of the 21th. The treatment had latterly been directed by generous diet and * Reported by Mr. A. "W. Moore, Clinical Clerk. 848 DISEASES OF THE BLOOD. stimuli, to support his streugth, relieve pressure on depending parts, and to dressing his sores. Sectio Cadaveris. — Sevenfy-tioo hours after death. Body greatly emaciated ; a fistulous opening, the size of a shilling, existed imme- diately in front of the left sterno-clavicular articulation. Other sores, varying in size from half an inch to three inches in diameter, and laying bare the bones, existed over the right elbow, ankle, both hip joints, I'ight knee, and sacrum. Head. — The integument covering the occiput was separated from the skull, infiltrated with putrid pus, a great quantity of which had been evacuated by openings previously made. On removing the calvarium, an abscess, containing thick j'ellow pus, existed between the bone and dura mater, about the centre of the occipital bone- The bone externally was somewhat carious, but internally it was healthy. No communication could be traced between the external and internal abscesses. Brain healthy. Chest. — On removing the heart and aorta, a fluctuating oval swelling, about f inch in its long diameter, was situated outside the aorta, about an inch from the aortic valves, which was distended with yellow purulent matter. The posterior por- tions of both inferior lobes of the lungs were condensed. On section they {^resented a reddish purple colour, the air vesicles filled with a soft sanguineous exudation and readih' sinking in water. Heaii healthy. Abdomen. — Kidney's slightly enlarged — one section presenting a whitish mottled appearance, without great atrophy of the secreting, or encroachment on the tubular substance. Other abdominal organs healthy. Joints. — The left sterno-clavicular articulation was carious and disarticulated, with matter burrowing to considerable depths in the surrounding soft textures. The right shoulder, left elbow, right wrist, both hip joints, both knees, and both ankle joints, were filled with dirty purulent looking matter, which, in several instances, more especially in the left elbow and hip joints, had infiltrated itself more than half way down the fore arm and thigh. The various articular cartilages presented all stages of abrasion, softening, and ulceration, whilst the osseous textures below exhi- bited a carious and blackened necrosed condition. The base of the ulcer over the sacrum consisted of necrosed bone, and over the right elbow, riglit hip, and knee joints, bone was exposed and necrosed. The Veins were carefully examined, especially in the right inguinal region, and with the sinuses at the base of the brain, were everywhere found healthy, and free from coagula ; indeed, the blood was everywhere unusually fluid — even in the heart presenting small, dark, and soft coagula. Microscopic Examination. — The pus consisted of molecular and granular matter with debris of disintegrated jjus cells, with the exception of the abscess within the cranium, the pus of which was normal. The cartilage covering the joints was in some places healthy, but in others its cells were enlarged, filled with secondary cells, and not unfrequently with fatty granules. Around the articulations of the joints were laminte of chronic exudation, consisting of dense amorphous matter, principally composed of minute molecules. The blood was carefully examined, and everywhere found normal. Commentary. — This was a case of what is frequently called pj'jiemia, a disease wliicli is not uncommon as the result of mechanical injuries, or suppurative diseases. I believe it to be very rare, however, as a conse- quence of attacks of acute rheumatism, such as the symptoms and the history of this case prove it to have been. The lad was healthy and in ICHOR^MIA OR PYEMIA. 84:9 pursuit of Ins ordiuary occupation when, after exposure to cold and wet, lie was seized with the usual symptoms of rheumatic fever, including violent action of the heart, and on this supervened suppuration in almost all the joints, with numerous abscesses, accompanied by a low typhoid fever, under the effects of which he sank. Dr. Watson has recorded two cases singularly like it, but in them the constitutional disease was preceded by oton-lufia and abscess in the ear,* to which he theoretically ascribes the origin of the disease. In the present case there was no primary abscess, no evidence of a pre-existing collection of pus before the attack of rheu- matism, and I think there can be little doubt that the constitutional state of the blood, whatever it may have been, was dependent on the abscesses which residted from the acute inflammation of the joints. This morbid condition, so much dreaded by surgeons and obstetricians, in which typhoid fever comes on after severe accidents or parturition, accompanied with purulent infiltration, or multiple abscesses, in one or more organs, has received different explanations. The various obser- vations and experiments performed with a view of elucidating this sub- ject in modern times have led to the four following theories: — 1. That this condition is owing to an admixture of the blood with pus (pyohemia of Piorry), and that tlie pus corpuscles being larger than the coloured ones of blood, are arrested in the minute capillaries, and give rise to secondary abscesses. 2. That it is owing to the presence of some irri- tating body, which not being able to escape from the economy, produces capillary phlebitis. 3. That it is dependent on a property possessed by pus of coagulating the blood. 4. That it is caused by the presence of a peculiar poison which contaminates the system. All these views have been maintained with much ingenuity, and they are all supported by experimental and clinical researches. A knowledge of the circumstances previously detailed concerning leucocythemia will enable us to criticise these doctrines from a new point of view. 1. With regard to the first theory, it must, I think, be granted by all those who have examined the blood in leucocythemia, or will study the fio-ures I have given illustrative of that disease, that no difference what- ever can be detected between the colourless cells of the blood and those of pus. Their general appearance, size, structure, and behaviour, on the addition of re-agents, are identical, — indeed so much so, that in the first case I observed in 1845, I could not resist the conclusion that the blood was crowded with pus cells. It follows, that all explanations of puru- lent infection founded upon the mechanical impaction of these bodies in the minute capillaries must be erroneous. Some of these colourless corpuscles have been observed much larger than ordinary pus corpuscles. In one instance, many of them were twice as large ; and although this may in some measure be owing to endosmosis of serum, there can be lit- tle doubt that they must have exceeded the usual size of pus cells. In Case CLXXXIIL, also, it was observed that several of the colourless cells were larger than the average, and yet the circulation went on, and every drop of the patient's blood contained hundreds of these bodies. The first theory, then, is no longer tenable. * Practice of Physic, vol. i. p 381, 4th edition. 54 850 DISEASES OF THE BLOOD. Xeitlier does tliere seem to be anything peculiar in the nature of good and laudable pus, which necessarily leads it to poison the blood ; for it is a matter of common observation, that large abscesses are absorbed and eliminated without occasioning so-called purulent infection. In all such cases, the pus corpuscles must, in the first instance, be disintegrated and reduced to a fluid condition ; still the matter or substance of which they were composed passes into the blood. Hence, while leucocythemia proves that corpuscles, identical in form, size, structure, and chemical composition with those of pus, uiav float in the blood and circulate innocuously, the well-known fact of the absorption of abscesses demon- strates, that pus, when healthy, does not possess any poisonous proper- ties. If, then, the fever and other marked symptoms are owing to the absorption of pus, it must be of pus possessing properties wholly differ- ent from those of what is called good or laudable pus. 2. The second explanation was advanced bv Cruveilhier, who, on injecting mercury, ink, and other substances into the blood of a living ani- mal, found that abscesses were formed wherever these accumulated. From hence it follows, that the impaction of certain substances in the tissues may induce local inflammations, and lead to abscesses; but that such is not the necessary result of admixture of pus with the blood, is proved not only by the previous observations, but by numerous experi- ments of Lebert* and Sedillot,t in which the animals recovered. 3. The third doctrine was advanced by Mr. Henry Lee,J and resulted from observing that when pus was mingled with reccntlv-drawn blood, it coagulated more rapidly and more firmly than under ordinary circum- stances. This observation he connected with the well-known fact, that phlebitis was often associated with coagula causing obstruction of the veins. Now it is worthy of remark, that in decided cases of leuco- cythemia the blood is more highly coagulable than when drawn from the arm, and after death it often pi-esents firm coagula, filling the vessels, as in Case CLXXXIII. Figs. 471 to 473 illustrate these colourless coa- gula, as observed in difi"erent parts of the body. The same occurred in Case CLXXXIY. ; and yet, during the life of the patient, the blood, loaded with the colourless corpuscles, rolled through the vessels without impediment or the formation of coagula. It does not follow, then, that because dead pus is mingled with recently-drawn blood about to coagu- late, that therefore it should induce coagulation of living blood in the vessels of an animal. Indeed, numerous experiments by Lebert and Sedillot show that such does not take place; for although in some cases death followed, in others the animals lived, and the pus corpuscles were dissolved.§ Hence, although the fact to a certain extent must be admit- ted, that when pus is mingled with blood the coagulum foi'med is more firm, it by no means follows that it produces coagulation of living blood, and is the cause of phlebitis or purulent infection. * Physiologie Path ologi que, torn. i. p. 313. f De rinfection Purulente. p. 73, et seq. \ Ou the Origin of Inflammation of the Veins. London, 1850. § In 1852, to determine this point more definitely. I performed, -with the late Professor Barlow of the Veterinary College, the followins experiments: — Experiment 1. — The saphena vein of an ass was exposed, and a tnbe introduced confined by a ligature. Fresh and healthy pus was then slowly injected upwards towards the heart, from a syringe holding an ounce. A slight obstruction was now perceived, and the vein above the liga- ICHOR^MIA OR PYJEMIA. 851 4. The fourth theory seems to have been maintained by A. Boycr* and l>onnet,f who believed good pus to be innocuous, and the bad effects occasionally produced to depend -on its becoming putrid, or being other- wise altei'ed. This view was also more or less suppoi-ted by DarcettJ and r3erard,§ who, in order to explain the undoubted effects of putrid substances when injected into the veins, separated pyohemia from puru- lent infection. But as pus corpuscles do not alone cause the symptoms, it is certainly more probable that, in all cases, thei'c must be a toxic prin- ciple associated with pus when it proves mortal. Dr. Millington|| has shown, in repeating Mr. Lee's experiments, that putrid fluids prevent coagulation of the blood, and that the coagulum caused by the addition of pus is more j^erfect the fresher the purulent matter is. This fact is opposed to the idea, that multiple abscesses are induced by the coagula- tion, but corresponds with what is observed after death in cases of puru- lent infection. When, therefore, we consider the typhoid nature of the symptoms so similar to that of certain animal poisons ; the multiple abscesses so analogous to what occurs in glanders, plague, sypliilis, variola, etc. ; and the undoubted fact, that the blood may be loaded with corpuscles in every respect identical with pus cells, without causing tare could be seen to be somewhat swollen. This swelling, on beintr felt, was very soft; and on pressing the vein from below upwards, the mixed blood uud pus was readily pushed before the finger, when all obstruction to the passage of i>us from the syringe was removed. The syringe was ajain filk-il. and another ounce of pus injected, without occasiuninir any further local etfects. The aniuial was then allowed to get up, and exhiliited no change in its iini-ni;il condition whatever. E.rpi>rhnent 2. — The same ass was the subject of this experiment a fortniglit later, bavins: been perfectly well in the intervah Six inches of the jugular vein in the neck were carefully dissected and exposed ; and a minute aperture was then made in the npper end of the exposed vein, and the bent tube of the syringe introduced without a ligature. The coats of the vein were so transparent that the tiowing blood couhl be seen through them. An ounce of fresh and perfectly healthy pus ^vas then slowly injected doionicards towards the heart, and, owing to the transparency of the vein, the yellow opaque fluid was seen to join the blood, to continue a few moments running side by side with tlje crimson current, until at length the vein became full of pus. On removing the syringe to obtain a fresh supply, the blood from above could be seen to join the pus, to continue side by side with that fluid, presenting a streaked red and white appearance, without any coagula- tion, until all the pus was carried forwards and downwards towanls the heart, and the vein was again full of blood. Another syringeful of pus was then injected, which could once more be seen first to flow with the blood, then, as its quantity increased, to take the place of the blood, and then, on the syringe being exhausted, to receive blood from above; the two mixini: toiretber, and con- tinuing their course witlmut coau'ulating, until once more the vein contained ncjthintr but blood. The wound was now closed, and the animal allowed to rise, which he did without apparent sufter- ing. He presented no unusual symptoms whatever during the next four days, when he was killed, and the parts carefuUv dissected. The vein was pervious, presented no thickening, nor cording or abscesses, and the external wound was nearly healed. This experiment appeared to be so decisive, and so clearly opposed to the idea that the contact or mixture of pus and blood necessarily induced coagulation in a livini: animal, that it was thought unnecessary to repeat it. With regard to the slight coagulability ajipareiitly occasioned in the tirst experiment, it was attributed to injecting contrary to gravity, whereby the mixed pus and blood were allowed to fall backwards and remain stationary, while the liirature prevented any flow of blood from being continued, No such phenomenon was observed in the second experiment, where no ligature was employed, and where the etfect of gravity was avoided by injecting downwards. In a communication, however, received from Dr. Henry Lee, I was informed that no ligature was employed by him. The second experiment was in its nature the same as the seventh and eishth experiments of Dr. Henry Lee, and yet none of the appearances observed by that gentleman resulted. There was no fulness or cording of the vein, no acceleration of respiration or constitutional symptoms; and after death no coagulation of the blood, no obliteration of the vein, nor local inflammation. What are the circumstances which occasioned this difference, I am not jirepared to say ; but the positive fact of having introduceil the pus on two separate occasions, as recorded in Experiment 2, of hav- ing seen the pus mix with the blood and the blood with the pus, through the transparent vein, withi>ut producing coagulation, is sufficient to negative the general pi-iipo>iti(]n. tliat whenever pus is mingled with blood in a living animal, co.agulatiou of the latter fluid is the invariable result. * Gazette Med de Paris, p, 19:5. 1834. f Ibid. p. 593. 1837. Both cited by Sedillot, Op. cit. p. 5.5. X These Inaao;urale. Paris, 18-12. t? Dictiorniaire de Med,, torn. 26. 1842. I Monthly Journal. November 1851. P. 486. 852 DISEASES OF THE BLOOD. these symptoms, the irresistible conclusion is, that these effects are not owing to pus in the blood, but to an animal poison. This view has been opposed on the ground that fresh pus, to all appearance healthy and without odour, has yet caused the death of ani- mals. But what sensible property distinguishes the pus of the vaccine from the small-pox pustule, and either of these from healthy pus? And yet how different their effects when introduced into the blood ! The subject of animal poisons is certainly obscure ; but it is more in accord- ance with our actual knowledge to attribute purulent infection to such a cause, than to consider it as the consequence of the mere mixture of pus with the blood, or a so-called pyohemia. This doctrine, which was first clearly put forth in my work on " Leu- cocythemia" in 1852, seems now to be generally adopted, and the con- dition of the blood has been called septicaemia (Vogel), and ichorhfemia (Virchow). The so-called pus-corpuscles, which some observers have thought they saw in the blood, are identical with the colourless cells of that fluid, and if in excess, constitute white cell blood. Virchow himself, who has claimed so much for simply denying that leucocythemia can be pyaemia, is obliged to admit, when writing on the latter subject,* that the diagnosis between pus and the colourless cells of the blood is very difficult, and frequently impossible. In truth these bodies are the same, and in the majority of cases, what has been called pyaemia is not depend- ent on pus cells mingling with the blood, bnt on a matter derived from some kinds of pus, which poisons the blood, and occasions the secondary phenomena. GLUCOH^MIA. Case CLXXXVUI.^— Diabetes MeUitus. History. — Allan M'Clemont, fet. 32, labourer — admitted Ttli June, 1852. About three weeks ago, on recovering from a general rheumatic attack, he found himself much reduced in strength, and somewhat emaciated. He experienced great thirst, and passed a large quantity of urine. These symptoms have rapidly increased. Symptoms on Admission. — On admission, tongue moist and clean, appetite increased, thhst excessive, bowels rather costive, skin dry, urine very pale, and shghtly turbid. On heating a portion of the urine with an equal portion of Aq. Potassse, a deep brown colour is produced. He has passed during the last 24 hours, 380 oz., spec. grav. 1030, having drunk 460 oz. of water in that time. Other func- tions performed normally. His weight was 11 stone 8 lbs. Ordered pills of Aloes and Ipecacuan, and a mixture of Irf. Quassice and Tr. Aurantii. Progress op the Case. — On the lOth June, he was ordered the following diet: 3 cakes made of bran, butter, and milk, weighing half a pound ; 3 eggs; 4 oz. steak for breakfast, 12 for dinner, 4 for supper; 1 cabbage; 3 bottles of soda water; 8 oz. of lime water; 3 oz. of wine. To have a warm bath every third night. On 15th June the amount of urine passed was diminished to 120 oz. in the day, of density 1036, and he drank during that time 150 oz. His weight was 11 stone. On the 22d, he was ordered 4 oz. of steak additional, and another bran cake. From this * Gesammelte Abhandlungen. P. 653. f Keported by Mr. J. L. Brown, Clinical Clerk. GLUCOHJEMIA. 853 time the amount of urine fluctuated from IGO to 190 oz. daily; but on the bth July, it was reduced to 150 oz., spec. grav. 1034, and his drink was 167 oz. He tlien weio-hed 11 stone 2 lbs. ; but being wearied of the treatment, he insisted on going- out on the 6th. Case CLXXXIK..*— Diabetes Melliius — PJdhisis Pulmonalis— Vomica on Right Side — Death. History. — Robert Fallow, a tailor, xt. 24 — admitted into the clinical ward, July 8th, 1851. Last December, while in America, was attacked with bilious fever, which continued ten weeks. Shortly afterwards, he observed that the quantity of urine he passed was greatly increased, and that his thirst was excessive. Cough appeared sis weeks ago, followed by purulent expectoration ; and the skin, which had previously been remarkably dry, was now covered with copious sweat during the night. Symptoms on AD^[ISSIOX. — Percussion elicits no decided difference of sound on either side of the chest, but there is a much greater degree of resistance under the right clavicle than under the left. On auscultation, cavernous respiration is very distinct under the right clavicle, but the sounds are dry. The vocal resonance, also, is greatly Increased in the same situation, and has somewhat of a metallic character. Under the left clavicle, inspiration is harsh, and expiration prolonged. On the left side, posteriorly and inferiorly, the inspiration is everywhere harsh, -nath occasional cooing rales and prolongation of the expiration. The expectoration is copious, muco-purulent, and of brownish tint, without distinct traces of blood. Cough severe. Tongue furred and dry, coated near the base. Appetite good. Thirst insatiable. Sour-sweet taste in the mouth. Pulse 108. small and weak. Has voided 70 oz. of urine during the last twelve hours. The addition of liq. potassse, followed by heat, throws down a reddish brown sediment. Skin soft and moist. Progress of the Case.— On the 11 ^7i of July, gurgling was heard under the right clavicle. On the 20^^, there was complete loss of appetite, and repugnance to food. The urine varied since last report, from 170 to 230 oz. voided in the 24 hours. Profuse sweating at night. Mucous rales heard over the whole anterior surface of chest on the right side. Vocal resonance still metallic under right clavicle, with cracked-pot sound on percussion. August A.th. — The amount of urine passed now varies from 100 to 150 oz. during the 24 hours. 'S\'eakness and emaciation have greatly increased ; sweating and loss of appetite continue. Died at 7 p.iM. As to treatment, he was ordered a- diet, consisting at first of eggs, boiled meat, and stale bread and milk; pills of opium and hyoscyamus at night, and cod-liver oil internall^v. An expectorant mixture, afterwards combined with antispasmodics, was ordered to relieve the cough. Permission to examine the body could not be obtained. Commentary. — riitliisis pulmonalis is a very common complication of diabetes in persons under 30 — a circumstance which appears to nie to support the pathological views formerly given, as to the great import- ance which should be attached to derangement of the nutritive func- tions, as a cause of the tubercular disease. An animal and oleaginous diet is indicated in both disorders; which, however, when present in the same individual, may easily be supposed to constitute a hopeless form of malady. * Reported by Mr. W. M. Calder, Clinical Clerk. 854 DISEASES OF THE BLOOD. The excretion of sugar in large quantities by the kidnej^ has for a lengthened period excited the attention of pathologists, and given rise to abundant speculation. It hfiving been shown bv Mr. Macgregor of Glasgow, that sugar was foi'med in the stomach from the digestion of food, while that principle was subsequently detfcted in the blood by the same observer, as -svell as by Ambrosiani, Maitland, and Percy — the vicAv of RoUo was, on the whole, considered the coiTect one, and the treat- ment he proposed has been, in its main features, followed by subsequent })ractitioners. This theory supposed that the sugar formed in the stomach and alimentary canal, from the starchy and saccharine principles of the food, instead of being rapidly conveited into other compounds, as Prout supposeil, was absorbed into the blood, and excreted bv the kid- neys. The treatment based upon this theory was, therefore, directed to keeping up nutrition from substances which were thought incapable of being converted into sugar; and it is worthy of remark, that such treat- ment does often greatly diminish the excretion of sugar, without, how- ever, suppressing it, and also ameliorates the other symptoms. Dr. Gray of Glasgow was induced to give rennet in teaspoonfnl doses after each meal, and published three cases, in two of which it occasioned an appa- rent cure. (Monthly Journal, January, 1853.) He argued, that if out of the body rennet converts a solution of sugar into lactic acid, it may have a similar etfect upon a solution of sugar within the body ; and bearing in mind that lactic acid is found in the juice of tlesh, and, accord- ing to Liebig, is a supporter of the respiratory process, he considered that if sugar, formed in the body of a diabetic patient, could be con- verted by the rennet into lactic acid, it would be burned in the lungs; and that if a larger quantity was formed than could be consumed in this wav, that portion would be excreted by the kidneys. In consequence of this ingenious theory, and the facts in its support adduced bv Dr. Gray, rennet was tried in several cases admitted into the Eoyal Infirmary of Edinburgh, but without success. The researches of M. Bernard have given rise to other views as to the origin of diabetes. He admits that sugar may be formed in the process of digestion, and that a certain amount of it may, as a result of absorp- tion from the alimentary canal, find its way into the blood. But he has demonstrated that, in dogs fed entii-ely on animal food, sugar may exist in the liver and in the blood of the hepatic vein, while it is absent in the portal vein. Moreover, he has shown that sugar is a normal secretion of the liver of all animals, from man down so low in the scale of beings as the mollusca ; and that, moreover, it is secreted by the liver of the foetus. He has proved, experimentally, that this secreting function is increased, and diabetes produced, by irritating the eighth pair of nerves at their origin in the fourth ventricle ; while, on the other hand, section of these nerves destroys its formation. I have seen M. Bernard perform these experiments, and have repeated them myself in this city, and have no doubt as to the accuracy of these results. That sugar does not exist normally in urine and in blood drawn from the arm, is explained by its rapid decomposition in a state of health, and its excretion by the lungs. But when it is so increased in quantity that the lungs cannot excrete the whole of it, the remainder passes off by the kidneys, and hence diabetes. M. Bernard has also ascertained, that although section of the pneumo- GLUCOH^MIA. 855 gastric nerves destroys the formation of sugar in the liver, it is restored by artificially irritating their central cut extremities ; and that diabetes is produced exactly in the same manner as by irritating their origins in the brain. He was therefore led to conclude, that the nervous action necessary for the secretion of sugar does not originate in the brain, to be transmitted directly along the pneumogastrics, but indirectlv and bv reflex action ; the vagi being incident nerves, the medulla oblongata the centre, and the spinal cor I, communicating with the solar ganglion, the excident channel. Following oat this theory, he found that whenever the respiratory function is violently stimulated, sugar appears in the urine; and that, whenever aetlier or chloroform is given, a temporarv diabetes is occasioned. He further supposes, that in the same way that the lungs thus act by reflex nervous influence on the liver, so increased action of the liver acts upon the kidney ; consequentlv, that the sugar produced in excess by one organ is excreted by the other. Hence mav probably be explained the occasional temporary presence of suorar in the urine, independent of the disease known as diabetes. Continuing his researches, M. Bernard has arrived at the conclusion, that the liver does not secrete sugar directlv, but rather a substance which presents all the physical and chemical properties of hydrated starch, and which is transformed into sugar by the aid of a ferment. This substance he has at length succeeded in separating from the liver. The ferment he presumes to exist in the blood, so that the starchv substance formed by the vital action of the liver undergoes a chemical transformation into sugar when it comes into contact with the blood. The sugar, thus formed in the blood, on arriving at the lungs, is in its turn decomposed by the oxygen of the air, and disappeais. Hence the liver and the lungs are so far opposed to one another in function, that the one produces the substance out of which sugar is formed, whilst the other decomposes the sugar which in health exists in that part of the circulation only that lies between the liver and lungs. It follows that the occurrence of sugar in the circulation generally, and its pre- sence in the urine, is probably dependent not so much upon excess of hepatic, as upon diminution of pulmonary action. It is certain that the great majority of diabetic patients die phtiiisical. These more recent views of Bernard point to the importance ot the observations made by Yirchow, Busk, Carter, and others, as to the existence and even wide diflusion of starch corpuscles throughout the animal economy (Carter), and should stimulate organic chemists to ascertain whether some chemical change in the lung mav not be the true cause of diabetes. In the meantime, the researches of M. Bernard explain whv Rollo's treatment diminishes the excretion of sugar, by cutting off all that enters the blood through the alimentary canal. According to Trauhe, the intensity of the secretion of sugar varies at different times of the day, and under different circumstarices. Thus it is greatlv increased after meals, and is least during the night. At the commencement of the disease, it is principally derived from the food; in the latter stage, it is largely formed by the organism. Hence why treatment directed to the stomach does not cure, because it fails to affect the hepatic organ. Bernard's observations appear to me also capable of throwing 856 DISEASES OF THE BLOOD. light on the o-ood effects of opium — effects -which are universally recog- nised — from its power of diminishing nervous irritability. No other practical results, however, are as yet derivable from them, nnless the well-known symptom of dryness of the skin be connected with the cause of the disorder, in which case diaphoretics, though they have often been used with great benefit, would be more strongly indicated. Perhaps, also, exercise and a cold atmosphere, which increase the oxygenating power of the lungs, might be of some avail. Further researches are required on these points, and it is to be hoped that practitioners, no longer exclusively directing their attention to the digestive organs, may, by new efforts, ultimately be enabled to control this singular disorder. The diet ordered in Case CCVII. is one which admits of very slight formation of sugar in the alimentary canal, and, together w'ith opiates and the occasional use of the warm bath, constitutes the best treatment which has hitherto been adopted. Its good effects were well mani- fested, although it proves, in conjunction with the confinement of an hospital, ver}' irksome to the patient. CONTINUED FEVER. A state of fever may be said to exist when we find the pulse accele- rated, the skin hot, the tongue furred, unusual thirst, and headache. These symptoms are commonly preceded by a period of indisposition varying in extent and severity, the febrile attack being marked by a rigor or sensation of cold. This rigor, though not invariably well characterised, is the symptom from which, when present, we date the commencement of the fever. Although fever may in one sense always be said to exist when the above group of symptoms is present, such fever may be idiopathic and essential, or symptomatic of some local lesion. It is to the former condition that the term fever is universally applied. Some pathologists, indeed, have endeavoured to show that there is no such thing as idio- pathic or essential fever, although they have differed among themselves as to the lesion of which it is symptomatic. Intermittent fever has been supposed to be symptomatic of diseased spleen, and remittent fever of intestinal derangement. With regard to continued fever, some have spoken of cerebral, others of intestinal or abdominal typhus. Another class have supposed, from the occasional appearance of an eruption on the skin, that it is allied to the exanthemata. If, however, you carefully watch the Ediubui'gh continued fever, you will easily satisfy yourselves that it frequently occurs independent of any of these lesions. Did we indeed adopt these views, we might, as Dr. Christison has pointed out, with more plausibility, maintain the existence of a pulmo- nary typhus, as we observe the lungs to be much more commonly affected in this city than any other organ in the body during fever. I agree, therefore, with those who consider continued fever as an essential disease, dependent on some unknown constitution of the blood, and occasionally accompanied or followed by various local lesions of the CONTINUED FEVER. 857 cranial, thoracic, or abdominal viscera, and with various eruptions on the skin. Although this may be considered as the correct general view of con- tinued fever, it cannot be denied that it assumes various forms, which have been described in different ways by authors in this and foreign countries. Considerable confusion has consequently arisen, as to whether fevers observed in different places, and at various times, were identical or dissimilar in their nature ; and whether the varieties they presented were only attributable to the concomitant lesions which might be present. Any one who studies fever first in this citv, and afterwards in Paris, will soon convince himself that there are at least two predominant kinds of fever ; — the one called by us typhus, the other called by the French typhoid, — that is, resembling typhus. Ao'ain, those who have studied fever in Edinburgh tor the last fourteen vears consecutively, are aware that every now and then a form of the disease is prevalent, which runs a short course, but has a tendency to relapse at pretty regular periods. Lastly, there is in fever, as in most other diseases, a kind which is very slight, and soon ceases — a so-called febricula.* Every practical physician is acquainted with these forms of fever ; but whether they constitute varieties of the disease, which can be at all times separated, which have a distinct and invariable course, the one not being protective of the other, and so on, are points that are by no means determined. Dr. Jenner, in a very elaborate series of papers inserted in the "Monthly Journal" during 1849-50, has endeavoured to show that febricula, relapsing fever, typhoid and typhus fevers, are four distinct diseases. He considers them, to use his own language, "as distinct from each other as are measles, scarlet fever, and sinall-pox, the poison of the one being, by no combination of circumstances, capable of pro- * The variable amount and extension of fever at different times may be gathered from the following table, showing the number of cases which have entered the Royal Infirmary of this city during the present century, which I extract from a paper lately published by Dr. Cliristison. — (Edinburgh Med. Journal, Jan. 1858.) Table showing the Annual Number of Fever Cases in the Royal Infirmary since the beginning of the century. 12 Months to Dec. 1800, 329 12 Months to Dec. 1820, 63S 12 Months to Oct. 1889, 1235 " ISOl, 161 " ly21, 327 " 1840, 782 " l^(^2, 156 " 1S22, 355 " 1S41, 1372 " ls03, 282 " 1823, 102 " 1842, 842 " 181)4, 328 " 1824, 177 " 1^4:3, 20S0 " isn5. 1T5 " 1825, 341 " 1844, 3339 " 1806, 95 9 Months to Oct. 1826, 450 " " 184J. 088 " 1S07, 110 12 Months to Oct. 1S27, 1875 " " 1*^6, 693 " 1808, 111 " 1828, 2018 " 1847, 36^8 " 1809, 1S6 " " 1829, 771 " ls4s, 4693 " " isio. 143 " 1880, .346 " 1849. 726 " 1811, 96 " " 1S;31, 758 " 1>50, 520 •' 1812, 103 " 1S82, 1394 " " ls.'il, 959 " 1813, 75 " ■' 1833, .s78 " 18.i2, 691 " 1M4, 87 " 1884, C90 " " 1853, 574 " ISI.% 96 " " 1885, S26 " 18.H, 168 " 1S16, 105 " 1-86. 652 " 1S5.5, 201 •' l'^17, 4>5 " 3>37, 1224 '• ls56, 180 " 1818, 1.546 " 1888, 2244 " " 1857, 126 " 1819, 108S 858 DISEASES OF THE BLOOD. ducing, inducing, or exciting the others." He gives the following characters which, according to hiin, serve to distinguish these four kinds of fever. " Fehrkula, — A disease attended by chilliness, alternating with sense of heat, headache, white tongue, confined bowels, high-coloured scanty urine, hot and dry skin, and frequent pulse, terminating in from two to seven days, and having for its cause excess, exposure, over-fatigue, etc. — i. e., the cause of febricula is not specific. " Relapsing Femr. — A disease arising from a specific cause, attended by rigors and chilliness, heatiache, vomiting, white tongue, epigastric tendei'ness, confined bowels, enlarged liver and spleen, higli coloured urine, frequent p'ulse, hot skin, and occasionally by jaundice, and termi- nating in apparent convalescence in from five to eight days; in a week a relapse — i. e., a repetition of the symptom present dui'ing the primai'v attack. ' After death, spleen and liver are found considerably enlarged ; absence of marked congestion of internal organs.' " T//phoid Fever. — A disease arising from a specific cause, attended by rigors, chilliness, headache, successive crops of rose spots, frequent pulse, sonorous rale, diarrhoea, fulness, resonance and tenderness of the abdomen, gurgling in the right iliac fossa, increased splenic dnlness, delirium, dry and brown tongue, and prostration, and terminating by the thirtieth day. After death, enlargement of the mesenteric glands, disease of Peyer's patches, enlargement of the sjjleen, disseminated ulceiations, disseminated inflammations. " T[iphus Ferer. — A disease arising from a specific cause, attended by rigors, chilliness, headache, mulberry rash, frequent pulse, delirium, dry brown tongue, and prostration, and terminating by the twenty-first day. x\fter death, disseminated and extreme congestions ; in young ])er- sons, enlargement of tlie spleen." — [Medical Times — Twentieth Paper.) Dr. Dundas of Livei-pool has advanced another doctrine, entirely opposed to that of Dr. Jenner. llis views on the subject of fever are essentially these :— Not only are there no specific ditferences between the various kinds of continued fever, but there are none between con- tinned, intermittent, and remittent fevers. All these disorders, according to Dr. Dundas, are essentially one disease, and may all be cured by one remedy, viz., quinine. Given in doses of ten grains, repeated at intervals of two hours, until five or six doses had been taken, he says that it arrested or cut short a continued, as it did an intermittent fever. These statements, deliberately brought forward, and still maintained, by Dr. Dundas, who, in Brazil and in this country, has had abundant oppor- tunities of carrying out the practice, supported, moreover, by confii-ma- tory cases, published by difterent medical men in Liverpool, determined me to give this practice a fair trial. During the months of November, December, and January 1851-2, I treated nineteen cases of continued fever in the clinical wai'ds, of which four were febricula, one relapsing, three typhoid, and eleven typhus fever. In a disease so common as fever, I have thought it necessary to condense the facts as much as possible, from the lengthy and accurate reports taken in the hospital books. All these cases, however, were examined with the utmost care, and all the phenomena noted, especially in reference to the two doctrines I have placed before you, — viz., those CONTINUED FEVER. 859 of Dr. Jenncr and of Dr. Dundas. P^irther, to avoid repetition, I have simply stated that the quinine treatment was employed ; but in every case this treatment was practised exactly in the manner recommended by the last-named physician. The effects we observed to be produced by the quinine I shall notice afterwards. FEBRICULA. Case CXC.*— Margaret Divine, £et. 42— admitted 26tii Nov. 1851. "Was attacked with rigors on tlie 23d, after complaining for two days before of headache and general debility. On admission complained of pain in the limbs, and general dull pains over the bod}'. Had no appetite, but great thirst, with a dry furred tongue; she is very subject to pyrosis ; skin was hot and dry, pulse 80, strong ; a slight murmur accompanied the firet sound of the heart. 5 Sul. Acetat. Ainmon. §i; Villi Aniimoa. ^ij; Aqua, 2iij. M. To take one table-spoonful every four hours. Novembe)- 28Wi.— Better to-day ; pulse 72 ; a sediment filling one-fourth of the glass is deposited in the urine ; still general dull pain of surfece. 29revalent. During this epidemic, I opened the bodies of sixty-three individuals who had died of typhus and typhoid fever, with the following results : — Spleen.— The organ most frequently affected was the sple'en. In the majority of cases it was more or less enlai'ged and softened, presenting a mahogany-brown colour, and creamy consistence ; so that when pressed, the whole of its parenchyma could be squeezed out of its capsule. In ten cases the spleen contained yellow fawn-coloured discolorations with abrupt margins, sometimes diff\ised in masses varying in size fioin a walnut to that of a hen's egg, at others, disseminated in miliarv spots through the organ. In two" cases, these altered masses of the spleen's substance had softened and burst into the peritoneum, causing fatal peritonitis. In another case, a distinct line of separation was ob'served to be forming round a mass about the size of a walnut. * Medico-Chirurg. Trans of Loudon. Vol. xii. CONTINUED FEVER. 873 On examining this altered texture in the spleen with a power of 250 diameters linear, it was found to consist of — 1st, numerous molecules and granules ; 2d, free nuclei ; 3d, compound granular cells of various sizes ; 4th, fragments of the fibrous tissue and fusifoini corpuscles of the organ. The granu- lar cells were frequently ruptui-ed, more or less broken down, and appeared to me at tliat time to constitute the structural character of a new formation which had been described by Roki- tanski and other Gei-man pathologists, as typhus deposit. This deposition, according to them, bears the same relation to the constitu- tion of the blood in cases of typlius fever, as tubercle and cancer do to the tubercular and J^ig- -i"^- xr^.-njv. cancerous cachexia3. Although the facts described bv Rokitanski and others are quite correct, as well as his description of the structure of this altered tissue Avhich I confirmed in 184G-V, fuither observation has con- vinced me that these alterations are not peculiar to typhus, and do not constitute a distinct form of exudation. They consist, in point of fact, of a peculiar degeneration of the splenic pulp, which follows a greater or less increased growth of the glandular cells, the morbid anatomy of which is displayed in a series of preparations I placed in the University Museum, where they can be studied. Lungs. — The organs most frequently affected after the spleen were the lungs. The most common lesion was bronchitis, the bronchial lining membrane being of a deep mahogany or purple colour, more or less infiltrated with serum or exudation. The fine bronchial tubes Avere fre- quently filled with a muco-purulent matter, and in a few cases were choked up with a reddish-brown gelatinous substance, more or less fluid — probably a modified form of the exudation described by Remak, as discovered by him in the sputum. The apices of the lungs were very commonly axlematous, yielding on section a copious grayish fiothy fluid. In fifteen cases, the lungs were more or less consolidated by exu- dation, which seldom presented the characters of normal hepatization. It was sometimes of a dirty yellow tint, at others of a brownish choco- late colour, existing in masses of irregular outline, and of variable size, resembling the discoloured portions of the splenic pulp, formerly alluded to. In three cases there was pulmonaiy apoplexy. The dirty yellow or chocolate-coloured exudation into the lungs was ascertained, on microscopic examination, to consist of, — 1st, numerous molecules and granules, filling up the air vesicles, and infiltrated into the areolar tissue ; 2d, naked nuclei ; 3d, enlarged and isolated epithelial cells, with multiplying nuclei ; and 4th, several compound gramilar cor- puscles. This uoaterial was also supposed to belong to the so-called typhous deposits, but is more probably in part an altered exudation, dependent on the constitution of the blood, and partly a desquamation of the epithelium, with tendency to multiplication of inclosed nuclt-i. Intestines. — The intestines presented the lesion so well described by Fig. 495. Structure of a decolorized mass in the spleen. Fig. 496. The same after the addition of acetic acid. 250 diam. 871 DISEASES OF THE BLOOD. Bretoiinean, Louis, Cruveilhier, and others (dotliinenteritis, typhoid ulcer, etc.), in nineteen cases. It consisted of a peculiar alteration'of the round ^Si li_ 497 rig 498 ■'tis Vis. 499. and oval glandular patches of the small intestine, exhibiting in its first stage a flesh-coloured mass, raised above the mucous membrane, pre- senting in the round patches the form of a pimple, or a split pea, and in the oval ones an abrupt elevation, resembling an inverted dish. In the second stage this mass was more or less softened, especially round the edges, exhibiting a tendency to separate and slough. In the third stage, the slough had separated, leaving an ulcer, with abrupt edges, equal in area to the size of tbe gland afieeted, but varying in depth, occasionally passing through the muscular, and resting on the peritoneal, coat of the intestine. In this latter case, the peritoneum externally often presented a red or violet patch of congested vessels, indicating the ulcer below. The elevated patches were observed occasionally to extend as high as the duodenum, and as low as the rectum. In one case numerous dothinenteritic elevations, about the size and shape of a split pea, extended all over the ascending and transverse colon. In a few cases the isolated follicles in the large intestine were observed swollen and empty, pi-esenting in their centre a dark blue or black spot. In others, the round and oval patches of the small intestine exhibited a grayish or slate-blue appearance. Perforation of the intestine from ulceration, causing fatal peritonitis, occurred in three cases. Dysentery, with flakes of lymph attached to the mucous surface over the ascending and trans- verse colon, was associated with intense dothinenteritis in one case. Oval and round cicatrices, exhibiting ditferent stages of the healing pro- cess of the intestinal typhous ulcer, were observed in two cases. On examining the matter found in the intestinal slands in the above cases, it was shown to consist of numerous molecules and granules, asso- ciated with free nuclei and cells of the glandular sacs, which were unusu- ally distended, and filled with cell elements, in various stages of develop- ment and disintegration. In this respect it closely resembled the altered substance of the spleen, formerly described, and indeed appeared to con- sist of the same glandular lesion. Mesenteric Glands. — In all the cases where the intestinal ulcerations were recent, tlie mesenteric glands were enlarged, soft, and friable, and Fig. 497. Appearance of exudation and epitlielial cells in the lung in a case of typhoid pneumonia. Fig. 493. Another portion of the same lung, after the addition of acetic acid. Fig. 499. Portions of normal epithelium separated from the air vesicles. 250 diarn. CONTIXUED FEVER. 875 of a ofravish or reddish-purple colour. Some of these glands reached the size of a heu's egg. On section they presented a finely g-ranular surface, of a dirty yellow -grayish or dark fawn colour, and their sub- stance was generally soft and friahle, but sometimes, in one or more parts of the swollen gland, broken down into a lluid of creamy con- sistence. On examining this creamy matter, or the fluid squeezed from the gland, with a power of 250 diameters linear, it was found to contain mmierous cells, generally spherical, varying in diameter from the l-150th to the l-35th of a millimetre. In some cases numerous nuclei were con- tained in the cell, occupying three-fourths of its interior, generally about the l-200th of a millimetre in diameter. At other times from one to four of these nuclei were seen scattered within the cell. On the addi- tion of acetic acid the cell-wall was rendered very transparent, whilst the nuclei were unatfected. Many of them were free, and at first looked like altered blood corpuscles, from which they were at once distin- guished by the action of acetic acid. (See Figs. 200 to 202, p. 172.) Blood. — The blood, in the great majority of cases, "was fluid, and of a dirty brownish colour. In those instances, however, where the disease had been protracted, and especially in such as presented well-marked glandular disease, firm coagula w ere found in the heart and large vessels. Other Lesions. — AYith regard to the other lesions observed in the 63 bodies, it may be said that in two there were glossitis, and laryngitis with tonsillitis ; in one, abscess of the kidney ; and in one, abscess of the posterior mediastinum. The brain did not appear to participate much in the disease. It presented only occasional congestion, with slight etfusion into the subarachnoid cavity, or into the lateral ventricles. In seven bodies no lesion whatever could be discovered. Such is a summary of the appearances observed in sixty-three bodies of patients who died of fever during the prevalence of the typhoid form of the disease, during 1846-7. The proportion of typhoid to typhus cases I have now no means of ascertaining. On the whole, however, the account given is a faithful description of the frequency Avith which the individual lesions occurred, and of their minute structure. AVith regard to the nature of typhoid, as of all other forms of fever, we know little ; but, from what has been said, it is impossible to avoid seeing, that the spleen, mesenteric and intestinal glands, are especially liable to be aftected. Xow these glands constitute part of an apparatus which, I believe, secretes the blood (see Leucocythemia) ; and if so, we begin to catch a glimpse, at all events, of the connection between altera- tions of these structures and of the blood in fever. Further researches, however, are required to determine the nature of such connection, as well as how far in this disease the glands operate upon the blood, and the blood upon the glands. Of the numerous questions which will be found discussed in syste- matic works relating to the pathology and mode of propatration of con- tinued fever, I shall only here allude to one, namely, AVhether it be or be not advisable and right to admit fever cases into the general ward of a hospital. My reply is decidedly in the aflirmative, being satisfied it is far better in every point of view to dilute the contagious element, rather 876 DISEASES OF THE BLOOD. than to concentrate it by providing special wards for typhus cases. Pre- vious to 1825, a few fever cases were treated in each clinical ward of this Infirmary without injury to the other patients, the disposition of the fever beds being represented in shadow, in Fig. 500. The space around Fitr. 500. them was partially isolated by a screen partition, seven feet high, with a door at each end. At present the arrangement of fever beds in the clinical wards is represented, Fig. 501. Each bed has 1100 cubic feet of space, and 8i- feet of head room. There is a window on each , every fever bed, and a space of six feet between it and the ad] ones. The result of this system has been most satisfactorv, as the last ten years there has been no spi'ead of fever in the wards, on one occasion, which was traced by Dr. Christison to the rules house having been neglected.* side of oining during except of the Treatment of Continued Fever. The general treatment of continued fever which I have found most * Monthly Journal of Medical Science, March 1850. Fio:. 500. A clinical ward of the Royal Infirmary in 1817, GO feet by 24, showing the arrangement of fever beds, and the screen which isolated them. — (Christison.) Fig. .501. Clinical ward, No. XL, 1858, 81 feet by 24, showing the present arrangement. — ( Clwistison. ) COXTIXUED FEYER. 877 useful, anurgative of ndphaie of magnesia. December \Wi. — The vesicles are numerous and close together on the face, and in some places confluent. Eyelids much swollen and nearly closed. * Reported by ilr. J. L. Brown, Clinical Clerk. 894 DISEASES OF THE BLOOD. Bowels are open ; pulse 140 ; tongue florid. The hair was cut short, and mild mer- curial ointment, thickened with starch, spread over tlie face. She was also vacci- nated. Dtc. \Z(h. — Pustules fully maturated and umbilicated over the trunk and extremities. The mercurial paste forms a thick indurated crust over the face. Bee. lath. — Many of the pustules over the body have burst and discharged their contents. No constitutional disturbance. No pain or itching of the face : all swelling of the eyelids disappeared. Dec. ISth. — Pustules have all burst, except a few on tlie feet, "^as dismissed January 6th, cured. The face scarcely presented any trace of the disease, and afforded a remarkable contrast to those other parts of the skin -which had not been covered with the paste. Case CCXX.* — Michael Hogan, ajt. 9, admitted December 10, 1851. a brother of the former case, and also never vaccinated. Felt unwell on the 8th, with shivering, pain in the head, and usual febrile symptoms. On the next day vomited, and then observed an eruption on the skin. On admission, the face, trunk, arms, and legs are spotted with bright papules at considerable distance from each other, and he says the fever has considerably abated. On the 15th the pustules on the face were fuUy maturated, and here and there a few of them were observed to be confluent On the 18th those on the inferior extremities were in the same condition. Last night he experienced again considerable headache, and to-day the pulse is 120, full; the skin hot, and febrUe symptoms well developed. 19ih. — Headache violent last night, with great restlessness and insomnia; but to-day these symptoms have abated. From this time convalescence commenced, but he recovered slowly, and was not strong enough to go out untQ December 19tb. A few pits existed on the face, where the pustules had been confluent. Commentary/. — The general treatment of small-pox is similar to tliat of the other eruptive t'evei"s. There is a special treatment, however, applicable to it, which deser\'es some consideration. The Ectrotic Treatment of Variola. Various methods have been proposed, for the purpose of arresting the development of the eruption in variola, and preventing the cicatrices which are likely to form. The treatment, called ectrotic (;xri-PojCzcj, to render abortive), has been practised principally in France. Serres, Bre- tonneau, and Velpeau, cauterized each vesicle as it appeared with nitrate of silver, which immediately arrests its further progress. This is a very tedious process, while painting the surface with a solution of the caustic, causes so much pain and febrile disturbance, that it cannot be safelv employed. Dr. OlitFe, of Paris, recommended the vigo-plaster of tlie French Pharmacopoeia ; and having seen, in some of the journals, that mercurial ointment, thickened with starch, had proved very serviceable in the practice of M. Briquet, and others, in the Paris hospitals, I tried it in numerous cases which were admitted into the wards, and have seen the good effects of the practice. The two cases you have just had an opportunity of observing, however, especially demonstrate this. Case C XIX. presented the most confluent form of the disease I ever saw. The entire face was so crowded with the papules and minute vesicles of the incipient stage, that there was litei-ally not room to place a pin's head anywhere on the sound skin. It was evident that the whole sur- * Reported by Mr. W. M. Calder, Clinical Clerk. VARIOLA. 895 face of the face would be one mass of suppuration ; and sucli of you as Lave had an opportunity of observing a similar case of the disease, must be aware of its horrible aspect, the excessive agony produced, the great swelling of the eyelids, the dreadful suppuration and foetor of the dis- charge, the violent secondary fever, and the frightful cicatrices Avith which the countenance is afterwards covered. In this case none of these symptoms were present, and there can be no doubt that the ectrotic treatment really checked the progress of suppuration and modified the disease. From the moment the plaster was applied, all smarting and pain in the face ceased ; the eyelids were never swollen ; no supjniration occurred ; there was no secondary fever ; and on the mask leaving the face there was no pitting or suppuration. In other parts of the body the eruption passed through its usual stages, and the girl was dismissed from the house well, thirty days after the first commencement of the eruption. Considering this case was likely to be a very severe one, I felt myself authorised to use every means in my power to check the disease ; and as it has been asserted that vaccination, even after the com- mencement of the eruption, modifies its progress, I caused the gii-1 to be vaccinated on first seeing her. At that time the face, as we have seen, was closely covered with papuke and vesicles ; and I do not think that vaccination alone could have produced the remarkable result we have witnessed. I do not mean to deny altogether the influence of vaccina- tion in such cases, but I have no hesitation in ascribing the beneficial result almost entirely to the ectrotic treatment. To satisfy yourselves still more, if possible, as to the great advantage of this treatment, the case of the boy (Case CCXX.) may be contrasted with that of the girl (Case CCXIX.) who also had never been vacci- nated. His was evidently a very mild case, the eruption discrete, and the constitutional disturbance slight. I allowed it to run its natural course, and the result was in every respect difl^'erent from that in which the plaster had been applied to the face. The secondary fever was tolerably smart, the subsequent prostration proportionally severe ; recoverv was delayed to the thirty-ninth day, and notwithstanding the generallv dis- crete character of the eruption, a few pits existed on the face. Since I first practised this ectrotic treatment in small-pox, I have met with numerous instances in which slio-ht salivation followed the use of the mercurial plaster. Dr. George Paterson* of Tiverton, however, published a case in which the salivation from the employment of the strong mercurial ointment was excessive and dangerous. I quite ao-ree with that physician in thinking the occasional occurrence of such violent salivation would seriously compromise the otherwise remarkable advan- tages of the ectrotic treatment. But it may be asked whether, after all, the mercury is in any way necessary to the success of this treatment. Its original propounders iii Paris may indeed have supposed that the absorbent powers of the drug constituted the true cause of its success, but it seems to me that another explanation may be oftered. There is, for instance, a close analogy between the mode of healing of wounds and ulcers, so well described by Dr. Macartney of Dublin — that is, the so-called " modelling process," — and what takes place in the ectrotic treatment of small-pox. In the * Montlily Journal, Dec. 1852. DISEASES OF THE BLOOD. former, cicatrices are far less liable to be produced than after healing by the first or second intention, and in the latter the pitting or cicatrization is prevented. The artificial plaster therefore takes the place of the natural scab or clot of blood, protects the parts below, and enables them to heal slowly but more perfectly than if exposed to the air uncovered and uncompressed by supeijacent crusts. If this be the correct theory of the ectrotic treatment, the mercurial might be discarded, and any kind of plaster which would concrete on the face might be expected to produce the same beneficial result. In 1854 I determined to try the etfects of such a plaster, and after two or three failures succeeded in pro- curing one that answers perfectly. The first case I treated with simple lard, thickened with starch and powdered charcoal, but it was so little coherent, that the patient, during the night, rubbed it off on her pillow or with her hands, and on her recovery slie was pitted all over. In another case I tried carbonate of magnesia saturated with oil. But this also failed. In a third case, however, common calamine {zinci carhonaft)^ saturated with olive oil (proposed by Mr. Bird, one of the clinical clerks), formed a coherent, tough crust, which remained on the face, and was found to answer well. Numerous cases of natural small-pox have been since treated in this manner, with the result not only of preventing the pitting, but of diminishing the local and general symptoms, exactly in the same manner as I have formerly detailed, as being the efiect of the mercurial plaster. The following is one of these : — Case CCXXI.* — Alexander Ross, set. 13, never been vaccuiated, was seized with sliivering on the 7 th January, followed by the usual symptoms of fever. Entered the Infirmary on the 9th, when a few papules were observed on the face and arms. On the 12th the face was thickly covered with vesicles, which from their closeness would certainly have become confluent. The mask of calamine and oil was now applied. The disease ran its usual course, the eruption being confluent on the arras and trunk. Throughout the progress of the case the application of cala- mine saturated witli oil preserved a firm and coherent crust, and was renewed from time to time. The patient experienced no smarting of the face, there was no swelling of the eyelids, no purulent discharge, or local unpleasant symptoms of any kind. The secondary fever was tolerably smart, delirium being present two days. On the 22d tlie mask came oS", leaving a clean smooth surface, free from all trace of pitting. Dismissed quite well on the 26th. The following formula, after numerous trials, has been found to con- stitute the most efficient plaster: — Carbonate of zinc, 3 parts; oxide of zinc 1 part, rubbed in a mortar with olive oil to a proper consistence. Dr. Wallace of Greenock, in pursuing this treatment, ascertained that the tincture of iodine, which has been recommended as an ectrotic, is of little use, and was led to employ as the best application, a solution of gutta percha in chloroform, first used by Dr. Stokes, and recom- mended by Dr. Graves of Dublin. The general subject of small-pox opens up to our consideration a multitude of considerations, of which we may notice three. 1. There can be very little doubt that the small-pox is again becom- ing frequent amongst us, a circumstance which some have attributed to * Reported by Mr. Bird, Clinical Clerk. VARIOLA. 89V deterioration of the vaccine lympli. That this cause does operate to a certain extent is very probable ; but, for my own part, I have been led to the conchision, that the terror for the disease which formerly prevailed among the public, has, through the protective discovery of Jcnner, and the eneigy with which vaccination was originally pursued, in a great measure declined, and that this is the principal cause. At present, multitudes of the lower orders no longer have their children vaccinated, and hence why our hospitals are so frequently encumbered with cases such as those we have just witnessed. We have no remedy for this but rendering vaccination imperative by penal enactments, as is done in some continental states. For the mode of vaccination, I must refer you to the account given in systematic works on the practice of medicine. It consists, as yon know, of making a puncture just sufficient to penetrate the epidermis of the skin, and to enable the vaccine lymph to be applied to the vas- cular dermis. For doing this surely and rapidlv, the little instrument I now show you, invented by Dr. Graham "Weii-,"^ is the best you can employ. It consists of a small handle of ivory, with four needle points projecting from one extremity, and a small curved knife for collecting and separating the vaccine matter at the other (as shown in the cut). The skin is opened by a crucial scratch w^ith the needle points, which are held vertically, and are lightly applied, so as merely to remove the cuticle. The advantages of this instrument over the lancet are, that the operation is done more speedily, and that it opposes a larger surface for the absorption of the lymph, which is less liable to be waslied away by too great an eft'usion of blood. 2. Sometimes small-pox occurs epidemically in a remark- ably benign form. It then presents all the characters de- scribed b}^ some authors as varioloid. Occasionally it occurs twice, or becomes what is called recurrent, and it has been known to arise frequently after vaccination. In all these circumstances, when mild, it so resembles chicken-pox, as not to be distinguished from it. But more tlian this, it was observed in the epidemic that prevailed in Edinburgh in 1819 and 1820, that small-pox and chicken-pox existed together frequently in different individuals inhabiting the same room, and sleeping in the same bed. Well authenticated cases occurred of individuals inoculated with small-pox, in whom the eruption assumed the appearance of chicken-pox ; and again persons inoculated with chicken-pox had small-pox well characterised. The work of Dr. John Thomson, entitled "An Account of the Varioloid Epidemics in Scotland, 1820," contains many facts of this description, which were Avell known at the time, and an account of numerous experiments carried on in the Castle garrison of this place, which have never been controverted, and which fully establish an essential '^'^'' ^"^ unity in the nature of the two affections. It is evidently incon- * Monthly Journal, 184T-4S, p. 69. Fig. 502. Dr. "Weir's scarificator for vaccination. 51 898 DISEASES OF THE BLOOD. sistent to suppose that two distinct contagions should exist at the same time, each of Avhich is protective against the other. Those who admit this doctrine must maintain tliat, whenever the chicken-pox con- tagion prevailed, tlie small-pox contagion was excluded, or the reverse ; or, on the other hand, they must admit that variola is produced by the same contagion that gives rise to chicken-pox. The work of Dr. Thomson furnishes ample proof of tlic correctness of the latter proposi- tion. Dr. Gregory and others who oppose this opinion, do so on the ground of the incubative stage being shorter; the whole disease less prolonged, and the constitutional symptoms being mild. These circum- stances, you will observe, only point to difference of degree and intensity, not of kind. Dr. Gregory also alleges that he lias seen variola occur after cow-pox, and cow-pox after variola, and therefore they cannot be identical. So far, however, does tliis appear to me no argument, that, if possible, it confirms Dr. Thomson's observations. The variola he speaks of occurring after cow-pox is evidently modified small-pox, and cow-pox may, in the majority of cases, be reproduced at pleasure. 3. Dr. Jcnner, through life, was of opinion that cow-pox, the grease in horses, swine-pox, and small-pox, were only modifications of each other. He believed that in giving to man cow-pox, he was in reality giving to him small-pox in its primitive and mildest form. Whether cow-pox or small-pox is the original form has been disputed. It occurs to me as more probable that cattle caught it from man, rather than man from cattle, an opinion conti)-med by the experiments of Mr. Ceely of Aylesbury, recorded in the "Transactions of the Provincial Medical and Surgical Association," (vols. viii. and ix.) He showed that by operating on tlie mucous surfaces of the animal, the cow readily receives the poison of human sraall-pox, which the constitution of the animal converts into the vaccine. 1 need not enter at length into the discussion which has been raised on this subject. Suffice it to say, that the identity of the t-\fo diseases appears to me to be established by the following incontro- vertible facts : — 1. The prevalence at the same period of the cow-pox among cattle, and the small pox among men. 2. The transmission by coniar/ion of the small-pox to cattle, and the consequent development of cow-pox in these animals. 3. The transmission by inoculation of the small-pox to cattle, and the resulting development of cow-pox in those animals. 4. The transmission by inoculation of the cow-pox to man, and the development thereby of a pustule similar in character to the vaccine pox of the cow. 5. The transmission by inoculation of the cow-pox to man, and the consequent development of an eruption similar, if not identical with small-pox. All these propositions have been established by numerous facts, which you will find ably stated in the "Report of the Vaccination Section of the Provicial Medical Association." See also Mr. Simon's Government Report on the "History and Practice of Vaccination, 1857." SYPHILIS. 899 SYPHILIS AXD MERCURIAL POISOXING. Case CCXXII.* — Syphililic Ulceration of the Face. Anne Bruce, set. 24 — admitted Jan. 10th, 1852. Her face presented a most frightful appearance, being covered, as well as the neck and upper part of the chest, with circular masses of pustular scabs. These varied in size, from a fourpennj' piece to half-a-crown, several being in some places crowded together. Some of the pro- minent scabs were dry, others soft, with foetid pus oozing from their bases. In a few places they had fallen ofi" exposing circular, unhealthy-looking ulcers. Wher- ever the skin could be seen, it was of a fiery-red colour, and puckered with old cicatrices. The lower lip was swollen and dragged downwards, and the left lower eyelid was ulcerated and everted. The metacarpal bones of the left hand were enlarged, and the skin covering them red and painful. Xo ulceration of the throat or other complaints, with the exception of weakness. External appearance highly cachectic. The history she gave of her case is as follows : About five years ago she con- tracted primary sores from her husband, who had suffered from a very malignant form of them in the West Indies. Shortly after, she was attacked with a minute pustular eruption of the skin. This shortly disappeared, but was succeeded by occasional blotches on the skin, which sometimes broke, but alwaj's went away slowh". Eighteen months after the commencement of the disease, one of these appeared on her chin, when, being alarmed, she came to Edinburgh. The practi- tioner she consulted placed her under a mercurial course, and she was salivated for six weeks. The disease in the face, instead of healing slowly as formerly, now ulcerated, and began to spread. Six months afterwards, she was again salivated for four weeks, but the whole of the lower half of the face was now involved, and she entered the clinical ward of the Royal Infiruiarj-. She is confident that these are the only occa.sions on which she has taken mercury. She remained in tlie house upwards of a month, and went out with the face nearly well, from the use of topical emollient applications, and the internal use of small doses of iodide of iTOtassium. Six weeks afterwards, however, she was exposed to cold and wet, when the blotches, scabs, and ulcers returned in the face, and gradually spread to the neck and chest, as formerly described. She was ordered four grain doses of Iodide of Potassium in a mixture containing § i of tincture of Cardamoms, and 3 vij of compound infusion of Gentian. The face was dressed first with a zinc lotion, afterwards with one of chloride of lime, and subsequently with an ointment of iodide of lead. Gradually the further ulceration was checked, and the ulcers healed, and on the 19th of February' she was so much relieved, that she insisted on going out. I saw her in the following June, with the face cicatrized all over, but quite well. Commentary. — It is very rarely that we have an opportnnitv of seeing so frisrhtful a case of mercurial syphilis as the one just noticed ; it fully equalled many of the horrible representations I now show you in the work of Divergie. You will have observed fiom the history of this patient, that, previous to the exhibition of mercurv, she was subject to the slow formation of boils, which, however, spontaneously disappeared. * Reported by Mr. G. A. Douglas, Clinical Clerk. 900 DISEASES OF THE BLOOD. Tlie moment her system was saturated with that drug, the boils and ulcers first became stationary, and then commenced spreading over the integument. Tliis is an important fact too little attended to by those who practise the mercui'ial treatment. Case CCXXIIL* — Syphilitic Laryngitis. Margaret Dickie, a staymaker, a;t. 25 — admitted September 9tli, 1851, labouring under occasional vomiting, frequent cough, with haemoptysis, and copious purulent expectoration. There was considerable sweating at night, and her general health, owing to want of sleep aud the harassing cough, was much broken down. At the commencement of the winter session in November, I found her taking an acid mix- ture to relieve the sweating, a cougli mixture to diminish the cough, together with cod-liver oil. The chest had also been blistered. Careful percussion aud ausculta- tion convinced me that the thoracic physical signs were perfectly normal. I then examined the fauces, which were covered with purulent mucus, but presenting here aud there red and prominent follicles. The cough was also ascertained to be con- vulsive, the voice hoarse and broken, and, on placing the stethoscope over the larynx, a loud ringing sound accompanied the inspiration. From these facts I had no difficulty in diagnosing laryngitis ; and on ascertaining that the woman was a prostitute, and addicted to drink, there could be little doubt that it was of syphihtic origin. The fauces were freely touched with a solution of nitrate of silver ( 3 ss to § j of water). This was repeated on the following day, and on the next the upper part of the glottis was touched, causing severe convulsive cough. I subsequently passed the sponge, saturated with the solution, into the larynx every second or third day during the month of November, which at first caused very severe aud prolonged convulsive cough, that gradually became somewhat diminished. On the whole, however, no great amendment was produced, although the expectoration and cough during the intervals were lessened. The local applications were then suspended, but it soon appeared that they had been beneficial in checking the symptoms, from their severity again increasing, especially the amount of expectoration streaked Avitb blood, and the want of sleep at night owing to the severity of the cough. In the second week of December, therefore, the topical applications were resumed, together with occasional blisters to the larynx, and once more a certain amount of benefit was ob- tained. But as this treatment, combined with the internal administration of iodide of potassium and bitter infusions, for a period of tour weeks, seemed to produce no further improvement, she was dismissed on January 7th, 1852. Commentary. — Syphilitic disease of the laryn.x is one of the most common of the secondary forms of the disease, a fact indicated bv the lioarse and broken voices so frequently noticed among women of aban- doned character. The topical treatment with the fiponge, and a solution of nitrate of silver, does not seem to be so useful as in simple laryngitis ; but even here its eftects on the mucous membrane are evidently bene- ficial. Case CCXXIT.f — Syphilitic Rupia. foUoiced by Keloid Growths on the Cicatrices — Syphilitic Psoriasis. History. — John Young, set. 24, boiler-maker, native of Xew-Monkland — admitted * Reported by Mr. C. D. F. Phillips, Clinical Clerk, f Reported by Dr. T. A. Carter, Clinical Physician. SYPHILIS. 901 Xor. 29, 1858. The patient states that, until eighteen months ago, he was perfectly healthy, but at that time, while residing at Kilmarnock, he contracted a chancre upon the prepuce. This was treated by the external application of black-wash ; and he took what he believes to have been mercurial pills internally. The sore under tills treatment healed in a week. He then went to Leitli. and after remaining there a fortnight, discovered that an ulcer had spontaneously formed exactly where the pre- vious one had existed. He at this time (July 31st, 1 857) entered the surgical wards of the Edinburgh Infirmary, and there took pills which produced soreness of the mouth and gums, and increased salivation lasting for about three weeks. The ulceration of the throat, from which he then also suft'ered, was frequently cauterized, and black-wash was applied to the preputial sore. This plan of treatment was fol- lowed by a course of iodide of potassium. During his residence in hospital an erup- tion made its appearance, which was evidently rupia, as proved by the numerous large cicatrices which are at present visible all over the surface of the body. He gradually got much better, and was dismissed after six weeks' residence. At the time of his dismission, however, there were, according to his own account, nimibers of adherent crusts of rup'ia scattered over the greater part of his body. After leaving the Infirmary he went to ilotherwell, where his throat again became sore ; fresh pustules of rupia formed, many of the old crusts and sores enlarged, and deaf- ness supervened which continued for eight or ten days. He applied to a medical man, who syringed his ears with warm milk and water, and gave him some liquid to take internally, which he says benefited him while he continued to use it Fifteen weeks after this time he went to Cumbernauld, and there purchased a quack's book containing a prescription for .sarsaparilla and iodide of potassium, which he has con- tinued to take from lime to time until the present date. The medicine did not cure the disease, but kept it, he believes, from " turning worse."' Six months ago patches of psoriasis commenced to appear on the neck and shoulders, which were soon fol- lowed by a similar eruption over other parts of the body. Twelve weeks ago a medical man made three attempts to inoculate him with syphilitic virus, repeated at intervals of eight days, but without success. The operation was performed by scraping some of the matter off a glass upon which it had been dried, and inserting it under the skin by means of a lancet. Stjiptoms ox Admissiox. — The entire surface is scattered over with round and oval cicatrices of rupia, which are closest on the thighs, are not so common on the breast and abdomen, but pretty general on the back. In the centre of some of the cicatrices on the upper extremities and back are a few flesh-coloured solid elevations, .some occupying only a portion, others the entire surface of these cicatrices. In the latter case thej' constitute nodular swellings or tumours of a flesh or pinkish colour; smooth on the surface and elevated above the level of the skin from one-eighth to one quarter of an inch ; they are indurated and tough to the feeL oval or rovmd in form, and vary from one-eighth of an inch to one inch and a half in diameter. The largest of them is situated over the left shoulder, and about a dozen are scattered over the neck, back, and superior extremities; there are none over the chest, abdomen, or lower extremities. In addition to these there are irregularly shaj^ed patches of psoriasis scattered over the head, neck, abdomen, arms, legs, and back. On two of the largest patches irregular ulcers have formed, which are about half an inch in diameter, and are at the present time covered with elevated brown crusts. There are numerous small pustules resembling those of acne over the shoulders back, breast, and face, some of which are advancing towards suppuration. Other systems normal. He was ordered to take five grains of the Iodide of Potassium three times a day, and to apply pitch-ointment to the patches of psoriasis morning and night. 902 DISEASES OF THE BLOOD. Progress of the Case. — The treatment just stated was continued for two months. The patches of psoriasis gradually lost their scaly character, and assumed the appearance of copper-coloured blotches, and the intervening portions of the skin, owing to occasional baths, became much clearer and freed from the acne. He is still in the house (March, 1859). Commentary. — This case offers a good example of the inutility of mercury, and perhaps even of the evils it produces on the economy, for no one can say how much of the pustular and scaly disease niioht not have been owing to the effects of that drug. The keloid growths were evidently fibro-vascular tumours, occurring in the cicatrices, and o-ave liim no inconvenience whatever. It is seldom I have seen the skin of a young man so disfigured, presenting, as it did, circular and oval marks of the former rupia, the pink swellings, and the large copper-coloured blotches here and there. The literature of syphilis is exceedingly rich. The origin of the word, the source of the disease, the time of its appearance, its subse- quent course, and the identity of its different forms at various times, have all been keenly disputed. Even at the present day, its exact nature and mode of treatment excite lively discussion ; for such are the discordant facts reported, and such are the prejudices resulting from education, and ex parte statements, that it is extremely difficult to form an unbiassed, not to speak of a correct opinion. All then that I shall venture upon here, is to communicate some of my own reflections and observations on this subject. The venereal disease presents a great variety of symptoms, which are generally considered as primary and secondary. They may, with more propriety pei-haps, be divided into primary, secondary, and tertiary, as follows : — Primary symptoms — 1. Balanitis. 2. Gonorrhcea,- ■! ^^P^' or vlceratire. I Acute or chrome. 3. Chancre. 4. Granular disease of os uteri. ( Testes, Prostate, Rectum, V orofans, — •< 5. Irritation in other organs, — ) Schneiderian Menihrane, ( Conjunctiva, etc. Secondary syiiiptoms, affecting the — 1. Lymphatic glands, — Bubo. 2. Mucous membrane, — Ulcerations. 3. Skin, — Ulcerations or eruptions. 4. Eye, — Iritis, etc. Tertiary symptoms — 5. Disease of bone, — Exostosis, Caries, Necrosis. The forms of syphilitic disease which commonly fall under our notice, in the medical clinical wards, are such as affect the skin, fiuices, and SYPHILIS. 903 larvnx. Thev all require the same constitutional treatment, Lut the two latter cleniand also local applications, some of which have been referred to when speaking of laryngitis. All the different kinds of skin disease formerly described may occur in an individual affected with syphilis. They then become modified in their general appearance, course, and seats of predilection. Thus it has been observed that the ordinary red colour of skin diseases assumes, in those affected with syphilis, a darker or copper}' tint. This is especially observed in the scaly eruptions, the patches of which are also smaller, while the scales are thin, and of a gray colour, often approaching black. The pustular scabs are hard and thick, of a dark greenish or black colour, furrowed on the surface, and deep in the skin. The ulcers are deep, circular, with hard and callous edges. The cicatrices are unequal, round, or spiral, white and depressed. These eruptions may occur all over the surface, but are most common on the forehead, face, nose, back, and shoulders. In children they generally assume the form of maculse or of ulcerations; in adults, of tubercular and scaly disorders, altbough ulcers are also very frequent. Diagnosis of Syphilis. It has been said by some persons that they can readily detect a svpliilitic from all other skin eruptions. But I have known errors made in this respect by the most experienced and eminent dermatologists, one of which I may relate. A young gentleman, on rising one morning, found himself covered with an exanthematous eruption. He had dined out the previous day, and indulged in eating more than usual. He applied to an English physician practising in Paris, who pronounced it to be urticaria, recom- mended a dose of salts, and assured him that it would disappear in a couple of days. Some friends, however, advised him to consult M. Biett, at that time chief physician to the Hopital St. Louis, and certainly one of the most experienced dermatologists in Paris. He did so, and the eruption was stated at once to be syphilitic, and a course of mercury recommended. It was with the utmost difficulty that his English medi- cal adviser could prevail upon him to wait two days before commencing the mercurial treatment, when, however, he had the pleasure of seeing his diagnosis justified, by the disappearance of the eruption. Xow, I need not say, that if such an error could occur to one so experienced as M. Biett, how much more readily may it happen to a practitioner com- paratively unacquainted with such disorders. The same difficulty occurs with primary and secondary syphilitic ulcers. The question here is. Is there anything in the aspect of the sore itself which will enable us to determine its nature? Here, also, I have seen the greatest mistakes made by the most experienced surgeons. M. Ricord was so doubtful, after long practice, of the characters of a common chancre, that he commenced a series of inoculations to deter- mine which was, and which was not, a true venereal sore. I am satis- fied also, that individuals, whose systems have been imjjregnated with mercury, frequently have ulcers, which are constantly mistaken for 901 DISEASES OF THE BLOOD. venereal ones, although really the results of a poison with which the body is impregnated. The following case, which I observed twenty-two years ago, was the first which strongly impi-essed my mind with this truth. A girl, seven vears of age, entered the surgical hospital in 1836. She had a round ulcer over the tibia, about the middle of the left leg. It presented all the characters of a venereal ulcer, as described by Hunter. On inquiiy, it appeared that her bowels having been somewhat deranged, the mother had gone to a drugsfist's shop, and asked for some opening powders. She received twelve, which contained a white, finely powdered substance. One was cjiven morning and night. In four days profuse salivation came on. The whole dozen powders were given, however, and a cachectic state was induced. Owing to some accident, she received a violent blow on the leg, and the ulcer mentioned made its appearance. There had never been a venereal taint in the family, and the parents were perfectly healthy. The clinical professor declared publicly, that had the girl been seventeen instead of seven years old, no asseverations on her part could have persuaded him that the sore was not syphilitic. Thus, then, it is only when the symptoms arise in a certain order, that we can positively declare syphilis to be present. If an individual has chancre, which is followed by bubo, or ulcerated throat ; and this is accompanied by, or precedes, eruptions on the skin, then we may feel pretty confident. Again, when deep-seated pains in the bones follow the previous symptoms, we may consider them to be syphilitic. The circumstance of an osseous disease more frecjuently affecting the shaft than the extremities of a long bone will serve to distinguish syphilitic from scrofulous disease, and the existence of caries in conjunction with the peculiar ulcerations formerly alluded to, will confirm our suspicions. You should remember, however, that great caution is always required. The common idea that the gonorrhoea and excoriations in men, which often follow impure connection, are a proof of disease in the female, has led to great error; as it is now ascertained that they may occasionally arise from the presence of the menses, some unusually acrid discharge, or other non-venereal cause. A hasty opinion given to the effect that this or that eruption is syphilitic, has introduced discord into families, and produced incalculable mischief. The tertiary syphilitic symptoms also have frequently been confounded with the deep-seated pains of rheumatism, neuralgia, malacosteon, etc. Moreover, if such opinion leads to the entering upon a mercurial course, the original disorder is often replaced by an artificial one, not unfrequently more destructive in charac- ter, which is again confounded with syphilis, and so the error is per- petuated. Propar/ation of Syphilid. Actual contact from impure connection is the most common mode bv which syphilitic sores are communicated. A gonorrhoeal discharge also applied incautiously to the conjunctiva or other mucous membranes, will excite inflammation in them. The secondary forms of the disease are always the result of inoculation ; but this may arise, not only from the poison being absorbed directly from a primary sore, but may be commu- SYPHILIS. 905 nicated by the mother to the foetiis in utero, — by the infant to the nurse, — and again by the nurse to the infant. The following case, whicli was most carefully investigated, and was the subject of legal proceedings, illustrates how nurses may be affected by syphilitic infants. In 1842, the late Dr. W. Campbell brought to me a Avoman -with a child ill her arms, to obtain my opinion, whether a skin eruption on the latter was or was not syphilitic. I pronounced that it was, and that the woman should cease to nurse it, although her nipples at that time were in no way aftected. The cbild was the oftspring of respectable pai'ents, and had been sent to her to nurse. In consequence of my opinion, the infant was returned to the friends, whose medical attendant maintained the eruption to be non-syphilitic. The woman who applied to ]ne (nurse 1) was received as a wet-nurse into another family, and the child was sent to another nurse (nurse 2). In a week the child died ; and a few days afterwards, nurse 2 was attacked with sore nipples. Nurse 1, sliortly after entering her new situation, also perceived sores round her nipples ; and the medical attendant of the femily, after consultation with me, caused her to be discharged. She, in consequence, brought an action against the medical man, who had caused the syphilitic infant to be sent to her, and had mistaken the disease. The lawyer she employed then took me to visit nui'se 2, whose whole body was covered with a syphilitic tubercular eruption. Both nurses ultimately succeeded in obtaining compensation from the medical attendant. Pathology of Sy2)h.Uis. Syphilis is caused by a poisonous virus, which, mixing with the blood, taints the constitution, and predisposes it to those forms of secondary and tertiary disorders formerly alluded to. The nature of tliis virus is involved in the same mystery as that of other animal poisons. All that we know of it is from observation of its effects. Sir A. Crichton, adopting Liebig's view of a catalytic action produced in the blood, pointed out, in 1842, that this catalytic action was soon desti'oyed in cases of scarla- tina, small-pox, and similar acute diseases. Here "the fever, which destroys both the desire for food and the process of chymilication, and consequently the supply of new elements for the further formation of new virus, is cut otf. But in syphilis and yaws, which do not affect the brain or vital functions for a long time, the patient, by daily taking food in abundance, supplies every day new elements for the pi'od action of fresli quantities of poison, and consequently the disease goes on and is protracted indefinitely." This theory is supported by the comparatively mild character of syphilis in warm climates, where the natives live chiefly on vegetable food, and is abundantly proved by the ox»od effects of a low- diet and the most simple means, when contrasted with the effects of so- called specifics. For my own part, I believe that the virus of syphilis, if left to itself* and if the health of the patient be attended to, will generally wear itself out. Unfortunately we are only commencing to observe the natural progress of syphilis, and consequently we are unable to determine how long, under ordinary circumstances, it takes to accomplish this. So far 906 DISEASES OF THE BLOOD. as I know, we have no specific for any kind of animal poison, for you will remember that Jenner was of opinion (and there can be little doubt that he was correct), that in giving vaccination to man, he was merely giving him small-pox in a modified form. The idea that mercury is a specific for the svphilitic poison, and the incalculable mischief it has occasioned, will constitute a curious episode in the history of medicine at some future day. It is now well known that the poison of mercury produces a cachectic disease and secondary sores in the bodv, which have been to a great extent mistaken for those of syphilis. It consequently has happened that mercury given to cure primary sores, has produced a constitutional disorder closely resembling that of syphilis; more mercury has then been administered, increasing the mischief, and so the disease has been perpetuated. The real fact, however, is, that the sypliilitic poison is no exception to the general rule, which informs us that all con- tagious diseases of the blood run a certain couree, and that we have not yet discovered a specific cure for one of them. The great proof of this is, that the intensity of the disease in modern times has declined exactly in proportion as its treatment by mercury has diminished, and the disor- der been left to follow its natural course. When wc treat sy])hilis on tlie same principles that we do scarlatiiui and small-pox, it will prove intinitelv less fatal than those disordei-s. Treatment of Syphilis. The treatment of syphilis may be said to be of two kinds, namely, the simple and the mercurial. The profession are rapidly deciding in favour of the first, although some of its members still give mercurv in inveterate cases. Many of the cases we meet with, therefore, have taken the drug, and we have to eradicate the effects of the mineral poison as well as of the original disease. The Simple Trealinint is divided into internal or medical, and external or surgical. The first consists in the observation of certain hvgienic rules, and the employment of general therapeutic means. The diet must be light and mild — meat and all stimulating viands retarding the cure; even with the lightest diet, the hunfjer should never he (juite appeased. The regimen must be the more diminished and rigid in proportion to the youth and vigour of the patient. Diluent beverages, decoctions of barley, liquorice, and linseed, alone or mixed with milk, should be taken freely, to the amount indeed of several pints a day. Perfect repose must be secured by confinement to bed. Constipation must be obviated by the use of emollient clysters or mild laxatives. The air should be maintained at the same temperature — this is an indispensable precaution in chronic, consecutive, and mercurial affections. Exercise is only useful in the convalescent stage. In chronic syphilis, however, it may often be carried to fatigue with advantage. Tepid baths, repeated three or four times a day, are always attended with advantage. In the external or surgical treatment, strict attention to cleanliness, and the position of the diseased parts, should never be lost sight of Emollient decoctions or fomentations, or dressings of simple cerate, are the best applications, and the dressings should not be too frequentl SYPHILIS. 907 renewed. The greatest benefit is derived from the external use of a con- centrated solution of opium (in the proportion of about 3 i j to |j of water) ; it soothes excessive irritability in all cases. When the suppuration is moderated and the surface of the ulcer cleansed, stimulating dressings, consi?tino- of solutions of the sulphates of alum and copper, the nitrate of silver, and sub-acetate of lead, favour cicatrization. In inveterate cases, more especially those labouring under tertiary symptoms, the iodide of potassium, which was introduced by Dr. AVal- lace of Dublin, and used by him Avith considerable success, may be eraploved. I have myself given it in numerous cases with benefit, in doses of 5 gr. three times a-day, conjoined with emollient applications to the affected parts. The Mercurial Treatment used to consist in keeping up slight saliva- tion, by means of the internal administration of blue pills or some other form of mercury, sometimes conjoined with mercurial frictions or fumi- gations, at least for the space of a month. More recently much smaller doses, so as to produce scarcely sensible effects, have been given for a longer or shorter time. The physiological action of the drug may be produced by administering any of its preparations continuously in small doses. If combined with opium, they act less on the bowels, and more on the system generally. It is necessary during decided salivation that the patient do not expose himself to cold. A certain irritability is produced, and the constant soreness of the gums, the metallic taste in the mouth, not to speak of the inconveniences of profuse salivation, wliicli occasionally occurs, render this species of treatment anything but agreeable to the patient. Both kinds of treatment have now been extensively tested. In the year 1822, the Royal Council of Health in Sweden having been charged by the king to conduct a series of experiments upon the different modes of treating venereal diseases, reports from all the civil and military hos- pitals were ordered to be dra\yn up annually. These reports establish the inconveniences of the mercurial system, and the superior advantages of the simple treatment. In the yarious hospitals of Sweden, 40,000 cases had been under treatment, one half bv the simple method, the remaining half by mercury; the proportion of relapses had been, in the first class, seven and a half, in the second thirteen and two-thirds, in one hundred. Dr. Fi'icke's experiments in the Hambui'g general hospital were first made public in 1828. In four years, out of 16-49 patients of both sexes, 582 were treate<;l l)y a mild mercurial course, and 1067 with- out mercury ; the mean duration of the latter method was 51 days, and that by mercury 85. He found that relapses were more frequent, and secondary syphilis more severe, when mercury had been given. AVhen the non-mercurial treatment was followed, they rarely occurred, and were more simple and mild when met with. He tells us that he has treated more than 5000 patients without mercury, and has still to seek cases in which that remedy may be advantageously employed. He has never observed caries, loss of the hair, or pains in the bones follow his treat- ment, and in all such cases which have come under his care, much mer- cury had been given. In 1833, the French Council of Health published the reports sent in 908 DISEASES OF THE BLOOD. by tlie physicians and suro-eons attached to regiments and military hos- pitals in various parts of Fiance. Some of the reports are in favour of a mild mercurial course, others in favour of simple treatment. They all agree in stating the cure by mercury to be one-third longer than by the other treatment. At Strasburg, mercury was only given to very obsti- nate cases. Between 1831 and 1834, 5271 patients had been thus treated, and the number of relapses and secondary affections calling for the employment of mercury was very small. No case of caries, and only one or two instances of exostosis, had been observed. Full reliance may be placed on these facts, as regiments remain in garrison at Strasbui'g for tive or six years. In the various reports now published, more than 80,000 cases have been submitted to experiment, by means of which it has been perfectly established that syphilis is cuied in a shorter time, and with less proba- bility of inducing secondary syphilis, by the simple than by the mercurial treatment. These facts are now very generally admitted, and malignant syphilis is gradually disappearing. Twenty years ago, the most frightful secon- dary and tertiary cases were met with, and the usual treatment was profuse salivation. At present, such cases ai'e rare. Abroad, owing to wise police regulations, the disease is intinitely more innocent than it is even at present in Scotland ; and under the salutary inHuence of a mild and simple treatment, its virulence is daily abating. In apprec^iating the value of this important revolution in practice we should not forget to eulogise those who had first the boldness to introduce it. The credit of this is maiidy due, in England, to Mr. Fergusson, and other British army surgeons, who practised it during the Peninsular campaign (Medico-Chir. Trans., vol. 4) — and to Mi-. Rose of the Cold- stream Guards (Ibid, vol. 8). In Scotland, the writings and lectures of the late Professor John Thomson of this University were mainly instru- mental in convincing Scotch practitioners of the evils of mercury in venereal diseases. In Englan(i, the Hunterean theory and practice have been deeply rooted, and in Ireland have been supported by the writings of Carmichael and Collis. Mercury in consequence is still very generally employed in those parts of the kingdom. The gigantic experiments made abroad, however, ought to convince the most sceptical — if not, let him compare what syphilis is in Scotland with what it was, and especially observe that we never see an instance of the disease such as those recorded (Cases CCXXII. and CCXXIV.), unless the patient's system has been contaminated with mercury. For an account of the treatment by inoculations, or what is called "syphilization" in Italy and Norway, which was apparently commenced in Case CCXXIV., I must refer you to papers by Drs. Murchison and Lindsay, in the Edinburgh Monthly Journal for June 1852, p. 575, and November 1857, p. 407. See also the Brit, and For. Medico-Chir. Review, Vol. 45, p. 118. EHEUMATIS-AI AND GOUT. 909 RHEUMATISM AND GOUT. General Patholor/ij and Treatment. The present theory with regard to these affections is, that they are both connected with an increase of lithic acid in the blood. In rheu- matism, this is dependent on excess of the secondary, and in gout on excess of the primary, digestion. In rheumatism, however, there is con- siderable excretion of lactic acid by the skin (Todd), whilst in gout there is an excess of soda, which, uniting with the lithic acid, produces a com- pound of lithate of soda, that may be detected as such in the blood (Garrod), while sometimes it exudes into the cellular tissues of the skin, constituting tophaceous deposits. In both diseases there is an undue balance between the excess of lithic acid and the power of excretion — in rheumatism by the skin, and in gout by the kidney. This pathology serves to explain the similitudes and differences existing between the two af!ections. In both there is a certain constitutional state, dependent on deranged digestion, dui'ing which exciting causes occasion local effects. These exciting causes in rheumatism are bad diet, hard work, exposure to cold and wet, and its subjects generally are the poor and labouring- population. In gout the causes are good diet, indolence, repletion, indi- gestion, and its subjects ai'e for the most part the rich and sedentary. The local manifestations in both are acute wandering pains, with pain and swelling — in rheumatism of the large, and in gout of the small joints, constituting the acute attack in the one, and the so-called regular attack in the other. These are combined with a tendency to various compli- cations of the internal viscera, which are more or less dangerous to life. The general indications of treatment are, in both diseases, (1st) so to regulate the nutritive functions as to ensure a due balance between the amount of matters entering the blood as the result of digestion, primary or secondary, and the amount of mattei's discharged from the economy by the excretory organs. (2d) To conduct the acute attack to a favour- able termination, carefully watching the internal viscera, and being pre- pared to act with vigour should these become affected. Hence the treatment of these diseases resolves itself into what may be called cura- tive and preventive — the first having reference to the acute attack, the second to the means most likely to hinder its return ; the one must be carried out by remedies which act upon the blood and excretory organs, the other by the management of diet and exercise. Although the general pathology above mentioned, which considers rheumatism as a blood disease, may be considered, on the wliole, as cor- rect, we are not yet enabled to explain by it the symptoms of an acute attack of the disease, where in addition to the constitutional disorder, we have local pain, occasional heat, redness, and swelling, with febrile symp- toms. Most practical men have attributed these phenomena to a super- induced inflammation, although it has not been shown that exudation occurs, or that it is followed by the usual results of that condition. Be- sides, its erratic character is opposed to what we know of the process of true inflammation and calling it an unhealthy inflammation in no way 910 DISEASES OF THE BLOOD. clears up the mystery. The real pathology of acute rheumatism, therefore, has yet to be determined, and, as a preliminary step, a careful histological examination of the.aftected tissues is absolutely necessary. So far as I am aware, this has never yet been attempted, if we except some observations by IJasse on the structure of tlie bones in rheumatism (see Monthly Journal of Medical Science for June 1847). Oiu' treatment of this disease, therefore, is purely empirical, some- times directed against the pain, at others against the supposed inflam- mation ; now attempting to combat the pathological condition of the blood, then striving to remedy its ctfects by acting on the excretions, and not unfrequently giving specifics, in the hope that any change in the constitution, however produced, may be beneficial. In no disorder, probably, has such a crowd of opposite remedies and plans of treatment been extolled, and yet none of them can be depended on, so that it has been hinted that six weeks' rest is the most useful prescription (Warren). The latest author on rheumatism endeavours to explain the fact by observing, that this need not be wondered at by " those who consider the true nature of the disorder, and the variety of circumstances under Avhich the physician may be called upon to minister to his patient's relief. The bleeding, which in the young, plethoric, and robust, may be neces- saiy to allay excessive vascular ae-tion and cause free secretion, may in the weakly induce irritability of the heait, and a consequent attack of cardiac inflammation. The opium, whicii in one person mav prove of the greatest service in promoting free perspiration, and in allaying the general irritabilitv* of the system, may in another check the biliary and other secretions, and thus prevent the elimination of the rheumatic poison. The continued use of calomel, and the constant purging, which may be beneficial to one patient by removing large quantities of unhealthy secretions, may unnecessarily exhaust the strength of another, and tend very greatly to impede recovery. And so in regard to every remedy which has been proposed. What is useful at one time proves useless, or positively injurious, at another ; and the conclusion is forced upon us, that what is Avanted ' is far less the discovery of untried methods of treating disease than of discriminative canons for the proper use of those we possess ;' — far less the discovery of any new medicines, than the adaptation of our present remedies to the exigencies of each case." (Fuller on Rheumatism, p. 73.) These judicious observations may serve to explain the cause of our failure ; but until we obtain more exact infor- mation regarding the special pathology of rheumatism, it is in vain to hope for a rational treatment. Occasionally I have tried the effects of special remedies in this dis- ease, and watched a series of cases, all which were treated in the same manner. Thus I have tried aconite, and believe that alone it is of little service ; colchicum also I have given frequently, and am of opinion that in pure rheumatism it is of no advantage, although in gout it is invaluable. Treatment of Acute Rheumatism hy Xiirate of Potash. During the session 1851-2, I made another trial of this kind witli the RHEUMATISM AND GOUT. 911 nitrate of potash, a remedy fonuerly rccoininended by Dr. Brocklesby, and which had been given with good etiect l>y M. (iendrin, in the wards of La I'itie in I'aris, as recorded by Dr. Henry l>ennet (Lancet, 1844, vol. i. p. 374). It has more lately been {)ressed on our attention by Dr. Basham (Medico-Chir. Trans., vol. xxxii.), who tells us that from one to three ounces of tlie salt, if freely diluted in watei-, may be taken by the patient in the course of twenty-four hours, without any injurious results, but with the effect of relieving in a marked manner the swelling, heat, and pain in the joints. Li the following cases the remedy was tried in much smaller doses, and it appears to me with more than average suc- cess. Case CCXXV.* — Mrs. Anderson, set. 48, sick nurse — admitted December 30, 1851. States that previous to the present attack she had always enjoyed pretty good health, with the exception of a liability to a slight cough ; had been lately subjected to much fatigue in her occupation as a sick nurse, and had been exposed to cold from sitting up for several nights in succession in a large room, heated by a fire, and ventilated by keeping the windows open. Having no adequate protection from the cold draught thus caused, she became affected with sore throat, and had pain in the chest. This occurred in the latter part of October last, and from that time up to November 20th she suffered from slight sliivering and uneasiness; transient pain in different parts of the body ; nausea and vomiting. About a fortnight before admis- sion, she had a distinct rigor, followed by heat of skin and other febrile symptoms, witli very severe pain in the joints especially, much increased by any attempt at motion. The vomiting also continued ; and last week she suffered from pain and palpitation in the cardiac region, and at the same time an aggravation of her former symptoms. At present she cannot move without suffering excruciating agony, having severe pain apparently in every joint of the body. Heart's sounds, impulse, rhythm, and position normal; pulse about 100, weak. Irregular fits of copious clammy per- spiration, of acid smell ; no oedema of the joints. Urine scanty, dark-coloured, deposits crystals of the triple phosphates, with some mucus. Tongue loaded ; anorexia; thirst; occasional vomiting; no tenderness on pressing tlie epigastrium ; bowels confined; pulmonary functions normal. 5 MuriaUs Mo'iyMce semigranum ; Pulveris Aromatici grana quinque. If. Ft. pulv. Mittanf,ur tales sex. One to be taken every half hour. Dec. Ath. — She took three of the powders last night, after Avhieh she fell asleep ; and this morning feels somewhat better ; she has also had the bowels emptied by an enema, and is now using a diuretic mixture. Dec. 5th. — Pains in limbs much the same ; gets no sleep ; perspiration still copious ; urine not increased in quantity ; vomiting continues ; has been taking diuretics and Dover's powder. Dec. &Ji. — Had an exacerbation last night, the pain in the joints and limbs being excruciating. IJ Poiassce Nitratis semiunciam ; Aquce uncias sex. Misce et signetur — a iaUespoonful every four hows. Dec. lih. — Has taken three doses of the medicine ; she perspired a good deal during the night ; urine not increased in quantity ; pain is less severe. Dec. 8th. — Still sweats a good deal ; pains much the same as yesterday. Adde misturce Nitratis Potass., 3j. Dec. 9th. — Pains better; copious perspiration ; urine increased in quantity ; increase of the nausea and vomiting and of the thirst. Dec. lOth. — Pains nearly gone; sickness continues; refuses to use her medicine; pulse 80, weak; much general debility. After this date the pain ceased entirely, and she was shortly afterwards discharged cured. Commentary . — This was a severe case of both general muscular and * Reported by Mr. William Broadbent, Clinical Clerk. 912 DISEASES OF THE BLOOD. articular rlieumatism, of a fortnight's standing, when she entered the house. There was still, however, great pain on the slightest movement, which, during two days, in no way yielded to morphia, diaphoretics, and diuretics. On the exhibition of the nitrate of potash, profuse diapho- resis came on, which was apparently kept up by the medicine, with marked amendment to the rheumatic pains, followed by i-apid recovery. The improvement conld not be attributed to the occurrence of any criti- cal day in this case; and the night previous to the exhibition of the remedy, there had been a marked exacerbation. Every one who saw this case felt persuaded that the good effects were attributable to the nitrate of potash. Case CCXXVI.*— Jane Irvine, fet. 17, servant — admitted 19tb December 1851. States that seven days ago, whilst engaged at her usual occupation, she was suddenly- seized with severe febrile symptoms, and constant pain in the left ankle, which was increased by pressure and motion ; it was red and tumefied. On the following day the right ankle became similarly affected, and then in succession the knees, shoulders, wrists, and fingers ; the pain stUl continuing, but modified in severity in the parts first attacked. She has been undergoing treatment by diaphoretics, without, how- ever, having experienced any relief from them. On admission the pulse is 100. full and soft. A soft bellows murmur, synchronous with the radial pulse, accom- panies the first sound, heard loudest at the base, and is propagated along the course of the large arteries. Cannot sleep from the pain, which is general, and is causing intense suffering. Tongue moist, preternaturally red at the tip and margin ; no appetite; thirst, nausea, and vomiting; the bowels are costive; some tenderness on pressure in the epigastrium. Urine high coloured, deposits a slight sediment of lithates. Skin moist, from copious perspiration ; knees and ankles are swollen and painful on the least pres.sure. The right wrist, especially near the metacarpal bone of the thumb, is at present the seat of greatest suffering, and is red, painful, and swollen. Ordered to be hied to § xvj. and to have a imrgative enema. December 20(h. — Is much worse lo-day ; the pains in the wrist and hands are especially aggravated. Copious perspiration still continues. 1^ Potass. Nitratis, § ss ; Aqiue § vj. A iablespoonf id every four hours. Dec. 2\st. — Slept during the night. The sweating is still profuse. Urine in moderate quantity, sp. gr. 1016, deposits lithates. Pulse 90, weak ; cardiac murmur very indistinct. The pain is considerably relieved, except in the left lower extremity. Dec. 22d. — Still continues taking the Potass. Xit. ; the improvement more marked, and she can allow the Imibs to be moved about to-day. Dec. 23d. — She presents quite a cheerful appearance to-day, and is entirely relieved from pain ; all the joints can be moved quite freeh-, without exciting uneasiness. Pulse 68; skin cool; tongue clean ; appetite returning; bowels regu- lar; urine natural — some sediment. Cardiac murmur is more distinct to-day. Con- valescence proceeded satisfactorily from this date till January 5th, when she was attacked by typhus fever, from which, however, she ultimately recovered, and was dismissed well. Commentary. — This was also a very severe case of general rheuma- tism, which was in no degree benefited by diaphoretics, and a large bleeding on the seventh day. On the eighth day she was if anything worse, and then nitrate of potash was given, producing marked" relief on the following day. On the eleventh day of the disease, and third * Reported by Mr. J. L. Brown, Clinical Clerk. RHEUMATISM AND GOUT. 913 from the exhibition of the salt, tlie disease was subdued, and she became convalescent. Here, again, tlie period of improvement cannot be con- founded with critical days, and strictly corresponds to the administration of the remedy. The bleeding may have assisted its effects, but certainly was not followed, as is usually the case, by an evident amelioration. This girl had an endocardial murmur on admission, which continued during the progress of the case, and I asceitained from the medical practitioner who sent her into the house that she had laboured under tliis before the attack of rheumatism came on. Was this, therefore, an anemic murmur independent of the general disease, or produced by it ? We may ask another question, viz., Are all the endocardial murmnrs occurring in conjunction with rheumatism caused by endocarditis, and attributable to the rheumatic diathesis? These questions demand more careful attention to these murmurs in young women than has, I think, hitherto been paid to them. For my own part I am satisfied that these anemic murmurs in young girls are very common, and that they have frequently been mistaken for sounds dependent on endocarditis. As the patient becomes more robust these murmurs disappear, and hence, probably, has arisen the idea of the good effects of mercury when given in such cases. Case CCXXVIL* — Janet Wright. This woman had been admitted October 22d, 1851, labouring under the usual symptoms of acute rlieumatism, and had been under- going treatment by Dover's powder, diuretics, leeching, etc., up to the 6th December, without any benefit whatever, when on that day she was ordered !^ Potass. Nitratis, 3iij: Aq. § vj. Misce. A iable-spoo7ifid every three hours. Dec. ^th. — Has taken four doses of the medicine, but without any good effect. Took a dose of Dover's powder last night, and slept well ; pain in the shoulders very severe, and also in the knees. Dec. 8th. — Pain still continues. Adde onistune Potass. Nitraiis, 3 j- Dec. 10th — Has been using the medicine regularly ; she says it makes her very weak, sleepy, and stupid. She sweats a good deal at night, and the urine is increased in quantity ; is very thirsty, and complains of bad taste in her mouth; pains gone from knees. Dec. 13th. — Still continues the medicine. No return of pain in the knees ; greatly relieved in shoulders, etc. ; the increased secretion from the skin and kidneys continues. The improvement continued up to the ICth, when she was dismissed for disorderly conduct. Commentary. — In this case the nitrate of potasli, after being taken for three days, had caused much diaphoresis and diuresis, followed by dimi- nution in the rheumatic pains and rapid improvement, at the time she was dismissed. Case CCXXVIII.f— James Rough, s&t 26, blacksmith, admitted December 29, 1851. States that he has suffered on two former occasions from attacks of rheuma- tism. During his last attack, tliree years ago, he was treated in this hospital, and it lasted five weeks. The present attack came on nine days ago with great severity, having been preceded by febrile symptoms, which appeared to have followed exposure to cold ; the pain was very severe in all the joints, but especially so in the wrists and knees. He has noticed within the last year or two that considerable * Reported by Mr. William Broadbent, Clinical Clerk. f Reported by Mr. William Calder, Clinical Clerk. 58 914 DISEASES OF THE BLOOD. palpitation of the heart ensues after much exertion, or indulgence in ardent spirits ; but in his ordinary condition he is not troubled with it. At present the pain in the joints is not severe, unless on attempting motion ; pressure on the right shoulder and ankle causes considerable tenderness. The cardiac dulness measures a feAv lines more than two inches across; the apex strikes the thoracic parietes in the normal position. A very distinct bellows murmur accompanies the first sound, is heard loudest at the apex, and is not prolonged along the course of the great vessels ; the second sound is more sharp and abrupt than natural. The radial pulse is not synchronous with the impulse of the heart, but follows it after a very appreciable interval. A few sibilant rales can be heard here and there over the chest. Tongue is slightly furred ; appetite is impaired ; thirst not excessive. There is slight diarrlioea. The urine is normal. Skin is moist, but no excessive perspiration. 5 Potass. Nitratis, §ss; Aq., 3 vj. M. A tahle-spoonful to he taken, diluted with much ivater, three times a day. Dec. Slst. — Pains much easier to-day. The bellows murmur is much softer also. Urine deposits some lithates. Is sweating a little to-day. Pulse 86, soft and regular. Jan. 2d, 1852 (thirteentli day). — Has no pain to day. Continues to perspire a good deal ; and the urine deposits a copious precipi- tate of the lithate of ammonia. Pulse 68, soft and regular. Complains much of weakness. After this date, the amendment continued uninterruptedly, although only one bottle of the Nit. of Potash mixture had been used, and he was dismissed cured on the 12th January. Commentary. — The employmerit of the nitrate of potasli was followed by apparently marked effects in tliis case, producing diaphoresis and evident benefit on the twelfth day, and removal of pain on the thirteenth day of the disease. As the attack commenced nine days before admis- sion, we cannot suppose that the recovery was owing to the occui'rence of a critical day. Besides the good eff"ects were apparent the day after the exhibition of the salt, and on the following day the pains had dis- appeared. The valvular murnmr with the first sound at the apex, and the character of the pulse, could leave little doubt as to the miti'al incompetency ; and, as he had been previously subject to rheumatism, there is every probability that the cardiac lesion was the result of previous attacks of the disease. In a large number of cases which I have subsequently treated with niti'ate of potash, I have satisfied myself that the disease is more readily subdued by this treatment than by any other. Treatment of Rheumatism by Ziemon-juice. Case CCXXIX.*— Abigail Eankin, a servant, aH 39 — admitted 15th December 1852. Had rigors on the 7th, followed by febrile symptoms and acute pain in all the joints. On admission, jiulse 100, full and strong ; heart sounds normal ; con- siderable febrile .symptoms ; acute pains and swelling in all the joints increased on motion ; much sweating at night. Other functions healthy. Habeat Succ. Limonum 1 ij ter indies. On tlie 17th, she was ordered 9j of Dover's powder. Dec. 20th. — The pains have continued as acute as ever till to-day, although she has taken § vj of lemon-juice every twenty-four hours. At present she experiences somewhat less suffering on moving the joints. Habeat Succ. Limomim § iij ter indies. Dec. 22d. — * Reported by Mr. F. M. Russell, Clinical Clerk. RHEUMATISM AND GOUT. 915 There was great sweating last night, and to-day slie is much better. Ilabeat Succ. Lhnonum 3 i ter indies. Some swelhng of the left wrist joint remained until the 23d, on which all pain had left lier. Dismissed well January Glh, 1853. Case CCXXX.* — Catherine Rookc, set. 21, married — admitted December 23d, 1852. Had rigors on the 14th, followed by febrile symptoms, and excessive pain, at first, in the knees and ankles, but subsequently in everj- joint of the body. On admission, pulse 84, of moderate strength; heart's sounds and impulse normal; the joints are more or less swollen, painful on pressure and on motion ; skin bathed with perspiration ; febrile symptoms, with the exception of increased pulse, well marked ; a considerable deposit of lithates in the urine. Other symptoms normal. ]J Pulv. Doveri, gr. x statim sumend. 5 Sol. Mur. Morph. 3 ss ; Fotassce Bilart. § ss ; Sp. jEOier. Kit. § j ; Aqua, 3 j ; Ft. haust. hord somni sumendus. On the 25th, purgatives of calomel and jalap were ordered. Dec. 2(}th. — The pain and swelling of the joints have somewhat diminislied, but are still very acute. Haheat Succ. Limon. ^j ter indies. Jan. 2, 1853. — The pains have slowly subsided since last report, but there is still considerable soreness and stiffness of the knees. The arthritic swellings have everj'where disappeared. Jan. 4th. — Acute pain has returned in the right arm, which she cannot move. Jan. 5th. — Acute pain has extended to the right arm and back. Omiitatur Succ. Limmium. ^ Poiassce Nitratis § ss ; Aquce § iv. M. Sumat ^i ex aqua, § iv. ter indies. Jan. Gih. — The pains have now disappeared ; marked improvement. No critical discharge. Dis- missed well January 7 th. Case CCXXXL* — Thomas Aitken, fet. 30, blacksmith — admitted December 25th, 1852. Fourteen days ago, after exposure to cold, he was attacked by rigors, followed by febrile symptoms and pain in his joints, which have continued up to this date. On admission, pulse 74, rather weak. A blowing murmur with the first sound loudest at the apex, which it seems resulted from a previous attack twelve months ago. Slight swelling only in his right hand and wrist, but tliere is pain in all the joints, more or less of an erratic character. Febrile symiDtoms very slight. Slight bronchitis. Ilabeat Succ. Limonum, § ss. ter indies. On the 28th, the dose of lemon-juice was increased to ^j. On Jan. 2d, he was much better; but on the 4th the pains returned, but not so violently. On the 12th, he was free from paiii, having had some diarrhoea, and taken a two-scruple dose of Dover's powder. On the 22d the pains returned, but again subsiding on the 24th, he was dismissed. Case CCXXXIL* — James Ohason, a;t. 20, clerk — admitted January 4th, 1853, with organic disease of the heart of long standing, and chronic rheumatism of an erratic cliaracter, sometimes violently attacking one joint and sometimes another, accompanied with swelling and tenderness. Lemon-juice in |j doses was tried three times a day, for four days ; but, being evidently of little benefit, was then abandoned for opiates and sedatives. Commentary. — In no one of these four cases in wliicli lemon-juice was given, although in two six ounces and in one nine ounces were taken daii}', did it appear to me that the disease was in any way con- trolled or alleviated by the remedy. In Case CCXXIX. six ounces were taken daily without any effect, and then the quantity was increased to nine ounces daily, until the 21st day of the disease, when sweating and resolution of the symptoms followed, more from natural crisis, * Reported by Mr. Alexander J. Macarthur, Clinical Clerk. 916 DISEASES OF THE BLOOD. perhaps, than from the effects of the juice. In Case CCXXX. the remedy was continued for ten days, and until the 21st day of the dis- oider was fairly passed. The nitrate of potash was given with tlie immediate effect of relieving the symptoms — although liere also it is not improbable that a natuial crisis of the disease was then established. In any case the inefficacy of the lemon-juice appeared manifest. Cases CCXXXI. and CCXXXII. were cases of sub-acute and erratic rheumatism, which also resisted the lemon-juice; the first for a month, the second for four days. On the whole, this trial of the remedy was in no way favourable, and is strongly contrasted with the good effects of nitrate of potash, which I formerly biought beibre you. Case CCXXXIII.* — Diaphragmatic Rheumatism, History. — John Robinson, a bookbinder, ret. 24 — admitted February 5th, 1858. He says that on Sunday last, January 31st, he caught cold when at a funeral, and experienced some pain across the back and chest, especially on the right side. He felt extremely weak, and experienced great difiBculty in breathing. On the follow- ing day he noticed an eruption on the extensor surfaces of both legs. Beyond a blister which was applied to the painful side, he has been subjected to no treat- ment. SviiPTOMS ON Admission. — Pain on inspiration over right side, laterally and l^osteriorly. Slight cough with scanty expectoration. Percussion good and equal on both sides. On auscultation .slight harshness of inspiratory murmur ; pulmonary sounds otherwise normal. Pulse 110, soft. — Tongue furred, but moist; bowels open ; skin hot ; perspires abundantly. The extensor surfaces of both legs are covered with urticaria. Other systems normal. To have scruple doses of nitrate of potash in half a tumblerful of water three times a day. Progress of the Case. — Feb. 8th. — Perspired profusely yesterday, and to-day there is a copious sediment of urates in the urine. The pain is greatly relieved. The urticaria is nearly gone, but there is an erythematous spot over each patella. Feb. 15th. — Has now no pain, and complains of weakness only. 5 Quince Sulph. gr. i. ; Acid. Mtric. m. x.; Aqu^ 5j. ; M. Ft. haustus ter in die sumendus. Dis- missed well, March 10th. Commentary. — Deep-seated rheumatic pains in the cbest are very apt to be mistaken for pleural or pulmonaiy diseases. In the present case I found most of the clinical clerks disposed to consider the disease a pleuro-pneumonia, and they had framed a report which gave consider- able colour to their opinion. A careful examination of the chest, how- ever, convinced me that the lungs were sound, whilst the febrile symptoms, the pain on inspiration and its seat, satisfied me we had to do with diaphragmatic I'heumatism. The treatment, therefore, was governed by this view of the case, and we saw the usual phenomena of critical dis- charge by urine and skin on the seventh day of the disorder. He was of weak constitution, however, and lingered in the bouse some time longer. In the same manner intercostal rheumatism is very likely to be mistaken by inexperienced persons for pleurisy, especially if they are not sure of the non-existence of friction or other physical sign in the chest, which their pre-conceptions liave suggested to them exists there. * Eeported by Mr. Adolphe Baraud, Clinical Clerk. RHEUMATISM AND GOUT. 917 But if they carefully compress and rub the muscles between the ribs, while the chest is at rest, pain will be elicited, even to a greater extent than occurs during- inspiration; a symptom which is diagnostic. Such cases formerly must have frequently been mistaken for pleurisy, and bled of course with the etiect of ultimately causing a cure. In agricul- tural districts, slight intercostal or diajihragmatic rheumatism is most common at certain seasons of the year among labourers, who used con- sequently to be bled on a Saturday afternoon, rest all Sunday, and return to their work quite well on the following Monday. In such persons the venesection was supposed by both practitioner and patient to have cut short an incipient pleurisy. Case CCXXXIV.* — Rheumatic Iritis, folhvring Acute Rheumatism — Recovery. History. — John DuQy, jet. '25, Ordnance surveyor — admitted April 6th, 1857. Three weeks before admission, when in the pursuit of his occupation, he got wet, and a day or two afterwards was seized with rigors followed by febrile symptoms, pains in all his joints, and swelling of both knees, and of the left elbow. After being in bed a fortnight and treated medically, he entered the Infirmary, where he took Pulv. Doveri and Tr. Colchici internally, and had Tr. lodini applied locally. On taking charge of the case in May I first administered Xitrate of Potash ; subse- quentlv he was ordered warm baths, and then quinine with wuie and generous diet, under which treatment he became much better. Chronic pains, however, still continuing to linger about the joints, and especially the knees, cod-liver oil was ordered on the 2.5th of May, both internally and externally, and the quinine was dis- continued. OccuRREycE OF Iritis AXD Progress of the Case. — Junelth. — For three days has had slight redness of the conjunctivae, with watering of both eyes, for which he was ordered a zinc lotion. June 9th. — Conjunctivitis on the right side increased, and a small blister was applied over the right temple. June 10th. — Frontal headache. The conjunctiva, uumediately around the cornea, is surrounded by a zone of straight vessels, radiating outwards. Inferior half of conjunctiva of uniform red colour. To be cupped over riglit temple, and § v of blood extracted. Extract of belladonna to be applied externally round the eye. June llth. — The whole of right conjunctiva of a deep uniform vermilion, and zone of vessels round the cornea of a darker shade. Atropine to be dropped into the eye to ensure dilatation of the pupil. To wear a large shade. June I'dth. — Yesterday a weak lotion of Alum (gr. iij to | j of water) was applied, but has caused much irritation. Inner margin of iris thickened and irregular, pupil dilated. Discontinue lotion, apply belladonna externally, and a warm poultice over the e3"e at night. June l-ith. — To-day iritis and conjunctivitis have appeared in the left eye. Much pain in head, and restlessness during the night. Appetite bad; tongue coated; pulse 76, moderate strength. To have Quince Sulph. gr. iij three times a-day. To go into the side-room, and the window to be obscured. June nth. — Left conjunctiva now of as uniform redness as the right, and iritis well developed ; pupil, however, more dilated. Belladonna has been applied round both eyes. Last night had 3 j .of Castor oil, which not having operated, was ordered to-day, 01. Croton. gutt. unam et Ext. Colocynth. Co. gr. x. June 20ih. — Both irides, which naturally are of a light-blue colour, present a dark, dirty green colour. The pupillary margins are thick, and that of the right side irregular, especially at one * Reported by Mr. Stewart Lockie, Chnical Clerk. 918 DISEASES OF THE BLOOD. place where an adhesion has formed. Both conjunctivae are of a uniform dense ver- milion colour. There is considerable pain in tlie head ; photophobia and lacryma- tion. Discontinue quinine. 5 Pulv. Cinchon. Ruhr, et Pulv. Soda Bicarh. aa gr. v. Ft. pulv., to he taken three times a day. July 1th. — To day the right eye is much improved, redness of conjunctivae diminished, adhesion of pupillary margin disaj)- peared, and vision perfect. Left eye the same as before, but an adhesion has formed, which has rendered the pupil irregular for some da^-s. Cephalalgia has been some- times better, sometimes worse. Belladonna has been constant!}' applied. Applicent. hirudines iij tempor. sinist. July l-ith. — The right eye is now quite well. Left eye appears if anything worse. The pupil is dim, greatly contracted, and its margin much thickened. Yision also is nearlj^ gone ; he sees as if tlirough a thick cloud. Applicent. hirudines ij tempor. sinist. July 22d. — The leeches, he says, relieve the frontal pain, and they were again applied yesterday. To-day conjunctivitis less, and evident improvement ; pupil larger ; vision clearer. July 28th. — Since last report the morbid appearances in the eye have gradually disappeared. Two leeches have again been applied, and a blister to the neck. General health much improved, although still weak. August lOth. — Has been quite well for some days; vision in left eye is still slightl}- dim. but is getting clearer daily. Dismissed. Covimentary. — This case of double rheumatic iriti.«, with conjunc- tivitis, was of the most severe description. So much, liowever, lias been said about the danger of allowing- such cases to run their natural course, and of the necessity of treating them with sj)ecifics, more especially with colchicum and mercury, that 1 resolved to treat this case without them. It was watched on this account with great interest by the clinical class, especially as it was seen from time to time by my friend, the ophthalmic surgeon to tlie Infirmary, who predicted the worst consequences. Yet notwithstanding the weakened condition of the patient when iritis came on, the severity of the disease in both eyes, and the apparent closure which was about to take place in one pupil, 1 persevered, and the ix'sult in perfect recovery justified my expectations. It may be argued, how- ever, that the case would have got well much sooner if mercurials had been given. It is very difficult to determine this point, because few oculists have informed us what is the ordinary course of a severe rheu- matic iritis with conjunctivitis. According to Wharton Jones,* if taken in time before much exudation has occurred, and properly treated, it may be cured in three or four weeks. AVhat are called active remedies were not applicable in this case, even according to the principles of those who use them, and the amount of exudation was considerable. The complete recovery of the right eye, therefore, in five weeks, and of the left eye in six weeks, seems to me to have been on the whole a short period, considering all the circumstances, although, on this point, further observations are required. In the meantime, the case demonsti'ates that the most severe attacks of rheumatic iritis may get well, altogether inde- pendent of mercurials and active antijihloixistics. A similar conclusion had been previously arrived at by Dr. Williams of Boston, TJ. S., from a pretty extensive field for observation. (See p. 277.) * Ophthalmic Medicine and Surgery, p. 150. RHEUMATISM AXD GOUT. 919 Case CCXXXV.* — Chronic Gout vjith Toiihaceous Deposits in all the Joints. History. — Thomas Burns, a tobacco-pipe maker — admitted Xovember 4tli, 1857. Says he first became ill in Glasgow about ten years and a half ago, with pain and swelling in both his big toes. Soon afterwards the ankles and knees became affected. He was confined for a month, being unable to walk, or even to put on his shoes. Since then he has had on an average three such attacks every year, spring and autumn being the worst seasons ; but he has rarely been confined by them more than a week. Tlie attacks have generally commenced with rigors, followed by more or less fever and swelling in one or other of the joints. Almost every joint in his body has suffered in this way at one time or another. At the first attack, he says, chalk stones formed in his toes, and since then they have appeared in his feet, knees, elbows, and hands. The right hand especially has been much deformed by them. He is in the habit of cutting down upon, and extracting them, whenever they approach the surface and are unusually painful. He has been twice in the In- firmary, and on both occasions dismissed relieved. The present illness commenced suddenly six weeks ago, and has more especially affected the ankles. He has undergone a great amount of treatment, having been bled and cupped, and having taken much medicine. He had been accustomed to drink a good deal of porter, as weU as of spirits, until three weeks before his first admission, in June 1856, since which time he has been more temperate. Symptoms ox Admission'. — He complains of pain in the left wrist and both ankle joints, which latter are swollen, and pit on pressure. The joints of the fingers are nodulated and crooked, especially those of the right hand, hard to the feel, with numerous tophaceous deposits visible through the shining and stretclied integument, about the size of millet seeds. The elbow and knee joints are similarly affected, with several deposits over the olecranon and patella of each Imib. The toes are not so distorted as the hands. There is pain on pressure over the right lumbar region, with a slight trace of albumen in the urine. Other functions normal. ]J Potassce Acet. 3iiss; Sp. ^iher. ML 3ss; T>: Colchici 3j; Mist. Camph. ad ^xuy M. ^j to be taken three times a day. Progress of the Case. — Xovember 25th. — Small abscesses have appeared over the patella and heel, to which poultices have been applied. The mixture has been apparently of no service, and is to be discontinued. Dec. ISih. — Last night was seized with severe lumbar pain, and general febrile symptoms, and on examining the urine it was found to be highl}- albuminous. Tlie sediment contained numerous epithelial cells from the kidney, with granular and desquamative casts of the tubes. 5 V of bbod to be extracted from the loins by cupping, and to have at night Pulv. Doveri gr. x. Dec. 2lst. — Is much better. Albumen in the urine diminished. 5 Ammon. Fhosphat. Zy, Tr. Gent. Co. ^j; Inf. Gent. Co. ^v. M. A fourth part to be taken in half a tumblerful of water three times a day. Jan 6th, 1858. — Since last report has been comparatively free of pain and doing well, but last night was again seized with severe febrile symptoms, accompanied by painful sensations throughout his body. To-day the joints of the extremities, especially those of the hands, are very painful. The hands to be poulticed. To have Sol. Acet. Ammon. 3 j every hour. Jan. Sih — He has been perspiring much, and is better, although pains in joints are stOl very severe. The poultices have brought away several fragments of the tophi near the surface. They are of a pale yellow colour, friable, and when examined under the microscope present a mass of needle-shaped crystals of urate of soda. 5 Ammon. Phosphatis, 3ss; Tr. Colchici 3j; Aquie 3 vj. M. A third * Reported by Mr. WUkes, Clinical Clerk. 920 DISEASES OF THE BLOOD. part to he taken three times a day. Jan. 22d. — The paius in the joints have now been absent for ten days, and he was dismissed. Commentary. — The above is only the second case of gout I have seen in the wards of the Royal Intirmary, and it is a niatter of general observation that the disease is one from which the people of Scotland are remarkably free. Tliis has generally been attributed to tlieir frugal habits, but more especially to the drinking of whisky, instead of malt liquors and wines. Dr. William Budd has described gout to be common among a class of workmen on the Thames, whose occupation it is to raise ballast from the bottom of the river. "Those men," he says, " drink from two to three gallons of porter daily, and generally a con- siderable quantity of spirits besides."* Now, it is curious that this is what the man, whose case is before us, seems to have done, and to this habit, therefore, we may fairly ascribe the occurrence of the disease. He admitted that for some years he was accustomed to drink upwards of half a gallon of porter, besides from four to eight ounces of whisky daily. There was no hereditary tendency. The numerous local attacks frequently gave rise to excretion of the moi'bid products by tlie kidneys, with all the symptoms of Bright's disease, including albuminous iirine, and desquamation of cells with casts of the tubuli. In a week or so, however, they disappeared, and he enjoyed a temporary immunity from uneasiness. As to treatment, nothing seems to have been of permanent benefit, the tophaceous deposits apparently keeping up more or less irritation and tendency to local attacks, which in their turn excited constitutional ones, more especially the fever and urinary symptoms. SCORBUTUS. Case CCXXXYI.f — James Dermot, a^t. 21, railway labourer — admitted May 27th, 1847. Has been working on the Caledonian line of railway for nine months, and enjoj^ed good health till three months ago, when he received a blow on the right tibia. This produced a sore, and an ulcer formed. His diet consisted of bread, coffee, ham, butter, and sugar; but no milk or fresh vegetables. On admission, an elliptical-shaped ulcer, about two inches in length, is seated over the middle of the tibia, covered with irregular livid granulations, and surrounded by a raised purple edge. Another ulcer, the size of a shilling, is seated below this, and a third similar one on the outside of the leg. Eighteen months ago his left leg was burnt, and over the seat of the old cicatrix a number of ulcers, similar to those on the opposite leg, exist. One of these, towards the lower part of the leg, is the size of half-a-crown, and more livid than the others, which are smaller. The gums are swollen and fleshy, but not livid. Pulse 74, soft. Bowels constipated. To have fidl diet. ^. Aluminis 3 j ; Aquce § viij. Solve. Ft Gargarisma. 3 Sued limonis §iij; Sacchari §iss; Aquce § iss. M. Sumat pro potu ex aqua, indies. June 2d. — Ulcers looking more healthy. Their surface to be touched with nitrate of silver. July 27th. — Has slowly got well since last report, and is now discharged. * Library of Medicine, vol. v., p. 219. f Reported by Mr. J. Robertson, Clinical Clerk. SCORBUTUS. 921 Case CCXXXVII.*— John M'Kenzie, vet 26, railway labourer — admitted July 7th, 1847. During the last two months his diet has consisted chiefly of coS'ee or tea, with bread, butter, and sugar, but no milk. Two weeks ago pain and swelling came on in his left leg. Soon afterwards the right leg was also affected, and both became discoloured. Epistaxis now occurred, and has continued at intervals ever since, and has been so severe during the last two days, that his nostrils have been plugged. On admission, the left leg is much swollen, and of a purple colour chiefly on its anterior and inner aspect. The right leg is similarly affected, but to a less degree. He complains of pain and stiffness in both limbs, especially about the ankles. The gums are slightly swollen, and livid at the edges, but do not bleed on masticating food. Pulse 80, soft. Tongue clean. Bowels regular. To have full diet. Juhj 20th. — Since admission the symptoms have gradually disappeared, and to-day he was dismissed cured. Covimcntcn-y. — During the year from October 1846 to October 1847, no less than 231 cases of Scorbutus entered tlie Royal Iniii'niary, of whom 30 also laboured under continued fever. Of the entire number nine were females, and seven died. In the previous year only one case entered the Infirmary, and in the following one only six. I myself treated between seventy and eighty of these patients, having succeeded Dr. Christison in the charge of a long shed which contained a large number of them, besides seeing others who came into my other Avards. At the same period there existed a most extensive epidemic of typhoid or tvphus fever. Yet it is singular that the causes which produced scurvy, mostly in the able-bodied population, and especially among the class of labourers or "navvies" then working on our railways, were of a kind distinctly different from those usually giving rise to continued fever. The potato crop had failed for two successive seasons, and caused among the poorer population the consumption of a diet not only deficient in vegetables, but of milk and fresh meat also. Among the railway labourers, the truck system, and establishment of local stores, where provisions of inferior quality were given on a ruinous svstem of credit or exchange, greatly assisted the absence of vegetables in causing the dis- ease. The previous winter had been severe and protracted, so that whilst food of all kinds was high priced, the work and exposure of the labouring population were unusually severe. But scanty and improper diet, and especially such a kind as was deficient in fresh meat, milk, or vegetables, could in almost every case be ascertained to be the cause of its occurrence. Accordingly, in a large proportion of the cases, it was found sufficient to give the full diet of the house (Case CCXXVL), lo which, in unusually severe cases, two or three ounces of lemon-juice with ■wine were added (Case CCXXVIL). This, if the individual was not too prostrated before admission, always produced a cure in a period varying, according to the intensity of the disease, from thi-ee to six weeks. The vast majority of cases entered the house between the months of January and August. Dr. Christison, who has given a most able history of the epidemic as it was observed in Edinbui'gh and in the Perth Penitentiary,! con- * Reported by Mr. J. Robertson, Clinical Clerk. •)• Monthly Journal of Medical Science, June and July, 1847. See also Dr. Ritchie on Scorbutics, as it appeared in Glasgow at the same time, July and August, 1847. 922 DISEASES OF THE BLOOD. clasively shows that to tlie absence of milk, or its equivalent nitrogenous constituents, much of the disease was owing. In the Perth Penitentiary treacle-water had been given instead of it, and on restoring the milk no fresh cases occurred. I)r. Lonsdale again showed, that in the agricul- tural valleys of Cumberland, milk was abundant,* and that the absence of potatoes and fresh vegetables was the evident cause. The probably correct conclusion is, that health demands a varied diet, and that a too rigid abstinence from milk and fresh meat, as well as from vegetables, may occasion the disorder. The observations of Dr. Christison unques- tionably prove the anti-scorbutic properties of milk and of the full diet of the Edinburgh lutirniary, as these very frequently constituted the only treatment of individuals who recovered rapidly. The following table, drawn up bv Dr. Christison, shows the nutritive proximate principles in various dietaries, healthy, convalescent, and scorbutic. The numbers represent ounces avoirdupois. I. HEALTHY. I. Scott. Prison standard. •2. Glasgow Prison, 3d rate 3. Edinburi'h Prison, do. 4. Millbank Prison, 1521. 5. Do. Convicts, 1S40.. 6. Dublin Bridewell, 1S47 II. CONVALESCENT. 7. Edin. Inf. full diet.... S. Fever conval. diet TIL SCOPvBUTIC. 9. General Prison, 1846. . 10. Millbank Prison, ly23. II. Do. Soldiers, lSlO-1. 12. Do. do. Improved, 1S41 Tolal. IfOJJ-NlTEOGEXOnS. 1 NlTROGESOUS. 1 Slarch. Sug.ir. F.U. .Gluten. I.egum. AHmm. i Casein Mas. fib, Total. 25-2 25 24-3 25-0 231 19-5 19 4 201 24-2 20-9 lS-9 19-2 17-8 18-2 17S 19-4 17-9 13-4 11-6 11-1 17-S 16-6 1.5-3 150 1-32 0-82 1-56 o-os 1-10 1-50 1-56 Oil 016 013 0.55 0-57 0-60 1-26 S-S3 111 0-20 0-3S 038 396 407 3 -89 3 01 3 06 2 93 2-36 1-82 396 3-80 2-97 304 0-13 013 0-26 0-47 013 0-23 0-21 0-113 004 0-04 0-3G 0-23 .. 01 0-49 003 00-4 1-36 1-36 0-38 0-40 1-57 1-50 0-03 0-or 0-55 0-23 023 121 0-99 0-94 1-65 2-16 0-55 0-30 0-78 0-64 6-08 5-83 4-79 5 05 4-74 5-49 5-52 4-40 4-74 39S 3-78 3-S9 Note. — 1, 2. 3. The standard third-rate diet of the Scotch prisons, as used in the General Prison at Perth, in healthy years. 4. Diet of Millbank Penitentiary. London, before being changed to No. 10. 5. Millbank diet of civil convicts, who remained free of scurvy, while the military prisoners were attacked under the diet. No. 11. The data given by Dr. Baly, physician tl) the prison. 6 The present diet of the DubliD i)rison. where male convicts are kept for long terms. 7. Edinburgh Koyal Infirniary full diet, under which scorbutics promptly recovered. 8. Coflvalescent diet of a fever patient of the wealthy ranks, rapidly recovering flesh and strength. 9. Diet of the General Prison before the scurvy broke out. 10. Ditto before the Millbank epidemic at London in 1^23. 11. Ditto before the military prisoners in Millbank Penitentiary were attacked with scurvy in 1840-41. 12. Improved diet on that occasion, but found ineffectual. The individuals subjected to the dietaries in the I. and III. Divisions were all in conflne- ment for long terms. Dr. Garrod.f from an examination of the composition of food, under the use of which scurvy was capable of occurring, as well as of such sub- stances as had been proved beyond doubt to be anti-scorbutic, was led to the conclusion that the absence of potash was the cause of scurvy. In * Op. Citat., August, 1S47. f Monthly Journal of Medical Science, January, 1S48. POLYDIPSIA. 923 this way lie sliows, 1st, That potash is deficient in scorbutic diet; 2d, That all bodies proved to be anti-scorbutic, including fresh meat and veo-etablcs, milk, lemon-juice, etc., contain a large amount of potash ; 3d, That in scurv\' the blood is deficient in potash, and the amount of that substance thrown out by the kidneys is less than what takes place in health ; 4th, That scorbutic patients, when kept under a diet which gave I'ise to the disease, recover when a few grains of potash are added to their food. The salts of potash, such as tlie nitrate, oxalate, and bitartrate, are -svell-known anti-scorbutics, but the eflicacy has always been ascribed to the acid rather than to the alkali ; 5th, That deficiency of potash in the system seems capable of explaining some of its symptoms, especially muscular weakness, as potash is a necessary constituent of the muscular system. These yiews undoubtedly merit attention, and it is much to be regretted that they were not made known until the epidemic which had called thein forth had disappeared. POLYDIPSIA. Case CCXXXYUI.*— Sudden Polydqma— Incurable. HiST0R\' — Margaret Shearer, a French pohslier, ait. 34 — admitted May 31st, 1854. States that a year and a half ago she went to work at six o'clock, a.m., in her usual state of good health, and at eight o'clock, two hours afterwards, was suddeulj' f-eized with great thirst, which has continued ever since, accompanied by excessive discharge of uriue. About three months afterwards, she was obliged to give up work on account of a pain in the loins. At various times she has expe- rienced loss of appetite, nausea, fulness of the abdomen, palpitations, constipation, or diarrhoea. Thinking that her strength had diminished of late, she entered the Intirmaiy. Symptoms ox Admission. — On admission, the amount of urine passed in twenty- four hours was 424 ounces — pale in colour — of sp. gr. 1005, not coagulable by heat or nitric acid, and containing no sugar, as determined by Trommer's test. She is a stout able-bodied woman, and speaks of occasional slight complaints. She has a pale countenance, furred tongue, and dry skin ; but in every other respect is quite healthy. Dr. Ahson, who first treated her, ordered warm baths and astringents, and afterwards galvanic shocks to be passed through the epigastric region. On taking charge of the case in the middle of June, I ordered bitter tonics, and the diet was carefully arranged, and the amount of water drunk limited, and mixed with milk and a little magnesia. No change, however, occurred, and she confessed that she could not admit of restraint with regard to the amount of drink. During the w^hole month of Julj-, she was weighed daily, and the amount of water drunk and emitted from the kidneys carefullj' measured. Her average weight was eight stone, which underwent little variation. The amount of water drunk varied from 370 to 520 ounces, the average being 440 ounces. The amount passed varied from 350 to 500 ounces; and it was observable that it was always from 20 to 50 ounces less than the quantit)^ drank. The sp. gr. varied from 1001 to 1005, and was frequently tested for sugar, with the uniform result of its never being detected. The bowels were generally open every other da}-, and the stool was of normal consistence and healthy appearance. * Reported by Mr. James Thorburn, Clinical Clerk. / 92-i DISEASES OF THE BLOOD. Progress of the Case.— From the 9th to the 14th of July, I tried the influence of narcotics, and she took three grains of opium daily, with 3 iss and then 3 ij of solution of morphia. Under this treatment she frequently appeared drowsy and stupid, but sound sleep was never prolonged, and no diminution of the thirst and diuresis was perceptible. She then took large doses of gallic acid, and subsequently, at her own request, cod-liver oil, under the use of which she became stouter, stronger, and the appetite improved. August 22nd. — All other treatment was suspended, and she was ordered to take ten minims of the liq. iodini comp., which was continued to the 14th of September without any efiect. On the 16th she was ordered 5 Mass. pil. aloet. et myrrhce 3j; Ferri sulph. 9ij; Ext. hyoscyam. 9ij. Ft. massa in pil. xij dividenda. Turn pills to he taken twice daily. On the 26th there was diarrhoea when the pills were discontinued, and an astringent mixture ordered. The report on the 1st of October was — "general health good," and from an observation made for the first seven days of this month, it appears that the thirst and diuresis had somewhat diminished, tlie amount of urine varying from 280 to 350 ounces. There was no further change up to October 10, when she left the house. Commentari/. — I prefer calling this case polydipsia to diabetes insi- pidus, as frequent careful inquiry established the fact that it commenced with thirst, and tliat the increased How of nrine was a simple result of the quantity of water drunk. In the present state of science, no reason- able theory can be conceived, e.vplanatory of the fact, that a woman, apparently in good health, is suddenly seized with great thii-st, and thereupon drinks two or three gallons of water daily, passes a correspond- ing quantity of urine, and that this continues for nearly two years with- out any marked change in her health. Where there is no scientific indication, the treatment is wholly empirical, and even the results of experience are wholly negative and useless. Astringents, diaphoretics, galvanic shocks, narcotism by means of opium, cod-liver oil, iodine, and purgatives, all failed. The latter, by increasing the alvine discharges, diminished somewhat tlie excretion of urine, but we could not flatter ourselves that she was in any way benefited by her four months' treat- ment in the Infirmary. Case CCXXXIX.* — Polydipsia — Ejxessive Amount of Albuminous Urine — Phthisis Pulmonalis — Waxy Liver, Kidneys, and Spleen. History. — Thomas Kegan, set. 40— admitted December 13th, 1848. Patient states that he was in the enjoyment of good health till last May, when he first expe- rienced intense thirst, and began to drink large quantities of water. At the same time he observed that his urine became very much increased in quantity, and he required to get up three or four times in the course of the night to micturate. He had no pain in the region of the kidneys or on making water. This polydipsia and excessive micturition continued undiminished till five months ago, when he expe- rienced a dull aching pain in the small of the back. This pain in the loins after- wards degenerated into a feeling of weakness, which has continued ever since. On the 29th October he went into the Glasgow Infirmary, complaining of loss of appe- tite, great thirst, weakness, and loss of flesh. He remained in this Institution for six weeks, and took several remedies without any benefit. During the last fortnight his appetite has returned, and he has been much better. * Reported by Mr. George Shearer, Clinical Clerk. POLYDIPSIA. 925 Symptoms ox Admissiox. — There was dulness on percussion and cracked-pot sound over the upper third of left lung in front. Over this part there were heard tubular breathing and loud raucous rales ; over the right apex prolonged expiration. Posteriori}' percussion equal on both sides. Crepitation and sibilant rales on left side. There is frequent cough, with copious niuco-purulent expectoration. Tongue dry, clean, red, and tremulous. Appetite good, but thirst excessive. Drinks, as nearly as can be ascertained, a gallon of water daily. Bowels regular. He is much emaciated ; skin dry. He has not jjerspired any for several weeks. No oedema or ascites. The urine acid, unusuallj' transparent, sp. gr. 1010, shows a considerable quantity of albumen, chlorides abundant, no sugar. Large waxy tube casts were detected in the urine, under the microscope. There is slight tenderness on press- ing tirmly over the region of the kidneys. Progress of the Case. — December I5ih. — He passes from 100 to 130 oz. of urine dailj'. He has expectorated a considerable quantity of muco-purulent matter. His mouth and fauces were so dry this morning that blood flowed on dragging the tongue from the palate, to which it adhered by clammy glutinous secretion. There was a slight discharge of blood after blowing his nose also. December 18th. — Passed 176 oz. of urine on the 16th, 128 oz. on the 17th, to-day 82 oz., and drinks large quantities of water. Ordered to be dry cupped over the kidneys. To drink soda- ivater, and milk and water instead of simph ivaier. December 20th. — Urine 112 oz. Ordered a tablespoonful of Oleum Morrhucb three times a-day, and the folloiving mix- ture: — 5 Spt. jEtheris Nitrici 31; Sol. Mur. Morph. 3ss; Mist. CamphorcB § ij. M. Half the mixture at bed-time., and the other half in three hours if the cough is trouhhsome. December 2\st. — Had a good sleep after the mixture, but felt drowsy and sick all daj-. Pupils contracted at morning visit. Passed 112 oz. of urine 22d — Feels very well to-day. Passed a good night. Urine 64 oz. December 25th. — Has still a feeling of weakness and heaviness in the loins, and breathes heavily and with some difficulty. Expectoration purulent and considerable in quantity. Slight oedema of left foot observed this morning. Urine diminished to 54 oz. in the twenty-four hours. December 26th. — Passed 48 oz. of urine since j^esterday. Has had no stool during last twenty-four hours. Complains of great sickness to-day, and vomited his dinner. Ordered XajMhoi Medicin. §ss: Tr. Card. Co. §i; M. A teaspoonful occasionally in a glass of water. IJ Fulv. Jalapce Co. 3 ss ; 7nitie tales xij ; 07ie three times a day. Oi'dered also 4 oz. of gin daily. December 21th. — Passed a very uncomfortable night, with frequent moaning and stertorous breathing. At 1 P.M., his respirations became very slow and laboured, a mucous rattle was heard in his throat, and at 45 minutes past one, he expired. Sectio Cadaveris. — Forty -eight hours after death. Bod\' a good deal emaciated. Thorax. — Very dense adhesions at the apices of both lungs. The upper lobe of each lung felt firm and dense. In the upper lobe of the left lung there was a cavity of tolerably regular oval form, and nearly the size of a hen's egg. The lower extre- mity communicated with a smaller one of an irregular form. These cavities were lined by a well organized lining membrane, having a cheesy-looking matter adherent to it at many places, and here and there the cavities were crossed by bands of condensed fibrous tissue. The pulmonary tissue around them was greatly condensed. There was much yellow tubercle scattered through the remainder of the lung, and several vomica. One or two small cavities and a good deal of tubercle were found scattered through the upper lobe of the right lung. About two inches below the apex, and nearly in the centre of the organ, was a cretaceous concretion, about the size of a pea, enclosed in a capsule of dense fibrous tissue. About an inch below / 926 DISEASES OF THE BLOOD. this, there was a second concretion. The middle and lower lobes contained little tubercle. Bronchial glands enlarged, indurated, and loaded with black pigment. Heart healthy. Abuomex. — The liver was much enlarged, and was of unusual firmness and density. On section it presented the waxy degeneration, well-marked, the surface of section being dry, of a somewhat mottled yellowish-red colour, with a peculiar translucent appearance; lobular structure very indistinct. The organ weighed 6 lbs. 6 oz. The spleen was enlarged S^ oz., and felt somewhat dense. On section it was found to be pretty abundantly studded with clear Malpighian bodies, resem- bling grains of boiled sago. The kidneys were enlarged, weighing 15^ oz. On stripping off the capsule, the surface of the gland was found quite smooth, very pale, of a whitish-yellow colour, and of unusual density. The surface was somewhat mottled, owing to some patches of vascularity, contrasting strongly with the generally ansemic condition. On section the cortical substance was found hypertrophied, and had a pale, translucent appearance. The medullary portion was moderately con- gested. Almost all the branches of the renal arter\' in each kidney contained whitish clots ; some of them were firm, others partially softened. Some chronic tubercular ulcers were found in the lower part of the small intestine, and in the upper part of the large intestines. Microscopic Ex-a^mixatiox — On examining microscopically a little of the softened portion of the clots in the renal arteries, it was seen to consist chiefly of granular matter with a comparatively small number of cells, having the character of pus globules. When a section of the kidney was examined, the minute arteries were found to be much thickened. The cells and otlier structures of the kidney presented the usual characters of waxy degeneration. Commentary. — Tlie polydipsia seemed to arise spontaneouslv in this as in tlie last case, but there came on subsequently pain in the lumbar region and other symptoms probably indicating the commencement of the renal lesion. After admission the persistent albuminnria and the waxy casts detected iu the nrine left \is in little doubt as to the existence of Bright's disease of the kidney, although there was no dropsv in con- sequence of the large quantity of water which was freely passed from the system. The complication of excessive thirst, great diuresis, and Bright' s disease, mnst be one of excessive rarity, if indeed it has ever been previously noticed. After death both kidneys exhibited a chronic state of waxy degeneration, a ccmdition which in this case was proved to be quite compatible with the excretion of large quantities of urine. Death was occasioned by exhaustion from the pulmonary disease, vomit- ing, and impeded nutrition. POLYSARCIA OR OBESITY. Case CCXL.* — Great Obesity — Fatty Degeneration of Heart and Muscular System generally — of Liver and Kidneys — Hypertrophy and Dilatation of Heart. History. — Anne Gilchrist, set. 42, a cook— admitted June ITth, 1857. With the exception of an attack of rheumatism when 13 years of age, she baa enjoyed good * Reported by Dr. John Glen, Resident Physician. POLYSARCIA OR OBESITY. 927 health until three _vears ago, when she ruptured a blood-vessel in the lung from over- exertion. Last March she caught a cold, and shortly afterwards observed a swelling of the feet, gradually' extending up the extremities. Since then she has suffered much from dyspnoea. She has been of a full habit of body since the age of thirteen ; has indulged largely in eating and drinking ; besides spirits, having drunk at least a bottle of porter daily. She has always been exposed to large fires in the kitchen, and, in consequence of corpulence, has taken little exercise. Symptoms on Admission. — The woman is of an unwieldy size from corpulence. The circumference of the body at the umbilicus is 61 inches, of the calf of the leg 20 inches?, ami of the ankle 13 inches. She can lie on either side, but is very uneasy on the back. Slight exertion produces dj-spnoea. The sounds of the lungs and heart are normal. Percussion of the latter organ is unsatisfactory, in consequence of the uncommon size of the left mamma, and accumulation of fat. Pulse 82, regular and of good strength. Tongue covered with a thick fur. Appetite good. Urine scanty and turbid, sp. gr. 1015, albuminous on being heated. The skin over the abdomen and lower extremities was indurated and coarse. The scales of the house would only weigh 25 stone, and she was much heavier than this. To have a scruple dose of Bitartrate of Potash three times a-day. Full diet and 4 vz. of wine daily. Progress of the Case. — June 2\si. — Since admission, pulse better, and passes more urine — yesterday voided 30 oz. July' 9th. — Has passed from 20 to 30 oz. of urine daily, and the legs have ceased to be oedematous. Complains of loss of appe- tite. Pulse 80, weak. To have ^v} of wine daily. Jidy lOth. — Urine again scanty, onlj'^ passed 10 oz. yesterday. To have a squill and digitalis x)ill three times daily, in addition to the powders. JulylMh. — At the visit to-day was found lying on the right side, too weak to raise her head, and breathing with difBcultj^, the respirations being short and laboured. The urine w^as again deficient in quantity, and there was con- stipation. A drachm of the compound Jalap poivder tuas ordered to be taken immedi- ately. In the afternoon, before the powder had operated, she suddenly grew livid in the face, a tracheal rattle was heard, and in two minutes she expired. Sectio Cadaveris — Forty-four hours after death. External Appearances. — Bod}' of enormous size, owing to excessive develop- ment of adipose tissue. The head appeared to emerge ^^'ithout any neck from the trunk. Mamma; enlarged, each above the size of an adult's head. The following measurements were taken: — Height ..... Circumference of chest below nipples Breadth from shoulder to shoulder Circumference of abdomen „ mamm;e at base „ upper arm „ lower arm ,, thigh . „ leg below the knee „ ankle . Thickness of integument over sternum . „ „ abdomen Thorax. — Heart much enlarged; it weighed 22 oz. All the cavities were dilated, the walls retaining their normal thickness. The valves were healthy. The muscular G5^ inches 54 36 69 36 19 16 28 20| 13 2 5 928 DISEASES OF THE BLOOD. tissue of the heart was pale and soft. The lungs were healthy. The osseous walls of the thorax were not larger than usual, the breadth internally being 11^ inches. Abdomen^. — There were two ounces of serum in the peritoneal cavity. The liver was much enlarged, weighed 7 lb. 10 oz., and was of a pale fawn colour The two kidneys weighed 13^ oz. They were of soft consistence, and pale colour. The spleen weighed 13^ oz. ; it was softer than natural. The intestines were healthy, and, with the exception of a few cysts in each ovary, the other viscera were normal. Microscopic Ex.\iiiN'ATiox. — The muscular tissue of the heart was seen to be in an advanced stage of fatty degeneration. The cells of the liver were crowded with large drops of oil, and the nuclei of many of them were absent. The cells of the kidney were also very fatty. Commentari/. — The circumstances in which this poor woman was placed were exactly those most favourable to the production of obesity. As cook in several noblemen's families, there had been no necessity for her undertaking much personal exertion, and having a good appetite and sound dio-estive oro-ans, she indulged laro;elvin eating and drinkinor, whilst always more or less in a heated atmosphere. It is much to be regretted that her e.vact weight was not ascertained. When standing on the Infirmar}' scale, which only allowed us to weigh to the extent of 25 stone, it seemed as if she was at least 5 stone more. In a table of obese persons given by Dr. T. K. Chamber.*,* one man is said to have weighed 30 stone, but he was 6 feet 1 inch high ; two others, a man and a woman, weighed 28, and another woman 26 stone. In the case before us, the increase of fat had certainly arrived at an extent seldom wit- nessed in the human subject, and with the result of gradually causing fatty degeneration of internal organs essential to life. Latteily, from fatty degeneration of the kidneys albuminuria made its appearance, with oedematous limbs. From this, however, she might have recovered, had not the ailvanced fatty degeneration of the heart and liver so enfeebled the circulation as to render fatal syncope at no distant period certain. It is probable that the change of diet and absence of her accustomed stimuli contributed to the result, although every care was taken to counteract such causes of exhaustion as much as possible. * On Corpulence. 1850. P. 139. COXCLUSION* The Ethics of Medicine. Gen-tlemen — After a lengthened period of study, and a series of examinations, intended to test the amount of your knowledge, you have received the degree of Doctor in Medicine, the highest academic honour it is in the power of any University to confer. The direct connection which has hitherto existed between you and your teachers here termi- nates, and all those restraints, which public opinion and legal forms have imposed upon the uneducated, are removed. The energies, which you have hitherto employed in acquiring the necessary preparatory informa- tion, you may now dedicate to the practical affairs of life. In short, gentlemen, you this day obtain a high status in society, and without, I hope, ceasing to be students, you -become members of a liberal and highly honourable profession. Such an event constitutes an important epocli in the life of every man, and is well calculated to excite not only deep feelings of reflection in yourselves, but those of lively emotion in all who are concerned (and who is not \) in the progress of that art which is directed to the prolongation of life and the cure of diseases. It will not, then, be considered superfluous if, in obedience to established usage before you leave this institution, a member of the medical faculty seizes the opportunity of offering to you a few words of advice, of point- ing out the importance of your future profession, and describing to you the spirit in which it ought to be practised. I. The first piece of advice that I shall take the liberty of oflering is, always to cherish a feeling of deep respoiisibility. A medical man is the earthly arbiter of life and death. He is the guardian of our race through the dangers of birth, and the perils of infancy. He is called upon to treat the diflFerent maladies which can afflict the human frame, nnder every circumstance of climate, age, sex, or condition ; and lastly, when all means fail to prolong life, it is his duty, if possible, to alleviate those pangs, and diminish those sufferings which accompany the separation of the soul from its present dwelling-place. If, then, we regard him as the soother alike of the entrance and the exit of this life, as the first and the last friend of frail humanity, and if we further consider him, in the social scale, 5is the superintendent of all public and private institutions for the * An Address delivered as Promo tor of the iledical Faculty to the graduates in medicine. August 1, 1849. 59 930 CONCLUSION. sick and the insane, as the adviser of legal tribunals in tlie administra- tion of justice, and as the regulator of the sanitary conditions of armies, fleets, and, indeed, of nations, it is scarcely possible to conceive a vocation in which every feeling of duty and honour ought more to incite to activity and usefulness ; to the cultivation of his intellectual powers and resources; to a life of beneficence and integrity, and, above all, to a sense of the deepest responsibility. This feeling is one which the most experienced and able practitioner can scarcely shake off, and Avhich ought to press, with enormous force, upon those who are newly called upon to decide concerning the awful aft'airs of life and death. A fellow-creature having received some violent accident, or being attacked by acute disease, calls upon you for assistance. There may be no more experienced practi- tioner near ; these is none to consult with ; the danger is imminent, and you feel conscious that not only something must be done immediately, but that what is done may save or destroy. Then there rushes upon your mind a peculiar feeling of dread and anxiety, rendered more embar- rassing, perhaps, by the conviction that your future prospects may be influenced by the manner in which you conduct the case before you. Such a circumstance, as I have supposed, may happen to any of you at the commencement of your career, and it is then, you Avill perceive, that the only true support to be depended on, is a consciousness that you are enabled to put in practice all those means which the present condition of the science and the art of medicine has recognised as being correct. At such moments there will be impressed upon you the convicrtion that the good of your patients, and your own mental tranquillity, are inti- mately united ; you will see the advantage of having studied your profes- sion, not merely as an object of gain, but from a love of its intrinsic excellence — not because it brings you consideration and respect, but because it enables you to do good and to relieve suftering — not with a vain effort at exhibiting your superior knowledge, but with that humilitv which is the necessary result of true wisdom. The object of medicine is to preserve health, prolong life, cure diseases, and thereby to forward the happiness of mankind; and it is evidently the duty of those who practise it, to lose no opportunity, and to adopt every means of prosecuting that object to its fullest extent and in its widest signification. With this view, gentlemen, vour past studies have been directed to the acquirement of various kinds of knowledge, the pur- pose of which has been not merely the obtaining of professional rules, but enlarging the mind, and cultivating the reasoning powers. The time has now arrived when you must concentiate the miscellaneous information you have gathered together, in order better to carry out that particular kind of practice which you in future intend to pursue. Any of the so-called accessory sciences may (should your tastes allow) be still further prosecuted, but not to the exclusion of more important matters. Your duty is to cure the sick and relieve suffering, and not to be distinguished as a chemist, a botanist, or a naturalist. Neither is it expected that you should have all the knowledge which each of your teachers possesses in his especial department, but that irom the whole yovi should have obtained such a sum of learning, and such an available kind of information, that you may undertake the serious duties of a medical practitioner with credit to yourselves and advantage to the pub- THE ETHICS OF MEDICINE. 931 lie. Such an amount of knowledge is within the reach of all ; and should there have been any deficiencies or omissions in your past career, you are imperatively called upon to remedy them at once. Perhaps it is unnecessary for me to say your education is not comj)Iete ; indeed, in one sense, it may he said to be only beginning. Hitherto, you have depended on others, now you must advance by yourselves — the informa- tion of collegiate life must be perfected and elaboi'ated, in order to meet the exigencies of cvery-day aftairs. You must prune away those imagin- ings in which the student loves to indulge, and direct your thoughts to the stern realities before you. For this purpose, you should seize the interval which may elapse between your retirement from the schools and the commencement of actual practice, in arranging your past acquire- ments for ready use, and in extending, by every possible means, your experience in the observation and treatment of disease. By so doing, I consider you will be best qualified to meet the serious responsibility you have to undertake, and will thereby attain that comfort of mind and true respectability which the proper and enlightened exercise of our noble profession can alone secure. II. This leads me, in the second place, to impress upon you the import- ance of 2>'>'(''Ctising the art and cultivating the science of medicine, in a sjnrit of sincerity and of truth. — It is a well-known fact, that whilst the public can judge with tolerable correctness of merit in any other profes- sion, it is wholly incapable of forming an estimate of ability in medicine. The structure of the human body, the functions it performs, the laws which regulate it, and the derangements which aft'ect it, are to mankind in general completely unknown. All that your patients will concern themselves with, are results — but so ignorant are they of the means by which results are obtained, so little do they know of the operations of nature as distinguished from those of art, that they are especially liable to be led into erroneous conclusions. In consequence, unprincipled per- sons, from time immemorial, have successfully practised on public credulity, and some specious but shallow theor}^, some vaunted nostrum, some pecuHar accomplishment, or some singularity of manner, has each in turn been made the means of imposition. It is expected of you, gentlemen, that you are so well grounded in the facts and principles of medicine, as to be enabled, on all proper occasions, to put down ignorant presumption, refute false doctrines, and expose artful knavery. You will remember that medicine is a progressive science, and that whilst the wise and learned who have cultivated it have done much, more remains to be accomplished. You will therefore readily acknowledge its imper- fections where such truly exist, and prefer a frank avowal of ignorance to a false assumption of knowledge. There is one great ditficulty you will have to encounter, viz., that the rules and principles, which guide the profession, in the coui'se of time undergo a considerable variation. The arts and luxuries of life, the physical changes of the globe, and the differences of education and civili- zation to a certain extent, modify the constitution of man and the diseases to which he is subject. Maladies described as existing in former times are now unknown, whilst others are altogether of modern origin. It is of the utmost consequence, therefore, that the medical practitioner should 932 coxcLusiox. be alive to the importance of following the progress of his art, and not imagine that at any time he has learnt all that is useful, or that he can ever reach that point where improvement is not to be gained. At the same time, he must learn, amidst the multitude of suggestions, the num- ber of theories, and the opposing statements which will perplex him, to reject what is worthless, and only adopt what is truly useful. In all such cases, the best rule is to be on your guard against loose and confi- dent plausibilities, especially where such are advanced not in their true character as hypotheses, but as established laws which are to regulate your practice at the bed-side. It is sometimes allowable to give^ cer- tain rein to the imagination, and cultivate that power of generalization w-hich has led to the most important and brilliant results in scince ; but it this be not controlled within its proper limits, nothing can be more mischievous, especially w hen the errors may affect the lives of mankind. Strive, then, so to improve your intellectual resources and observing powers, that you may be enabled to shun error and admit truth, especially avoiding all those easy and fallacious paths to knowledge, into which the interested endeavour to entrap the unwary. A desire to practise your profession in sincerity and truth, will also lead you, in cases which you have not particularly studied, or which demand special kiuds of treatment, to require the"^ assistance of some brother practitioner. Xo two persons prosecute their studies in exactly the same direction ; and the subject of medicine is so extensive, so complicated, and requires so much application, that it is almost impossi- ble for a single individual to become master of the whole. Vanitv and self-conceit, it is true, have led some men to maintain the contraiy'; but where is the individual who is at the same time a good physician, a good surgeon, and a good obstetrician ? There are "many, doubtless, who practise very usefully in all these branches, and you may be so circum- stanced hereafter as to do the same. If so, you will necessarily be often consulted in cases where you must fee! internally convinced "that you cannot do full justice to your patient, and then it will be right to bear in mind that, if you possess a gi-eater share of infoi'mation in some respects than others, they in certain particulars know more than you. Do not, then, be deterred by a false feeling of shame, or a desire* for gain, from consulting your medical brethren ; reciprocal services beo-et mutual kindness, and it is at all times better to resign the treatment of a case you do not understand, than subject yourselves, bv undertaking it, to a perpetual series of mortifications and disai>pointment's. By exercising your profession, then, in a spirit of sincei'ity and truth, you will be ani- mated by a proud desire to advance its claim to public confidence, rather than your own immediate interests ; you will despise the miserable vanity of announcing what is new, without a scrupulous regard to its being cor- rect. You will, while retaining the right of thinking boldly for ''your- selves, not forget that observation is" diflicult, theon- imperfect, and experience frequently fallacious. You will not, therefore^ rashly substitute your own authority for that of those whose knowledge is more extensive, or commit yourselves to the ephemeral doctrines of the day, by which a few otherwise respectable men have lost their professional reputation. You will remember that the conclusions of youth are almost always modified by the experience of age ; and that the wisest and most emi- THE ETHICS OF MEDICINE. 933 nent men of science have given the best proofs of a solid understanding, by the readiness with which thev have acknowledojed their own io-no- III. The third and last point to which I shall direct your attention is, that you oxujlit to be strouf/ly imbued with a sense of duty and of moral obligation. Xo profession demands that its members should be governed in their practice by purer principles of honour than our own. The medical man is received into the bosom of private families, where he is intrusted with mattei-s of such a nature, that, if they were disclosed, they would be attended with the greatest distress, and would plunge parents or children into the most bitter and poignant agony. It is your office not only to regulate the corporeal, but, in many cases, the mental derangements and irritability of your patients ; but who can govern the minds of others, if he is incapable of commanding his own .- Prudence, sobriety, kindness, and delicacy of feeling, are therefore especially enjoined upon those who treat the sick. It is true, you will labour among scenes of woe, and have to watch incurable diseases, and loath- some maladies ; but he whose sensibility is thereby blunted, and who can look with indifference on the agonies of a fellow-creature, will sel- dom feel that anxiety, or experience that watchfulness, which is so necessary for detectmg the true condition of his patient. Self-interest is the worst of all models for a medical practitioner, and is a vice which our profession may proudly claim exemption from. You, I trust, will never experience it, but rather those pleasurable emotions which result from lessening human suffering, without thought of profit, and from exercising friendly offices with that politeness and delicacv of sentiment which distinguish every man of a gentlemanly and refined mind. Mixed, as you occasionally will be, with every branch of society, you must expect sometimes to meet with ingratitude, and be ignorantly unde- servedly charged with committing errors. All men are liable to misre- presentation ; and although I do not, at such periods, advise you quietly to submit to insult, I strongly recommend great circumspection in manifesting resentment. "Unjust suspicions may attach to an inno- cent man ; the general consistency and integrity of his life will wipe them away ; the imprudences of }"outh may be repaired by the circum- spection of middle age ; but if you once lose your reputation for professional prudence and honour, you wnll find, whatever be your attainments, that your influence is gone, and that you are, in all respects, lost and ruined men." In addition to the duties which you discharge to the public at laro-e, there are others of no less importance which you owe to yourselves. Opportunities will frequently occur, where you may, bv looks or words, seriously injure the reputation of some brother practitioner, when in reality he does not deserve it. The period of the disease, or the circum- stances which have occurred, may enable you to do what your predecessor could not. Every good feeling demands, that under such circumstances you should explain the cause of yonr success to the patient, and not allow him to suppose his previous attendant was in fault. Besides, the most scientific and experienced physician may sometimes err unavoida- bly, and you must never attempt to aggravate the consequences of his 934 COXCLUSIOX. failure, by adding to the patient's dissatisfaction. Conduct of tliis kind Avill cause the offender to be shunned, and sooner or later to feel that no success, and no wealth, can compensate for the absence of self-esteem, or the good opinion of the enlightened and honourable men of his own profession. Gentlemen, habitually engaged as you will be at the bedside of the sick and the dying, you will have abundant opportunities of rio;htly esti- mating the insufficiency of mere worldly considerations. I think vou will tind, notwithstanding what is said to the contrary, that there is no class of society in which the true spirit of religion is more extensively diffused than among members of the medical profession. True, they shrink from an officious and public manifestation of it, and their habits of thought teach them to distinguish between trifling forms and essential truths ; but I know of no calling more practically engaged in acts of charity, in an abnegation of self, a desire to do to others what we wish others should do to us, and an endeavour, if occasion require it, to afford all those consolations which a pure Christianity can alone impart. This has ever been the conduct by which all the brightest and most eminent characters in our profession have been distinguished, and I earnestly pray that such may be yours. And now. gentlemen, I and my colleagues bid you farewell, trusting that whatever part you are destined to fulfil in the affairs of life as medical practitioners, you will ever labour under a deep sense of res{)onsibilitT, that you will always act in sincerity and truth, and ever be governed by a high feeling of duty and of moral obligation. Let us hope that you Avill regard your past teachers as your future friends, and that in whatever part of the world, however distant, your lot may be cast, we shall still be united by a chain of good feeling and mutual esteem, which, however it may be lengthened, can never be cut across. We desire that you will con- sider the reputation of this University as in some degree identified with your own, and, whilst on the one hand you take care never to sully the degree she has this day conferred, on the other you will, by constant good conduct, and by well-directed endeavour, add fresh lustre to the reputation she holds among the academic institutions of this great country. TABLE OF CASES. DISEASES OF THE NERVOUS SYSTEM. Case Page I. — Acute Hydrocephalus — Recovery 312 II. — Acute Hydrocephalus in a scrofulous child — Recovery . . . 312 III. — Acute Hydrocephalus — Phthisis pulmoualis — Death — Eflusion into the lateral ventricles — Non-inflammatory softening of the central parts of tho brain — Meningitis at the base of cranium — General tuberculosis 314 TV. — General Acute Meningitis supervening on pleuro-pneumonia . . 319 Y. — Acute meningitis at the base of brain — Serous effusion into the ven- tricles, with white softening of cerebral substance — Phthisis . 320 VI. — Acute Meningitis at the base of the brain — Etiusiou of serum into the lateral ventricles — Eflete tubercle, in the pons varolii and lungs 322 YII. — Chronic Meningitis — Serous effusion into the ventricles — Tubercular mass in left lobe of the cerebellum — Cretaceous tubercle in the lungs, with fibrous cicatrix ........ 325 YIIL — Chronic Cerebral Meningitis ; induration surrounded by softenuig of a portion of the left cerebral hemisphere . . . . . 327 IX. — Acute Cerebritis — Abscesses in the brain — Old Tubercle in vai'ious Organs — Chronic Peritonitis 329 X. — Acute Cerebritis — Abscesses in the brain — Pulmonary tubercle — Abscess in kidney . . . . . . . . . 331 XI. — Chronic Cerebritis — Epileptiform convulsions — Hemiplegia of tlie right side — Loss of smell — Blindness of the left eye; amyloid bodies in the brain ......... 333 XII. — Chronic Meningo-Cerebritis — Sudden convulsions — Hemiplegia of left side — Softening of anterior lobe of right cerebral hemisphere — Adhesions of arachnoid ........ 336 XIII.- Clu-onic Cerebritis of the right hemisphere — Cancerous ulcer of the oesophagus and neighbouring glands — Patty heart . . . 338 XIY. — Paralysis of the abducens oculi and auditory nerves — Exophthahnia — Tumour at the base of the cranium — Partial Recovery . . 342 XY. — Paralysis rapidly becoming general — Old apoplectic cyst in riglit corpus striatum — Softening of pons varolii — Clot obstructing basilar artcrj' — Pneumonia of left lung. ..... 345 XYI. — Apoplexy — Hemiplegia of left side — Convulsive attacks — Cardiac and renal disease — Old clot in the right cerebral hemisphere, with surrounding softening 348 A 936 TABLE OF CASES. Case Page XVII. — Two sudden attacks of Apoplexy — Hemiplegia — Cardiac dis- ease — Persistent albuminuria — Enlarged and diseased spleen — Cerebral softening — Anasarca — Atheroma of arte- ries — Obstruction of left middle cerebral artery . . 351 XVIII. — Apoplexy, followed by Hemiplegia of left side — Recovery . 356 XIX. — Apoplexy followed by Hemiplegia of the right side — Recovery 357 XX. — Palsy — Hemiplegia of left side — Recovery .... 358 XXI. — Sudden Paralysis of face and left arm — Pneumonia — Bright's disease — Recovery ........ 359 XXII. — Apoplexy — Extravasation of blood into the left corpus stria- tum — Pneumonia — Arrested tubercle of lung . . . 3G0 XXIII. — Apoplexy — Hemiplegia of left side — Hemorrhage into right cerebral hemisphere — Diseased heart — Pneumonia . . 3G2 XXIV. — Apoplexy — Hemorrhage at the base of the brain in a boy aged 14 years 363 XXV. — Apoplexy, followed by delirium, and proving fatal in eight hours — Hemorrhages into the meninges of the brain . 365 XXVI. — Hemorrhage into the right crus cerebri — Meningitis at the base of the encephalon — Serous effusion into the lateral ventricles — Chronic phthisis — Vertigo — Paralysis — Spasms of the jaw — Delirium and coma 366 XXVII. — Apoplexy — Hemorrhage into right optic thalamus, causing hemiplegia on left side — Progressive recovery — Two months afterwards, hemorrhage into pons varolii and membranes on right side — Death in seven hours .... 370 XXVIII. — Five years before admission, hemiplegia, followed by recovery — Four months before admission, apoplexy, with convul- sions and partial recoverj^ — Pulmonary disease — Death by asphyxia — Chronic softening of right corpus striatum — More recent hemorrhage into the pons varolii — Cardiac hypertrophy, with mitral constriction — Hemorrhage into the lungs 371 XXIX. — Cancer of the brain, spinal cord, liver, and bones . . 378 XXX. — Chronic hydrocephalus — Paracentesis Capitis — Xo benefit . 381 XXXI. — Acute myelitis in the cervical portion of the cord — General pains, resembling those of rheumatism — Fugitive paralysis in the arms and legs — Engorgement of the lungs — Death . 385 XXXII. — Slight paraplegia — Recovery 388 XXXIII.— Paraplegia— Partial Recovery 388 XXXIV. — Paraplegia — Incurable 389 XXXV.— Paraplegia — Chronic myelitis— Death 390 XXXVI. — Paraplegia — Tubercular caries of dorsal vertebrte — Myelitis — Pulmonary Tubercle 392 XXXVII. — Paraplegia — Cancer of vertebral bones — Softening of the cord from pressure — Cancer of lung, liver, and lumbar glands — Ulceration of urinary bladder ...... 395 XXXVin. — Partial amaurosis — Spectral illusions — Perversions of hearing, smell, and touch — Spinal Irritation 399 XXXIX. — Delirium tremens— Recovery 410 XL. — Delirium tremens with ocular spectra — Recovery . . . 410 XLI. — Dehrium tremens with con-vulsions and coma — Recovery . 411 Case TABLE OF CASES. 937 Page XLIL— Coma and death from excessive drinking— Opacity of arach- noid— Sub-arachnoid eflfusion— Fluid blood . . . 411 XLIII. — Poisoning by opium — Recovery 413 XLIV. — Poisoning by Hemlock— Death 413 XL v.— Poisoning with lead— Painter's colic— Lead paralysis— Partial recovery ...••••••• 418 DISEASES OF THE DIGESTIVE SYSTEM. XLYI.— Tonsillitis 421 XLYIL— Follicular Pharyngitis 422 XLTIII.— Stricture of the CEsophagus from Epithelioma . . . 423 XLTX.— Epitheliomatous Ulceration of the (Esophagus, communicating with the Lung— Pneumonia terminating in Gangrene . 424 L. — Carcmomatous Stricture of (Esophagus — Cancer of the Liver —Pulmonary Emphysema and Tubercle — Pneumonia . 426 LI. — Dyspepsia ^^^ LIL — Dyspepsia — Oxaluria 430 LIU. — Dyspepsia — Hypochondriasis — Oxaluria .... 430 LIT. — Dyspepsia^ — Vomiting of fermented matter containing Sarcinge. 435 LY. — Dyspepsia — ^Yomiting of fermented matter containing Sarcinte. 438 LYI. — Chronic Ulcer of the Stomach — Recovery .... 438 LYIL— Chronic Ulcer of the Stomach— Cure 439 LYIII. — Chronic ulceration and perforation of the stomach — Peritonitis — Limited pneumonia with gangrene — Abdominal abscess — simulating pleurisy — Death 440 LIX. — Chronic ulceration in the stomach — Perforation occasioned by a faU (?)— Recovery 445 LX. — Cancer of stomach, pancreas, and mesenteric glands— Cystic atrophy of right kidney 448 LXI.— Colloid cancer, with perforating ulcer of stomach — Peritonitis. 449 LXII. — Acute congestion of the liver — Hepatitis? — Recovery . . 454 LXIII. — Acute jaundice — Albuminuria — Recovery .... 4.54 LXIY. — Impaction of a gall-stone in the common bde-duct — Jaundice —Death 456 LXY. — Jaundice — Compression of the ductus communis choledochus from a cancerous tumour, composed of epigastric and lum- bar glands — Occlusion of cystic duct — Enlargement of gall- bladder—Cancer of the pancreas — Biliary congestion of the liver — Cancerous exudation into various organs — Shght leucocythemia .....-••. 458 LXYI. — Jaundice— Cancerous tumour of the pancreas, comprising the ductus communis choledochus— DUatation of the gall-bladder, and passage of gall-stones into the gall-bladder — Cancer of the liver and kidneys 461 LXYII. — Enlargement of the liver — Ascites — Albuminuria — Recovers'. 463 LXYIIL— Fatty Enlargement of the Liver 464 LXIX. — Cirrhosis with Atrophy of the Liver — Ascites . . . 467 LXX. — Cirrhosis with Enlargement of Liver— Hyj^ertrophy of Spleen — Slight leucocythemia — Jaundice — Constriction of arch and descending Aorta 468 938 TABLE OF CASES. Case Page LXXI. — Cancerous Exudation into the Liver — Cancerous Ulceration of oesopliagus — Simple stricture of the pylorus — Profuse hematemesis — Aneurism of thoracic aorta, bursting into the left pleura . ■ . . . . . . • . 472 LXXIL — Diarrhoea — Eecoverj-- 476 LXXIII.— Diarrhoea— Recovery 477 LXXIV. — Acute Dysentery — Recovery 479 LXXV.— Sub- Acute Dysentery — Recovery 479 LXXVL — Chronic Dysentery — Ascites and oedema of the legs — Leu- cocythemia — Cirrhosis of the liver — Cancer of the lung . 480 LXXVn. — Obstruction of tlie large intestine — Cancer of stomach, liver, peritoneum generally, and mesenteric glands . . . 486 LXXVIII. — Strangulation of the small intestine from Inguinal Hernia — Gangrene, ulceration, and perforation of the intestine — Peritonitis ......... 488 LXXIX.— Tape-worm treated by the ^Ethereal Extract of the Male Shield Fern 495 LXXX. — Tape-worm expelled by the yEthcreal Extract of the Male Shield Fern 496 LXXXI. — Tape-worm expelled by the same remedy .... 497 LXXXII. — Tape-worm expelled by Kamala 498 LXXXin. — Acute Peritonitis from bursting of Graafian Yesicles into the Peritoneum — Pleurisy — Inter-lobular Pneumonia . . 499 LXXXIV. — Tubercular Peritonitis with great Deposit in Parietal Layer — Tubercle and Hepatisation of Lungs — Pleuritis — Adhe- rent Pericardium —Commencing Fatty Degeneration of Heart — Biliary Congestion and Fatty Degeneration of Liver — Slight Leucocythemia 501 LXXXV. — Cancer of various Abdominal Organs and of the Lungs, pro- ducing S^'mptonis of Peritonitis ..... 504 LXXXVI. — Cancerous Peritonitis — Ascites and H^vdrothorax — Para- centesis Abdominis — Arrested Phthisis Pulmonalis . . 508 DISEASES OF THE CIRCULATORY SYSTEM, LXXXYII. — Acute Pericarditis — Recovery 514 LXXXVIII. — Pericarditis and Endocarditis — Hydropericardium . . 515 LXXXIX. — Acute Pericarditis followed by Acute Double Pneumonia — Recovery— Aortic Incompetence — Subsequent Articular Rheumatism — Sudden Death — Adherent Pericardium — Fatty Enlarged Heart — Thickening of Aortic Valves . 516 XC. — Acute Pericarditis supervening on Phthisis . . . 620 XCI. — Ascites — Anasarca — Adherent Pericardium with Fatty Atro- phied Heart — Congested Liver ..... 523 XCII. — Rheumatic Pericarditis 525 XCIII. — Incompetency of Aortic Yalves — Dilated Hypertrophy of Left Ventricle — Dilatation of Ascending Portion of Aortic Arch — Chronic Arteritis with Aneurismal Pouches . . . 533 XCIV. — Incompetency of Aortic Valves — Hypertrophy of Left Ven- tricle and Auricle — Obstruction and Incompetency of Mitral Valve — Pneumonia ........ 534 536 TABLE OF CASES. 939 Cask ^5^ XCV.— lucoaipetency of Mitral Valve 536 XCVI.— Incompetency of Mitral Valve— Pulmonary Hemorrhage— Hydrotliorax XCVI [.—Mitral Incompetency— Hypertrophy of left Ventricle— At- tack of Acute Kheumatism, followed by Aortic Incompe- tency . ■5^'' XCVIII.— Mitral Incompetency— Hypertrophy of left Ventricle- Aortic Incompetency and Obstruction — Angina . . 539 XCIX.— Incompetency of the Aortic Valves with Musical Murmur- Hypertrophy with Dilatation of left Ventricle — Pneumonia — Pulmonary Hemorrhage 540 C— Mitral Incompetency— Hypertrophy of left Ventricle — Dila- tation and Disease of Arch of Aorta— Aortic Incompetency 542 CI.— Constriction of Mitral and Tricuspid Orifices— Aortic Incom- petence — Anasarca— Hydi-othorax-Collapse of left Lung — Bright's disease of Kidney 543 CIL— Constriction of Mitral and Tricuspid Orifices— (Edema- Hemorrhage into the Lungs 544 CIIL — Soft Adherent Polypus, causing incompetency of the Mitral Orifice — Anasarca 546 CIV.— Enlarged Foramen Ovale — Phthisis - 548 CV. Aneurism of the Ascending Arch of the Aorta— Incompetency of Aortic Valves — Hypertrophy of left Ventricle . . 557 CVI Aneurism of Ascending Aorta, immediately above the Aortic Valves— Incompetency of Aortic and Mitral Valves— Hyper- trophy of left Ventricle— T^axy Kidneys— Pulmonary Hemorrhage— Anasarca 558 CVII. Aneurism of Ascending Arch of Aorta— Chronic Pericarditis —Disease of Aortic Valves— Great H^-pertrophy of Heart — Anasarca .....•••• 560 CYIII.— Large Aneurism of the Ascending Arch of the Aorta, causing Absorption of a portion of the third Rib, and bursting into the Pericardium — Chronic Pericarditis — Incompetency of Aortic Valves — Hypertrophy of left Ventricle . . 562 CIX. Varicose Aneurism of the Ascending Aorta communicating with the Poilmonary Artery— Jaundice and Xutmeg Liver 564 ex. — Aneurism of the arteria innominata 568 CXL Aneurism of transverse aortic arch— Chronic pericarditis with effusion — Tubercular lungs — Anasarca — Former popliteal aneurism cured by compression 572 CXII. — Aneurism of lower portion of the thoracic aorta, pressing on the thoracic diict — Aneurism of abdominal aorta —Chronic ulcer of stomach — Chronic tubercular abscesses of liver and right kidne}^ — Liver and left kidney waxy — Leucocythemia 575 CXIIL — Aneurism of the superior mesenteric artery and aorta — Obscure aneurism of descending thoracic aorta — Treatment by the method of Valsalva — Pleuritis — Caries of the verte- brae, softening of the spinal cord and Paraplegia — Sudden death by poisoning with tincture of aconite . . . 577 940 TABLE OF CASES. DISEASES OF THE RESPIRATORY SYSTEM. Case Page CXIV. — Acute Laryngitis — Treated by topical applications— Recovery 593 CXV.— Chronic Laryngitis — Topical applications — Recovery . . 594 CXVI. — Acute oedema of the glottis — Chronic pharyngitis and laryn- gitis — Sudden death 598 CXYII. — Chronic lar^-ngitis and pharyngitis — Tracheotomy— Recovery 599 CXYIII. — Acute bronchitis — Recovery 602 CXIX.— Acute bronchitis 603 CXX. — Chronic bronchitis — Acute peritonitis — Collapse of the lung 605 CXXI. — Chronic bronchitis— Emphysema — Acute laryngitis . . 606 CXXIL — Chronic bronchitis— Emphysema— Injection of the bronchi with a solution of the nitrate of silver .... 600 CXXIII. — Acute pleurisy — Recovery 613 GXXIY. — Acute pleurisy without functional symptoms — Rapid recovery 614 CXXV. — Chronic pleurisy on both sides — Bronchitis . . . 616 CXXVL — Empyema, witli fistulous openings between the lung and pleu- ral cavity, and between the pleural cavity and external surface ......... 621 CXXVII. — Chronic pleuritis and pneumo-thorax, without symptoms — Articular rheumatism — Pericarditis — Recovery . . 623 CXXVIIL — Empyema, following chronic phthisis — Paracentesis thoracis — Pneumo-thorax — Singular mode of death from enormous distension of tlie stomach and emphysema of its coats — Tubercular pleuritis — Adherent pericardium — Waxy spleen — Tubercle in the kidneys 625 CXXIX. — Pneumonia on right side and slight pleuritis — Recovery . 630 CXXX. — Double pneumonia — Recovery 631 CXXXL — Pneumonia on the right side — Early bleeding — Slow recovery 632 CXXXIL — Erysipelas of the face followed by pneumonia of the right . side — Recovery 634 CXXXIII. — Double pneumonia — Treatment by mercury, which caused profuse salivation before admission — Prolonged recovery 635 CXXXIY. — Pneumonia of right side — Critical diarrhoea on the twenty- first day — Recovery 637 CXXXY. — Pneumonia of left side — Critical diarrhoea on the fourteeutli day — Recovery 638 CXXXYL — Double pneumonia — Critical diarrhoea on the twenty-first day — Recovery 638 CXXXYIL — Pneumonia ushered in by violent vomiting and gastric pain — Recovery in five days 639 CXXXVIIL — Double pneumonia, with urgent symptoms, and fuU, strong pulse — Pleuritis on left side — Recovery in nine days . 641 CXXXIX. — Bronchitis and pulmonary congestion, from morbus cordis, resembling pneumonia, but no absence of chlorides in the urine .......... 645 CXL. — Chronic pneumonia of upper tliird of right lung — Gangrenous abscess — Recovery 648 GXLI. — Chronic pneumonia of both lungs, with rdceration — Death — Great condensation, with cavities and pigmentary deposits in the lungs — Chronic tubercle in various organs — Disease of both supra-renal capsules, without bronzing of the skin 649 65i 672 672 TABLE OF CASES. 941 Case ^''f CXLII.— Gangrene of the luugs— Dysentery 651 CXLIII.— Gangrenous abscess of the right lung, caused by the swallow- ing of a piece of chicken bone four and a half years pre- viously ...•■••••• CXLIV.— Phthisis pulmonalis in its last stage, with incompetency of the aortic valves— Cod-hver oil— and nutrients— Complete re- covery • CXLV.— Phthisis pulmonaUs— Amendment from treatment and disap- pearance of symptoms— Their subsequent return— Death . 662 CXLVL— Plithisis pulmonalis— Large vomica on left side— Caries of left wrist joint— Febricula— Variola— Scrofulous nephritis 665 CXLVII.— Phthisis pulmonahs— Vomica on right side— Death from haemoptysis °"° CXLVIIL— Phthisis pulmonalis— Two vomicaa on right side— Small cavi- ties on left side— Death from exhaustion . • . 670 CXLIX.— Phthisis pulmonalis— Large vomica with pneumo-thorax (?) on left side— Softened tubercle on right side— Bright's disease ....•••••• CL.— Chronic phthisis— Enlarged liver— AJbuminuria— Large ex- cavation in left lung— Cicatrices and mduration of right lung— Waxy liver and kidneys— Tubercular ulceration of intestines ....-•••■ CLI.— Advanced phthisis— Restoration to health— Death many years afterwards from delirium tremens — On dissection, a cicatrix, three inches long, in apex of right lung, and cretaceous con- cretions, with puckering at the summit of left lung . 682 CLIL— Cancer of the lung, thyroid body, and lymphatic glands of the neck — Bronchitis — Leucocythemia .... 696 CLIIL— Carbonaceous lungs with black expectoration ... 699 CLIV.— Carbonaceous luugs with black expectoration in a female . 700 DISEASES OF THE GEXITO-URIXARY SYSTEM. CLV. — Ovarian dropsy— Frequent paracentesis — Excision of both ovaries— Strangulation of the intestine— Phlebitis— Death from ileus the seventieth day after the operation . . 706 CLVI. — Ovarian dropsy — Spontaneous ulcerative opening of the cyst into the bladder, and evacuation of its contents— Recovery 716 CLVIL— Ovarian dropsy which gradually emptied itself spontane- ously by openings through the fallopian tube — Singular attempt at imposition of pig's bladders, for cystic forma- tions in the uterus '^^ CLVIII. — Acute nephro-pyelitis — Recovery "^26 CLIX. — Subacute nephritis, with great anasarca — Recovery — Acute nephritis of left kidney — Recovery . . • • 728 CLX. — Acute Desquamative Nephritis, proving rapidly fatal from diminished flow of Urine, general Anasarca, and (Edema of the Lungs '^^^ CLXL— Acute Desquamative and Hemorrhagic Nephritis— Hydro- thorax— Collapse of the right lung— Pulmonary (Edema and Bronchitis, with symptoms of Pneumonia . . ""SS 9-12 TABLE OF CASES. Cask P^e CLXIL — Acute Xephritis — Clinniic Pneumonia — (Edema of the Long and Anasarca p«)Fing fatal — ^Perfwating Ulcer of the Duodenum, without symptonig 735 rr.TTTT — ^Xephritis followed bj toe Cinnation of a large Ahecess in the right Kidnev, opening into the lumbar cellular tissue — Ulceration of Ureter and Bladder — ^l^ickening of Mitral and Trictx?pid Valves — Partial Atrophy of Ltings, with and without Induration — Partial (Edema. . . . T37 CLXIT. — Scrofulous Xephritis and Ab«:esses in the Kidneys — Exten- siTe deposition of Tubercle in the Longs and Latestines 740 CL5T. — Calemloos Nephritis and Gangrenous Abscess of right Kid- ney — Waxy Liver — Rectovesical Fatuia . . . 742 CLXTX — Chronic Pyelitis, and Cvstic Kidneys — DilatatioD of Ureters — ^Fungoid Ulceration of Urinary Bladder . . . 745 CLXTIL — ^Albuminuria — General Anasarca — (Edema of Long — ^Re- covery 749 CLXTin. — ^Albuminuria — (Edema of both feet and legSj left arm and hand — Recovery 750 CLXIX- — Albuminuria — (Edema — Ascites and General Anasarca — Coma and Convulsions — Recovery . . . . 752 CLXX — ^Tbird Attack of General Anasarca with Albuminuria — Enormous Dropsical Distension of the Abdomen. Scrotum, and Inferior Extremities — Complete Recovery under the Action of Sapertartrate of Potash .... 7-53 CLXXI. — Second Auack of Albuminuria with Anasarca — ^Dismissed relieved 756 CLXXII. — Second Attack of Albuminuria after an interval of twenty- nine years, with Anasarca^Bronchitis — ^THsmissed re- lieved 757 CliXXHL — ^Third Attack of Albuminuria with Anasarca — ^Dismised relieved 758 CLXXTY. — Albuminuria, with General Anasarca, terminating fataUy — Waxy Kidneys, Spleen and Liver, with Extensive Depo- sition of Tubercle T60 CLXXY. — ^Albuminuria coming on during the pnogress of Phthisis Pnlmonalis, terminating fatally — ^Extensive Deposition of Tuberde — ^Waxy Kidney. Liver, and Spleen . . 761 CLXXYI. — Albuminuria, with Phthisis Pulmonalis. terminating fataUy — Extensive Deposition of Tubercle and Colliquative Diar- rhoea — ^Atrophied Fatty Kidney — ^Ulcerated Intestines 763 IHSEA.SES OF THE DTTEGUMENTAKT SYSTEM. CLXXYII. — Favus of the Scalp in an Adult — Incurable . . . 7&4 CLXXTIII. — Favus of the Scalp of three years' standing — (Jured . . 795 CLXXIX. — Favus caught in the Ward from Case CLXXVII— Cured . 795 CLXXX. — ^Favus of the Scalp o? fijur years' standing, cured by a Sul- phuric Acid Lotion 796 CLXXXX — ^limited Favus of the Cheek, cured by Cauterization with Xitrate of Silver ........ 796 CLXXXIL — Parasitic Pitvriasis — ^Incurable 797 TABLE OF CASES 943 -En- the iffht DISEASES OF THE BLOOD. CLXXXUI— LeuoocTthemia discovered after deatli— HTpertropbr of the Spleen, Liver, and Lrmpliatic Gland^-Absenee of Phle- bitis and of Piiralent Collections in any part of the body CLXXXIT.— Leneocythemia detected daring Life— Hypertrophy of the Spleen — Ascites ..-•■• CLXXXY.— Commencing Leuoocythemia deterauned daring Lii" larg^d Spleen and Liver — Ascites CLXXXTL — Chlorosis and Anaemia — Cored ... CLXXXTIL — AOTte Ariicalar Eheamatism — Multiple Absce^c-s in Joints, in the Musdes, within the Cranium, etc CLXXXTHL — Diabetes Mellitas CLXXXIX.— Diabetes Mellitas— Phthisis Polmonalis— Tomiea on Side — Death CXC. — ^Febricula, convalescent on the axth day . CXCL — Febricnla, convalescent on the eighth day CXCIL — Febricola, convalescent on the seventh day CXCIIL — ^Febrieula. convalescent on the fourth day CXCIV. — Relapang Fever CXCV. Typhoid Fever, convalescence on the forty-second day CXCVL — ^Typhoid Fever, fatal on the twenty-fifth day CXCVIL— Typhoid Fever, fatal from perforating aloer of the intestine CXCVIII — Typhus Fever, with cerebral complication CXCLX Typhus Fever, terminating on the fourteenth day CC. Typhus Fever, terminating on the twenty-third day CCL— Typhus Fever, with petechijc — Convalescent sixteenth day CCIL ^Typhus Fever, convalescent the twenty-fourth day CCELL Typhus Fever, convalescent the fourteentli day CCIV. ^Typhus Fever, convalescent the fourteenth day CCV. Typhus Fever, complicated with bronchitis and collapsed lung — ^Fatal on the twelfth day CCYL ^Typhus Fever, convalescent on the twelffli day CCVIL ^Typhus Fever, convalescent on the twenty-first day (XVIIL— Tvphus Fever, convalescent on the twenty-second day CCIX. — Remittent Fever, resembling Acute Hydrocephalus CCX. ^Tertian, Litermittent, cured by Quinine CCXL — Scarlatina, with Angina CCXIL — Scarlatina, with violent delirium CCXnL ^Scarlatina, with diminished Urine and Coma CCXIY. Scarlatina, with Angina and delirium CCXV. — Scarlatina, with Purpura and delirium CCXVL — Scarlatina, with delirium and c^oma . CCXTIL — Erysipelas — ^Recovery on the eleventli day CCXVIIL Eryapelas in an Litemperate Man — Slow Rec-overr CCXLX — ^Variola — ^Severe confluent case ... CCXX. — ^Variola— Discreta CCXXI. — ^Variola treated locally with a mask of calamine and CCXXIL — Syphilitic Ulceration of the fece .... CCXXUL — Syphilitic Laryngitis oil Base 814 S-21 S26 S44 847 852 853 S59 859 S59 860 860 862 863 864 866 866 867 868 868 869 869 869 869 870 870 880 882 885 886 888 839 890 891 892 892 893 894 S96 899 900 9M TABLE OF CASES. Case CCXXIV. — Syphilitic Eupia. followed by Keloid Growths on the Cica trices — Syphilitic Psoriasis ..... CCXXV. — General Rheumatism treated by nitrate of potash CCXXVI. — General Rheumatism with endocardial murmur . CCXXYII. — Rheumatism treated by nitrate of potash . CCXXVIII. — Rheumatism with mitral incompetency GCXXIX. to CCXXXII. — Treatment of Rheumatism by Lemon-juice CCXXXIIL — Diaphragmatic Rheumatism CCXXXIV. — Rlieumatic Iritis, following Acute Rheumatism — Recovery CCXXXV. — Chronic Gout with Tophaceous Deposits in all the Joints CCXXXVL— Scorbutus CCXXXVII.— Scorbutus, with epistaxis— Treated by full diet . CCXXXVIIL— Sudden Polydipsia— Incurable OCX XX IX. — Polydipsia — Excessive amount of Albuminous Urine — Phthisis Pulmonalis — "Waxy Liver, Kidneys, and Spleen CCXL. — Great Obesitj^ — Fatty Degeneration of Heart and Muscular System generally — of Liver and Kidnej'S — Hypertrophy and Dilatation of Heart 900 911 912 913 913 914 916 917 919 920 921 923 924 926 INDEX. Abdoraon, auscultation of, 58; inspection of, 80; post-uiortcm examination of, 24; view of the viscera in, 26. Abscfss, pathology of, 138; in the brain, cases of, 329; in the abdomen, 410; in the liver, case of, 575; inthelnng, cases of, C4S; in the kidney, cases of, 737, 7-10, 742. Acarus scablei, description and treatment of, 7S9. Achorion Schoenleini, history of the, 798. See Favus. Acne, diagnosis of, 780 ; treatment of, 786. Aconite, case of poisoning by, 577, 585; symp- toms of, 587 ; inlhience of on the heart, 408. Address to graduates in medicine in 1849, 929. Adenoma, 170. Adhesions, between serous surfaces, pathology of, 129 ; of arachnoid, case of, 327 ; of perito- neum, case of, 501 ; of pericardium, 523 ; of pleura, 619. Albumen and oil considered as types of nutri- tive substances, 100. Albumen, detection of in urine, 94; in solution, 210; raemliranous, 211; fibroid, 212; celloid, 213; molecular. 214. Albumiuoiis degeneration, 210; concretions, 238. Albumiuuria. persistent, cases of, 749 ; patho- logy of, 765 ; diagnosis of, 769 ; treatment of, 772. Alison, Dr., his views as to Mood-letting in in- flammations, 251 ; Dr. Scott, his stetho-gonio- meter, 35. Alkaline lotions in skin diseases, 784. Amaurosis, case of partial, 899. Ammonia, urate of, microscopic appearance of, 89. Amphoric resonance in cases, 623, 625. Amyloid and amylaceous concretions, 247; in the auditory nerve, ib. ; in the pancreas, ib. ; in the brain, 335. Andral's opinion of the expression " inflamma- tion," 123, note. Anaemia, case of, 844 ; pathology and treatment of, 846. Aneurism, nature and varieties of, 181 ; cases of, in arch of aorta, 557 ; varicose, communicating with pulmonary artery, 504; of arteria inno- minata, 568 ; of thoracic aorta, 575; of supe- rior mesenteric arterv. 577 ; eeneral diagnosis of. 5^7; pathology of, 530; treatment of, 591 ; Valsalva's treatment of, 583. Angina pectoris, 656; case of, 539. Angionoma, 181. Anorexia in phthisis, treatment of, 692. Antimonials. treatment of pneumonia, by large .loses of. 272. . J' S Anxietv and despondency' in phthisis, treatment of. 6',i5. Aortic valves, disease of, 540. Apoplexy, definition of 304, 402; cases of, 356; ])re(lisposina cause of, 373; histology of, ib. ; diairnosisof, 375; pathologvof, 354; treatment of. ;H77. Appetite, treatment for loss of in plithisis, 692. Arteries, cerebral disease from obstruetion of, 8-15; pathology of, 354 ; fatty degeneration of, 220 ; mineral degeneration of, 235. Arteritis, chronic, case of, 533. Ascites, microscopic appearances in fluid of, 87; from enlarL'cmcnt of liver. 463. 523 ; from peri- tonitis. 503 : from abdominal cancer, 504; from cirrhosis, 480; from ovarian disease, 721. Assimilation of the food, lUl ; ettects of bad assi- milation. ]iiT. Atelectasis. 6i!6. Atheroina. cystic, 166; of blood-vessels, 220. Atrophy of face, remarkable case of, 122. GO Auscultation, general rules for practice of, 40; of abdomen, 58 ; of circulatory organs, special rules for, 55 ; sounds elicited in health and dis- ease, ib. ; modifications of healthy sounds, 56 ; new or alinormal sounds. 57; of piilmonary organs, S]iecial rules for, 51 ; sounds elicited by, ib. ; alterations of natural sounds, 52 ; new or abnormal sounds, 53 ; of the large vessels, 68; relative value of sounds in, 54; of aneu- risms, 5&8. Bael, Indian, use of in dysentery, 482. liile, detection of, in urine, 94. Kiliary calculi, 240. Uladder, percussion of, 48; urinary calculi in, 242 ; opening of ovarian cyst into, 716 ; fun- goid ulceration of, 745. Blood, appearance of, under the microscope, 75; in thickened blood. 76; in hiematocele, ib. ; in leucocythemia, 77, 816; appearance of, in a case of choler.a, 77 ; fol-mation of, from ali- mentary matters, and the changes it under- goes in the lungs, 101 ; structure and chemical composition of, ib ; formation and sustenta- tion of tissues by the, 102; re-absorjition of transformed tissues into the, ib; Zimmer- mann's views as to the formation of fibrin in, 103 ; arguments in favour of this opinion, 104 ; pathological changes in the, ib. ; diseases of the, 100, 813; causes of disease in the, 107; prin- ciple of treatment of, ib. ; post-mortem exami- nation of, 24; microscopic examination of, 76; mixture of pus with, 850. Blood corpuscles, relation between the colourless and coloured, 829; origin of the, b32 ; ultimate destination of the, 887; structural alterations in, 76. Blood-forming glands, structure of, 883. Blood-letting, diminished enjployment of in treatment of acute intlaninialioiis. 251 : former reasons for, erroneous. 2.'>7 ; loe;il. observations of Dr. J(jlin S^truthers on. 202 ; can the materies morbi in the blood be diminished by '! 257 ; can it diminish the flow of blood to tiie inllamed part? 258; can it diminish the amount of blood in an inflamed part? 260 ; should it be indi- cated by the character of the pulse? 202; in acute pneumonia, 270; useful as a palliative, 263; and in over-distension of the ri;,dit side' of the heart, venous <-on-vjtioii, ei:t;dii;emeiit, etc., 276; in functional nervous disorders, 408. Blood-vessels, changes in ju-evious to intiamma- tion, 123; new f.n-mation of, 184; fatty defe- neration of, 220 ; mineral degeneration' of, 286. Bone, fatty degeneration of, 224; formation of new, 193; myoid, 129; gi-anule. lol ; fibre. 132: of cancer. 133; de- velopment of morbi->S: of bimc, 224; of the exudations, ■J2a; of morbid growths, 226; of tlu' heart, 554 ; general pathology and treat- ment of, 23:i. Deu'eneration, mineral, 284; of blood-vessels, 2!5; of the exudations, 236; of nervous tex- ture, 235; of morbid -rouths, 237. Deu'eneration, pigmentary. 227 ; general patho- loiiy, and treatment of.'232. Degenei-atiou, waxy, 214. Degenerationaof texture, morbid, 210. Delirium tremens, cases of, 410; pathology and treatment of, 412. Deruiatophytiu, diagnosis of, 7S1, 794. See Favus. Dermatozoa, 789. Uespondencv and anxietv in phthisis, treatment of, 6i)5. Determination of blood, theory refuted, 25S. Diabetes Mellitus, cases of. i>:4 : theories regard- iuiT the nature and treatment of. 854. Diaixnosis, etfeets of advanecil knowledge of, 250. Diagnosis, mieroseopie, of saliva, 72; milk, 74; blood, 75; pus, 78; sputum, ib. ; vomited mat- ters, SI ; fieces, 83; uterine and vaginal dis- ehirges. 85; mucus, SO; dropsical fluids, 87; urine, ^S; cutaneous ern|itions and ulcers, 91; diagnosis, general, of cardiac diseases, rules for the, 512: of thoracic aneurisms, 5S7; of abdo- minal aneurisms, 5i)0; of pulmonary diseases, rules for. 592; of skin diseases, 779: of con- tinued fevers, S70. Diarrliiea. cases of, 476; varieties and causes of, 477: patholou'y of, 483; treatment of, 477; treatment of in children, 486 ; treatment of in phthisis. 693. Diastaltic or reflex movements, 115; classifica- tion of disorders. 4(l6. Diet, irregularity in, the most common cause of disease, 100 ; causing scurvv, 921. Digestion, 99; kinds of, 105 ;" disorders of, 429 ; pathology and ti-eatment of derangements of, 432. Digestive system, examination of, 20 ; diseases of the, 421. Discharges, uterine and vaginal, microscopic examination of, 85. Disease, definition of, 97 ; Bright's, cases of, 74^) ; cerebral, front obstruction of arteries, 315 ; general laws of nutrition and innervation in, 99; irregularity in diet the most common cause of, 100 ; importance of a knowledge of the causes of, 251 ; cause of recent changes in the treatment of, ib. ; of nutritirm, 106. Diseases of the nervous S3'stem, 803; of the di- gestive system, 421 ; of the circulatory system, 512 ; of the respiratory system, 592 ; "of the genito-nrinary system, 706 ; of the integu- mentary syst'em,"774; of the blood, 813. Dropsical fluids, microscopic examination of, 87. Dropsy. 210; general, 525, 728, 753; of the brain, ease of, HSi ; of the pericardium. 515: of the chest, 536, 543; of the abdomen, 463, 467. Dropsy, ovarian, cases of, 7ncephaloma, 134. Knchondroma, 186 ; structure of, ib. ; diagnosis of, 188. Endoearditis. 532. Eni:orL'einent, bleeding useful in, 276. Entoznon follieulorum, description of the, 792. ICphelis, diagnosis of, 780; treatment of, 787. Eiiilejisy. delinition of, 304, 403; case of, relieved bv galvanism, 406; case of, from chronic cere- bri tis, 333. Epithelial growths, 173. See Epithelioma. Epithelial, scales in saliva, 72 ; ulcer, 93 ; growths, 173. Epithelioma, 173; principal forms of, 174; struc- ture of. 176 ; of the lip and tongue, ib. ; of the Ivmpliatie ixlands, 179; of the urinary bU^ider, i"b. ; iiathology nf, 201. Epithelium, fringe-like, 78. Ei)Ulis. 193. Eremacausis, 143. Erupticms, cutaneous, microscopic examination of, 91. Erysipelas, cases, diagnosis, and treatment of, s92. Ervthenia, diagnosis of, 779 ; treatment of, 784. Ethics of Medicine, 929. Examination of patient, 18; by interrogation, 19; by inspection, 28; by palpation, 30; by mensuration, 32 ; by succussion, ib. ; by per- cussion, 35; by auscultation, 49. Examination, iiost-mortem, 22; method and order of. 23 ; object of, ib. ; of external appear- ances, 24 ; of head, ib. ; of spinal column, ib. : of neck, ib. ; of .chest, ib. ; of abdomen, ib. ; of blood, ib. ; by microscopic examination, ib. ; hints for carrying out i)ost-mortem exami- nation, ib. ; knowledge rcipiired for correct examination, 26 ; necessary to determine the value of remedies, 5b4 ; Dr. .Sibson's " Medical Anatomj-,'" 27. Exanthemata, definition of, 775 ; diagnosis of, 779 ; treatment of, 784. Excrescence, ca\iliflower. 177. E.xcretion of ettVte matters from the bodj", 105. Exophthalmia. case of, 342. Exostosis, 191. Expoct(n'ation and cough in phthisis, treatment of, 691. Experience, past and present, in the treatment of inflammations, 254. Exudation, definition of the term, 128; varieties of, ib. ; production of, 124; theory of, 126; vital transformations of the, 128; simple, ib. ; cancerous, 183 ; tul)ercular. 137 ; pathology of the three kinds of, 138: death of the, 141; general treatment of, 146 ; fatty degeneration of the, 225; mineral degeneration of the, 236 ; essential to inflammation, 252; transformation of, in pneinnonia, 265; in cerebritis, 305; in pericarditis, 260; in pleuritis, 618; seat of in dysentery, 4b4. Face, remarkable case of atrophy of, 122. Fatty concretions, 238. Fatty degeneration, 216 ; of cells, 217 ; of muscle, 21S; of blood-vessels, 220; of the i)lacenta, 222; of cartilage, 223; of bone, 224; of the exudations, 225; of morbid growths, 226; of the brain, 307 ; of the liver. 464 ; of the cardiac valves, 553 ; of the heart, 554; of the kidney, 767. Fatty growths, 159; steatomatous and lipo- matous, 160; fibro-lipomatous, 161. Favus crust, composition of. 92. Favus of the seal|i, diagnosis of, 7.S1; cases of, 794; history of favus as a vegetalde i)arasite, 798 ; mode of development and symptoms of, 798; causes of, SOI; pathology (jf, S(i3: treat- ment of, 810; on the face of the mouse, 802, note. Febricula, characters of, 868 ; cases of, 859. Febrile symptoms in phthisis, treatment of, 694. 948 INDEX. Fern, male shield, as a vermifuge. 495. Fever, continued, chanpres of type in, 255, 285 ; symptoms of. S56: forms and characters of, 8b7 ; diagnosis of. 870 ; morhid anatomy of the Edinburgh efiidemic of, during 1846^7, 972 ; treatment of. 876. Fevers, eruptive. 8s4. Fever, intermittent, case of, 8S2; nature of, 883; treatment of, 8S4. Fever, relapsing, character of, 858 ; case of, 860 ; identical with the ^ynocha of Cullen, 861. Fever, remittent, case of, 880; nature and treat- ment of. 8S1. Fever, therapeutic action of quinine in, 879. Fever, typhoid, character of, 858; cases of, treated by quinine, S62; diagnosis of, 870; nature of. 875: morbid anatomy of. 872. Fever, typhus, character of, 858 : cases of, treated by quinine. 866; cases of. treated without quinine, 869; diagnosis of. 870 ; treatment of, 876. Fibres, molecular, 152 ; nuclear, ib. : cell. ib. Fibrin, origin of, in the blood. 103; Zimmer- mann's opinion, ib. ; arguments in favour of this opinion, ib. Fibroma. 151. Fibrous growths, 151 ; molecular, nuclear, and cell, 152; flbro-nucleated and fibro-cellular, ib. : sarcomatous or soft. 153 ; dermoid or hard, 155 : neuromatous. 158. Fistula, recto-vesical. 742. Fluctuation, examination of patient b\-, 31. F«ces, microscopic examination of. S3. Food, assimilation of the, 101; etfects of bad assimilation. 107; effects of improper quantity or quality of. 1-21 ; in scorbutus. 921. Foramen ovale, enlarged, case of 548. Freckle, diagnosis of 780; treatment of, 787. Function.s. influence of dei-angement of one over another order -if 121. Functions of the bodv. influence of predominant ideas on the. 292. Fungus ha-matodes, 185. Fungus fi-om a favus crust, 92 ; in the ear, ib. Gansrene. moist. 141 ; dry, 143 ; of the intestine, 483 : of the lungs. 651 ; from obstruction of pulmonary artery. 657 ; of the kidney, 742. Gall-bladder, with" gall-stones in, 456," 461; en- largement of, 45S. Gall-stone, 2-38; case of impaction of, in common bile-duct. 456 ; passage of into the gall bladder, 458. Gastric glands, organic ch.anges in, 453. Genito-urinarj- system, examination of, 20 ; dis- eases of the. 706. Gland, thyroid, liability of to new formation of tissue, 171 ; enlargement of in bronchocele. 215. Glands, mesenteric, liability of, to increased growth, 172. Gland, prostate, calculi found in the. 244. Glands, structure of blood forming, 838. Glandular growths, 170 ; forms of, ib. ; structure of. 171 : of the thyroid gland, ib. ; of the lym- phatic glands, 172; causes of. 173. Glottis, case of acute oedema of the, 598. Glucohivmia, cases of, 852 ; theories regarding the nature and treatment of. 854. Gout, general pathology and treatment of, 909 ; case of chronic. 919. Granulations, formation and structure of, 132. Granule cells, 181. 21S. Granules and molecules, deposition of fatty, 217. Growths, morbid, 148; classification of 149 ; ulti- mate elements of, ib. ; general pathology of, 197: origin of 198; development of, 199: pro- pagation of, 202 ; malignancy and non-malig- nancy of. 204 ; curability of, ib. ; Van der Kolk"s viewsof causes of propagation of 20C: decline or degeneration of, 207 ; general treatment of. 208 : means of retardation and resolution of, ib. ; means of extirpation of ib. : necessity for microscopic examination of, 2C9 ; constitu- tional treatment of, 210 ; fatty degeneration of 226 ; mineral degeneration of, 237. Growths, morbid, of texture, 14b; fibrous. 151 ; fatty, 159; cystic, 161 : melicerous, 105; eho- lesteatomatous, ib. ; atheromatous, 166; glan- dular, 170; cartilaginous, 186 ; erectile, li-3; Bteatomatous encysted, 166; epithelial, 173; vascular. 181; osseous, 190; myeloid, 193; can- cerous, 196. Growths, distinction of cancerous from other, 196. Gruby's pocket microscope, 64. II;ematocele, appearance of altered blood cor- puscles in the fluid of an, 76. niemoi)tysis in phthisis, treatment of f93. Hairy, formations. ISO; concretions, 244. Hammer, Dr. Winterich's. 36. Head, post-mortem examination of 24. Headache, definition of, 4o2 : treatment of, 408. Healing i)rocess, results of the, 14S. Health and disease, general laws of nutrition and innervation in. 99. Heart, functional disorders of the, 556; treat- ment of, 557. Heart, rules for the diagnosis of diseases of the, 512. Heart, sounds of the, 53 ; percussion of the, 40 ; mechanical injuries of the valves of, 650 ; exu- dation into or on the surface of the valves of, 551: dejiosition of fibrin on the valves of, 652; degeneration of the valves of the, 553 : fatty degeneration of the. 654; hypertrophy of the, ib. : inflammation of the substance of the, 655. Heart, valvular diseases of the, 532; cases of, 58:3; causes of, 550; pathologj- of, ib. ; treat- ment of 555. Heat, source of animal, 105. Hemiplegia, definition of 403; cases of, 848; pathology of, 375; treatment of 377. Hemlock, case of poisoning by, 413 ; symptoms of, 416 ; physiological action of, ib. ; death of Socrates b}-, 41s; identity of ancient with modern, ib. Hemorrhage, cerebral, cases of, 356 ; predispos- ing cause of. 373 ; microscopic appearances of, 374 ; diagnosis of 375 ; treatment of, 377. Hepatitis, case of, 454. Herpes, diiignosis of, 779 ; treatment of^ 785. Homy productions, l80. Hutchinson's spirometer, 35. Hydrocele. 164. Hvdrocephalus. acute, cases of 312 ; nature of, "316 : treatment of 317. Hydrocephalus, clu-onic. case of 3S1. Hydro-pericardium, 515 ; pathology of, 528 ; treatment of 531. Hvdrophobia. definition of, 403. Hydj-o-thorax. 5:36, 543. H vpertroj>hv, 148 ; of the liver, 463 ; of the heart, '554. Hypnotism, 297. Hysteria, definition of, 403 ; treatment of, 408. Ichora'mia, case of 847 ; theories regarding the nature of. 849. Ichthyosis, diagnosis of. 7S0 : treatment of 787. Ideas. predominant.influence of on the functions of the body. 292. Ileus, case of 488 : following ovariotomy, case of, 706 : pathology of 490 ; treatment of, 491. Illusions, spectraf, cases of, 399, 410 ; theory of, 297. Impetigo, diagnosis of, 7S0 ; treatment of, 785. Incompetency of aortic valves, cases of 533 ; of mitral valve, cases of £36 ; of tricuspid valve, cases of 543. Induration. 143. Infection, definition of 938; purulent, 809. Inflammation, Anclral's opinion of the expres- sion. 123. note. Inflammation, fallacious character of past expe- rience in the nature and diagnosis o^ 251, 262 ; INDEX. 949 definition of the term, 252; unchangeable nature of. 2M ; natural progi'ess of, 269 ; dimi- nished emidoyment of blood-letting in acute, 251; former reasons for bleeding erroneous; 257 ; value of bleeding in. 270 ; etfects of gene- ral blood-lettiniT on local. 260 : character of the pulse as an indication for blood-letting in, 262 ; real use of blood-letting in, 276 ; reply to ob- jections as to treatment of internal, 277. See also Exudation. Inttuenz.T, nature and treatment of. 604. Innervation and nutrition, general laws of. in health and disease, 9i1. Innervation, function of. lOS ; influence of dis- ordered nutiitiou on. 121. Inoma. 149. 151. Insanity, definition of, 402. Inspection, examination of patient by, 28. Integumentary system, diseases of the, 774 Integumentary system, examination of, 20. Intestinal concretions, 245. Intestine, case of obstruction of the large, 486. Intestines, percussion of, 46 ; diseases of the, 476 ; condition of in typhoid fever, S73. Intestine, small, case of strangulation and per- foration of. fr(jm inguinal hernia, 4S6. Iritis, case of rheumatic, 917. Irritation of the nerves of special sense, defini- tion of, 403. Irritation of special nerves of motion, definition of; 403. Irritation, spinal, definition o£ 402. Itch insect, descrijition and treatment of the, 7S9. Jaundice, cases of, 454, 456, 458, 468. Kamala. as a vermifuge. -^98. Keloid growths, case of, 9;10. Kidney, percussion of the, 48 ; waxy degenera- tion of the. 214: calculi in the. 241 "; inflamma- tion of the, 726 : abscess in the. 737 : scrofulous abscesses in, 740 ; calculous inflammation and gangrene of, 742 ; chronic inflammation of, and cystic, 745 : orisrins of cystic disease of the. 747; Bright"s disease of the. 74S: remarkable case of Brighfs disease of the, recovering un- der the influence of super-tartrate of potash, 753 ; atrophied, 763 ; see Bright s disease, also XepJiriti.-i. Laryngitis, cases of. 593: method of applying topical remedies in, 595; svniptoms 0^597; diagnosis of. 600 : treatment"of. 601. Laryngitis, syphilitic, case of. 900. Lead, case of poisoning with, 41S ; treatment of. 419. Lenses, objective, of microscope, 65. Lentigo, diagnosis of, 7S0 ; treatment of, 7S7. Lepra tuberculosa, diagnosis of, 780 ; vulgaris, diagnosis of. ib. ; treatment of, 7S6. Leucocythemia. S13: definition of. S14: cases of, ib. ; pathology and treatment of. S27; discovery of. 840 : appe.ii-ance of blood in. 77. Lichen, diairnosis of, 7-0; treatment of, 786. Life, Beclard's definition of, 97. Lime, oxalate of, microscopic appearance of, 89. Lifioma, 159. Lithic acid calculi, 241. Liver, percussion of. 44: waxv degeneration of the. 214 467 : diseases of the." 453 : case of acute congestion of the, 454 ; cases of enlargement of the. 46:3; fatty enlargement of the, 464; cii-rhosis of the, 467 ; cancer of the, 472 ; nut- meg, 471. Lungs, percussion of. 40 : abscess of the, 648. G54 ; case of gangi-ene of the, 651 ; condition of. in typhus fever, t>73: fistulous openings in. 621 ; partial atrophy of the. 737 ; compre."' Nephritis, acute e.-ise< ,.f tor. .. O'agnosis of. 723 • tr T^O; b^orr^^'^^b^,^,,t^^^-t^je, \ Ovariotomy, case oi;1 7-10; cal- rm. K . ' "r"""-^ "'i 'ao; aes ^cluS^S;:^- '?^ ^•=^"^'<'- ot-loa' '^"''■'''' "'''"'■• '^'^'^nitions of irritation Nerves, function and properties of 113 JNorvous system, examination of 19 • trener-il anatomy and physiology of the. ios st?uctul st'xti'/'T^''"''?^ of the,ib.; refle.xand div t .ms oi- ■ hi"?*- *.*"t"°","^"^^-« views.ni; func- tions ol the bram, ib. ; functions of spinal cord 112; general pathologv of 115; effects of sti mull or disease on the functions of the 11 '^ influence of rapid and slow lesions of on svmtitoiiis loo- )„« „^ ".S10II5, oi, on Organs, pulmonary, auscultation of 51 • sounds produced by. ib ; circulatory, auscu tktion of ^.•ta^ro^^sr"^'''^ '•^' ''■■■ ^'^'^-'-'-anf' Ovarian dropsy, cases of. 706: patholo^'v of 721 ■ diagnosis oi: 723 ; treatment of 724 '^ ' ^m^ne^.^Th'l''- ^?f ''''''' «''' "2; myeloid, ill' "*'''' '^-S >»> "le eye and other teitures, &mrm'''^''^^"'^^"^^"'''-'lS6. Osteoma, cystic, of femur and tibia. 168 "" s^nafiS"!,^'^"^ ^ *« ^'^'^ structure of the Oxaluria, cases of, 430. symptoms, 120rinflrncrof'sS"o7dt^e ^l"'!-' -'-' -se of, 418. ^.r^oi;!::^— "^i^^i^'t-^™^ : ^aS^iS:-""- - ^«-- ^- ^-^ ^^ ^n^nnes of the, 120; influence ot, on m.trit?°n! ' of mV.""' °^ """ ^''^'' -^"'^^ '"'^ treatment Nervous system, diseases of the. 303 > ^''''.'^''^'as- ''"ses of cancer of 448, 461 ; Bernard-g Nervous system, functional disoiSers of th . ' ^ '.<-"s "♦ '•- <'■ = -- ' '•^'"•a s :issifi<.nt>,>„ ,.e A^.^. ^ i..'^^ 1' tii^N 1 Painllom., ^nt*""'"""- "'' ''^' •I'^nosis of, 780; minis. 706. -''^''''''^^^-^ thoracis, 625; abdo- Pai-alysis. definition of 304- cases of 949 -iaa. u!];:;!'::"i'-'!:;^'^= "^abdt^n^ns ervous system. fu'nctionar"dis"oi5ers of t>, . t. ^ '"iJ^* "* "'** functions of,"462. 3-.'9; classification of 402; pa ho^/v^ of 4.U •' i ?'!«' "ma, 175. , causes of, ib. ; treatment of, 4^.s ".^e of 39^ •' "^'''''f ' 'I'^fl"*""" congestive disorders of the 404 ■ diastaltic ..; p f'^atment of. 786. thellof ""■""' "f the, 406 ;' toxic Sers of P--"-"-"'-^^*'* "'^iti V,!!^r!!f ^''^t",''^- mineral degeneration of. 235 in]r o^ltl^' '^''^'^ "^ ^''-^ --^=^--1 Neuralgi.a. definition of, 403; treatment of 403 Neural disorders, classification of 403 „ -^~^. .^..,, ^...osification of 403. Sr^mrm 15^^"'' <='-^"^-"- of, 404. Nihilismus, 16. Noli me tangere, 177. Noma. 144. Nutrition, complemental ''58 ^f^lllr "?'l.'n°'>"-ation, general laws of in health and disease 99 ' Nutrition, function of 99; division of process into five stages, ib. ; introduction of apmS ate alimentary matters. lo„: formatiirfr^m thereof a nutritive fluid, the blood, and the changes It undergoes in the lun£rs,101 pLia^e Tissues lo" ■ '""y '''''"'' '" ''" t^^"^^fo«"-J inTo tissues, 102 ; disappearance of transformed tissues, and their re-absorption into the blood boaj'Tol.''"" ''^'^''' '^'''' °^='"^^* fr*'^ "1"=' Nutrition, importance of albumen, oil. and mi- neral substances in the process of loo J«utritiori. diseases of 106 ; causes of, 107 • prin- ciple ot treatment of, ib ' ^ ^Sm.'^''"''^'''"'' ^°'l"<'n<^e of on innerva- i Oberh«user-s microscope for medical men, 62 I Obesity. lo9 ; case of 9-'6 (Edema, of the brain, 3.7: of subarachnoid cel- lular tissue case of, 334; of the le-s from ' cirrhosis. 480; from car.liac disease fril of I CEgophony, 54. CEsophjiaus. case of stricture of from epithelio- ' ma. 423 : cancer of 338. 4-'6 470 ^l"t"eiio Oil and albumen, importance of in the process of nutrition. 100. c ^.loctss Oligocythemia, 846. Opisthotonos, definition of 40'' Opium, case of poisoning by, 418. auditorv nerves, ;^2 :^3r:^,;i:^?'^l:'^.:;!^^''^=— ^SSS;ca„se Pattn'r'^'.V'ih"? of adv.-,nced knowledge of 250. torv sVTt^ ^1"' examination of 18;^circHla- lory S3 stem, 19 respiratorv system ib • ner voiis system, ib. ; digestive svstem. 20 4ni r""T"H-'lT' '^•- ' i"t'-f-'ument.arv svltem b antecedent history, ib.; hints for carrying out examination, 21. "' "-.uj^m^ Patient, ex.amination "of bv inspection "8 ■ bv s^iofrs^^^i^!T^^"^^^ 40:u.eof^K:^n^a^i,='::j^^: PecLifoq^^nf '"'' " ---nation of, 94."' Pemphigus, diagnosis of, 779; treatment of 7<^ i ^'^'-"t^- lunl^th"'"f"r''"'"'«' ^P^"^' -^'^^for. ; ,?"*• ^°-' of heart. 4;3; of liver ib • of I t'rr"- -^,1 "^ stomach and intestin ef b •' of ki.lneys. 48; of bladder, ib.; of aneurisms A<38 Percussion hammer, utility of gg '^^"'688. , Perforation of the stomach, cases of 440- of the I ^odenum, 735 ; of the intestine frtlnherniX Pericarditis, changes which take place in the I t>r '''Ji^- "° "^^ 266 ; ™ses of 514; pa?holo°v of i S,^S^-|^^^^«^-"*^-o^ I Peritonitis, cases of; 499; acute, ib.; tubercul.ar 50l;Sn::ro^.t|-*-lo'^--esembHS Pharyngitis, case of follicular 422 Pharvnx. diseases of the, 421. ' Phk-bohtcs. ].'i7. Phosphorus, in spinal diseases. 391 ^^n;|-:^^::^^^,ll^=-—d causes Phtosis of colliers, appearance of sputum in, 81, IXDEX. 951 Phthisis puhnonalis. cases of. 658: natural pro- gress of, tendenev to ulceration, ami modes of arrestment of, (iT5; patholo^'v and general treatment of, 6S4; indications for the treat- ment of, 685; cod-liver oil as a remedy for, 68T : value of microscopic examination of spu- tum in. 80. Phthisis puhnonalis. sjiecial treatment of, 601 ; cough and txpectoration, 6!'2 : loss of appetite, ib. ; nausea and vomiting, 6; 3: diarrhcea. ib. ; hamojjtysis. ib. ; sweating. 6'J4: febrile symp- toms, ib. ; debility, 695; despondency and anxiety, ib. Picrotox'ine, efl'ects of. 4(l7. Piirmeutary de^'eueration. '227; general patho- logy and" treatment of, 282: concretions, 289. Piirniiiit, formation and varieties of, 227 ; causes ot; 2o2. Pityria^is, diagnosis of, 780; treatment of, 787; parasitic, case of. 797. Picirrv's pleximeter. 80. Placi-nta. fatty di-generation of the. 222. Pleiiritis. cases of. 613 : pathology, diagnosis, and tri-atment of. CIS: chronic, cases of, 616. Pleurosthotonos. defiuiti5; hard, 156; in the heart, 546. Polysarcia. 926. Porrigo, detinition and varieties of. 7S2. Post-mortem examination. 22 ; method and order of. 23; hints for canying out, 24 ; knowledge required for, 26. Posture of patient, inspection of. 28. Pressure and compression, distinction between, 116. Probang, method of using, in laryngitis, &95. Prostatic concretions. 244. Prurigo, diagnosis of, 7S0; treatment of, 786. Psoriasis, diagnosis of, 780; treatment of. 786. Pulmonary organs, special rules for auscultation of. 51 : sounds produced by, ib. Pulmonary diseases, injections of the bronchi in, 611 : case of, 609. Pulmonary artery, varicose aneurism of. £64. Pulse, characters of 19; as an indication for bleeding. 262. Purgatives, use of, in intestinal disease. 478. Purpur.% diagnosis of, 780 : treatment of, 787. Pus, microscopic examination of. 7S. 130; forma- tion of. in pneumonia. 265; effects of mixture with the blood, 649; injection of, into the blood, 850. Pus. scrf)fulous, microscopic appearance of, 78, 180. Pustula?, definition of, 776 ; diagnosis of, 780 ; treatment of, 785. Pvaiuia. case of. 847; theories regarding the "nature of. 849. Pvilitis. cases of, 726. Pyrosis. 437. Quain's stethometer, 32. Quinine in continued fever, therapeutic action of. S79: in intermittent fever, 8S4; in hectic fever, 695. Eammollissement. See Softening. Rattles, moist. 53. Reeto-vesical fistula, case of, 742. Remedies, indications for the use of, 260. Renal calculi. "241. Resonance, vocal. 54. Respiration, motions of chest during, £9. Respiration, natural and exaggerated, 51; pue- rile. 52 : alterations of, 63. Respiratory sounds. 51: alterations in natural, 62 ; new or abnormal sounds of, 68. Respiratory system, examination of. 19. Respiratory system, diseases of the, 6ii2; rules for the diagnosis of. ib. Reticulum of cancer. 225. Rheumatism, general pathology and treatment ot 909; treatment of, by nitrate of potash, 910; treatment of, by lemon-juice, 914; dia- phragmatic, case of, 'jl6. Ringworm. 787. Roseola, diagnosis of. 779 : treatment of. 784 Eupia, diagnosis of, 780 ; treatment of. 786. Saliva, microscopic examination of. 72. Salm(» salar. structure of the spinal cord in, 1C9. Sarcina ventriculi. 83. Sarcoma. 153; cystic. 169: compound cystic, of the mamma. 163: osteo, 154. 188. Scabies, diagnosis of. 779; treatnient of, 785. Scalp diseases, treatment of. 7&7. Scarlatina, cases of 8S5; diasrnosis and treatment of, SS7; colchicum in, 940; bodies found in urine, in a case of, 90. Scirrhus. 183. Scorbutus, cases of 920 ; epidemic of. in Edin- burgh, 921 ; observations of Dr. Christison and Ur. Lonsdale on, 922; Fir. Gan-od on, ib. Scrofula, see Tuheiciilur Exudaiion. Scrofulous pus cells. 78. ISO. Sectio-cadaveris. method and order of. 23; object of, ib, ; external appearances, 24; head, ib. ; spinal column, ib. : neck. ib. : chest, ib. : abdo- men, ib. : blood, ib. ; hints for carrying out post iiioitem examination, ib. : knowledge reqinred for correct examination. 28. Sensation, definition of. 113. Sensibility, definition of, 11.5. Sibson, Dr.. his "Medical Anatomy," 27; his chest measurer. 33. Silver, nitrate of. action and use of. in laryngitis, 595. Skin diseases, classification of, 775; definitions of, ib. ; diagnosis of. 779 ; varieties of. 7^1 ; treatment of, 7f3; scaly diseases of. 174; treatment of, 7?4; treatment of syphilitic dis- eases of the, 7S8. Small-pox, cases of, 893; general treatment of, 894 : ectrotic treatment of, ib. ; greater fre- quency of. 896; relation of, to varicella, 697; identical with cow-pox. 898. Socrates, his death by takii.g hemlock. 418. Softening, cerebral and spir.al, pathology of. 8C6; exudative or inflammatory, ib. : hemorrhagic, 806: fatty, 307; scrims" or dropsical, ib. ; mechanical, 308 : putrefactive, ib. ; necessitj' for microscopic examination of. 310: cases of, ib. ; cerebral, cases of, £88 ; spinal, cases of, £92. Solanoma, 1S7. Sounds produced by percussion. 87 ; elicited over lungs. 42; produced by pulmonary organs. 51 ; cracked-pot sound. 43; alterations of natural, 52 : abnormal. 53 ; rubbing or friction, ib. ; rela- tive value of in auscultation. 64: of the circula- tory organs. 55: diagnostic of diseases of the circulatory systenu 512: of aneurisms, 688; diasnostic of diseases of the respiratory sys- tem. 5<.'2. Spasm, definition of, 804, 408 ; of the jaw, case of, 366, 952 INDEX. Spermatocele, appearance of spermatozoa in fluid of, S7. Spinal-column, post-mortem examination of, 24. Spinal cord, functions of, 112. Sijinal softening, pathology of, 305; origins and varieties of, ib. : necessity for microscopic examinatiiin of. 310; cases of, 392. Spinal irritatiiii), di-tinition of, 402. Spinal (lisordrrs. classitication of functional, 402. SpiruuKter of Mr. Hutchinson, 35. Spleen, percussiS£ W f!'^ 'i(fWw^S' \)Wa^v> ffisk THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW AN INITIAL FINE OF 25 CENTS WILL BE ASSESSED FOR FAILURE TO RETURN THIS BOOK ON THE DATE DUE. THE PENALTY WILL INCREASE TO 50 CENTS ON THE FOURTH DAY AND TO $1.00 ON THE SEVENTH DAY OVERDUE. §mL:..ZJ l^^^t^y^^y 18 1947 I -12'5g MAV21 \%/ m T r ^ iA^ JUN 3 '%'' ct: ■^^ 11nri;j?p 7'>2. LD 21-10m-5,'43(6061s) A" Sf ^ j^ ^'^'^ v*yW UV^v^'iC \^:^ w > e' . ^^tjOOi^yv ^^^i/ij^^ «',l> uc-t'i;/. jyy^i;. W^^V^Lm «-V.{ ' ■ 'J^Jti?' 'U^^fe>^^ 'v^gg% A^' V^ / 3-^ =«;^«^i^^^v^i ^"UiW 7'i ^8 V V V ^ J :^, "^ '« '^ ,^ 'V 'ii^i| m r^:m^m^^,^^^ i. B^m:-ci^^^^^ ^^'^^i;ij &ww^^,; mmm ,yk/yv^ :.c*^'';y^w. <:$igit> rr,M«i*^iiwi£irn ^Sm;