THE UNIVERSITY OF ILLINOIS LIBRARY Q>IG> Digitized by the Internet Archive in 2016 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/clinicallectures00benn_0 ^ .'R- .'-... ' , . T *. I r f , ■ '.■ ' \ ■ 4 ' • '.. ' t' / I '■ ■ , 4 /■ '■'■V, ■ 4 I CLINICAL LECTURES ON THE PRINCIPLES AND PRACTICE OF MEDICINE. . ' ( I ■ i \ '’''i- i ( : ( I V Of I i . -mao/. BY JOHN HUGHES BENNETT, M.D., F.R.S.E., PROFESSOR OF THE INSTITUTES OF MEDICINE, IND SENIOR PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF EDINBURGH . Formerly Lectnrer on the Practice of Physic, Physician to the Fever Hospital, Director of the Poli-Clinic at the Royal Dispensary, and Pathologist to the Royal Infirmary, Edin- burgh ; Honorary Member and Emeritus President of the Royal Medical Society of Edin- burgh ; Member and Corresponding Member of various other Scientific and Med- ical Societies in Edinburgh, St. Andrews, Philadelphia, New York, Paris, Brussels, Vienna, Berlin, St. Petersburg, Jena, Stockholm, Athens, Buda-Pesth, Copenhagen, Amsterdam, etc. FIFTH AMERICAN, lEVom tlie E^oiarth. TioikIoix Edition. difre Jittitbreb anb |l(ustraRons mt S^oob. NEW YOKK: WILLIAM WOOD & COMPANY, 27 GREAT JONES STREET. 1874. PREFACE. tr' This work having been some time out of print, a fourth edition is now published, every part of which has received numerous ad- ditions, while some portions of it are altogether new. In Sec- tion II. I have introduced an account of the molecular and cell theories of organisation, and re-written descriptions of the gen- eral laws of nutrition and of innervation in health and disease, of inflammation, and of tuberculosis. In a note appended to the general treatment of morbid growths, I have inserted a let- ter from M. Yelpeau, in which that distinguished surgeon has, from numerous cases in his practice, demonstrated the correct- ness of the opinion I long ago formed, on pathological grounds, viz., that true cancer may be permanently extirpated with the knife. The facts he has recorded ought to put an end to further discussion on the subject. In Section III. I have introduced new considerations on the subject of General Therapeutics, and have referred, under dis- tinct heads, to the natural progress of disease ; the knowledge derived from an improved diagnosis and pathology ; the fallacy of the change of type theory; an inquiry into our present means of treatment ; and the proposition that physiology and pathology constitute the true foundations for medical practice. Regarding these subjects, which. constitute important principles of our science, I shall be satisfied if their perusal should induce my readers to refiect on the uncertainty of our art, and stimu- 2532 ! 9 VI PEEFACE. late some of them to renewed investigations as to the exact value of remedies in the treatment of disease. In Sections lY. Y. and YI. several new’ subjects, and many valuable cases, have been introduced, which it is hoped will render the account given of the diseases of the nervous, diges- tive, and circulatory systems, more useful to the medical prac- titioner. In Section YII. I have tabulated every case of acute Pneu- monia treated by me in the Poyal Infirmary of Edinburgh since the year 1848, in order to satisfy my medical brethren that the restorative (not stimulating) treatment of the disease is in every way well worthy of their confidence. The facts shown by that table also will, I trust, serve to correct some prevailing errors, and establish a few new truths. In Sections YIII. IX. and X. are many additional wood illustrations and new cases ; some of the latter, illustrative of albuminuria, with increased secretion, from waxy degeneration of the kidney, are deserving attention. I trust to be excused for having still further defended my claim to the discovery of Leucocythemia. The subject of Diabetes has been extended by cases taken with great care, and a laborious trial of sugar as a remedy in that disease recorded. Certain views concerning the diagnosis and etiology of Typhus and Typhoid Fevers have been re-investigated. A very careful trial of the wet sheet in Scarlatina is detailed, and a singular new fact in the history of mercurial poisoning illustrated. These, and numerous other additions, which it is calculated have increased the work to the extent of 300 pages, I have, by curtailments, condensations, the employment of a closer type, and a slight enlargement of the page, been enabled to effect without adding to the bulk of the volume. I have again to express my obligations to numerous friends for assistance rendered to me in various w’ays, and especially to PEEFACE. Vll Dr. Angus Macdonald, House Physician to the Eoyal Infinnary, for valuable aid in correcting the proof-sheets. Notwithstand- ing the extra pains bestowed upon it, I am still deeply sensible of the many imperfections with which this book is chargeable, and for which I once more solicit the kind indulgence of my nuedical brethren. It is with no small gratification, however, that I have seen the modifications which I ventured to intro- duce into the principles and practice of medicine gradually adopted by medical practitioners in this and other countries; and the good results which have everywhere followed may, I trust, now be regarded as satisfactory proof that such modifica- tions are not merely temporary changes, but permanent im- provements in the practice of the art. J. HUGHES BENNETT. Edinburgh, A ’ pril ^ 1865. CONTENTS. List of Illustkations .... Introduction ..... The relation of the science to the art of medicine Mode of conducting the clinical course The political state of the medical profession . The social 4rtate of the medical profession The present state of practical medicine SECTION I. EXAMINATION OF THE PATIENT Arrangement of symptoms, etc. ..... Inspection of the dead body ...... Relative position of internal organs ..... Inspection ......... 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 the liver in percussing the spleen in percussing the stomach and intestines in percussing the kidneys in percussing the bladder Auscultation ........ General rules to be followed in the practice of auscultation . Special rules to be followed during auscultation of the pulmonary organs ........ Of the sounds produced by the pulmonary organs in health and in disease ........ B pAcre xvii 1 2 6 13 19 20 26 26 30 33 36 36 36 36 37 43 43 44 44 46 48 60 51 61 63 63 66 67 69 60 61 62 63 63 66 66 X CONTENTS. PAGE Special rules to be followed during auscultation of the circulatory organs . . ..... 70 Of the sounds produced by the circulatory organs in health and disease ..... . . 71 Auscultation of the abdomen ...... 73 Auscultation of the large vessels ..... 74 Use of the Microscope ....... 76 Description of the microscope ..... 77 Mensuration and demonstration ..... 83 How to observe with a microscope ..... 85 Principal Applications op the Microscope to Diagnosis ... 87 Saliva ........ 88 Milk ......... 89 The blood ........ 91 Pus ......... 93 Sputum ........ 94 Vomited matters ....... 97 Faaces ........ 99 Uterine and vaginal discharges . . . . .100 Mucus ........ 102 Dropsical fluids . . . . . . .103 Urine . . . . . . . . . 103 Cutaneous eruptions and ulcers . . . . .107 Use op Chemical Tests . . . . . . .110 To detect albumen in the urine . . . . .110 To detect bile in the urine . . . . . .110 To detect bile acids in the urine . . . . .Ill To detect leucin and tyrozin in the urine . . . .Ill To detect sugar in the urine . . . . . .Ill To detect chlorides in the urine . . . . ,112 SECTION II. PRINCIPLES OF MEDICINE . . . 114 Molecular AND Cell Theories OF Organisation . . . .115 On the General Laws op Nutrition in Health and Disease . . 124 Function of nutrition . . . . . . .124 Op the General Laws op Innervation in Health and Disease . . 137 General anatomy and physiology of the nervous system . . 138 General pathology of the nervous system . . . .148 Inflammation . . . . . . . .156 Tuberculosis ........ 179 Morbid Growths op Texture — ^their General Pathology and Treat- ment ......... 185 Classification . . . . . . . .187 Fibrous growths . . . . . .188 Fatty growths . . . • . . ,196 Cystic growths . . . , . . .199 Glandular growths ....*• 206 Epithelial growths ...... 210 Vascular growths . . , . . .216 Cartilaginous growths ...... 220 Osseous growths . , . . , ,226 Cancerous growths ...... 229 CONTENTS. xi PAGE General pathology of morbid growths . . . .233 General treatment of morbid growths .... 242 1 Morbid Degenerations of Texture ..... 245 , Albuminous degeneration ...... 246 Fatty degeneration ....... 252 Pigmentary degeneration . . . . . .262 Mineral degeneration ....... 269 Concretions ......... 272 Albuminous concretions . . . . . .273 Fatty concretions . . . . . . .273 Pigmentary concretions . . . . . .274 Mineral concretions . . . . . . .275 Urinary concretions ....... 275 Prostatic concretions . . . . . . .278 Hairy concretions . . . . . . .279 Vegetable fibrous concretions ..... 280 Amyloid and amylaceous concretions ..... 282 SECTION III. GENERAL THERAPEUTICS . 284 The Influence which the Mind exerts over the Body . . . 284 The Natural Progress of Disease ..... 295 The Knowledge derived from an improved Diagnosis and Pathology . 297 Fallacy of the Change of Type Theory ..... 299 On the diminished Employment of Blood-Letting and Antiphlogistic Rem- edies in the Treatment of Acute Inflammations . . . 302 Proposition 1. — That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations . 303 Proposition 2. — That inflammation is the same now as it has ever been, and that the analogy sought to be established between it and the varying types of fevers is fallacious ... * 305 Proposition 3. — That the principles on which blood-letting and anti- phlogistic remedies have hitherto been practised are opposed to a sound pathology ....... 306 Proposition 4. — That an inflammation once established cannot be cut short, and that the object of judicious medical treatment is to con- duct it to a favorable termination . . . . .313 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 ........ 316 An Inquiry into our Present Means of Treatment . . . 320 Dietetica ........ 320 Hygienica ........ 323 Materia medica . . . . . . 331 Action of medicines on the ultimate elements of the tissues . . 336 on the nervous system .... 337 on the respiratory system . . . 339 on the circulatory system . 339 on the digestive system .... 341 on the genito-urinary system . . . 342 on the integumentary system . . . 343 xii CONTENTS. General theory of the action of remedies .... 344 Physiology and Pathology the true Foundations for Medical ^ Practice ........ 347 SECTION IV. DISEASES OF THE NERVOUS SYSTEM . . 352 On the Pathology of Cerebral and Spinal Softenings, and on the Necessity op employing the Microscope to ascertain their Nature . 353 Acute Hydrocephalus — C ases I. to III. ..... 360 Pathology and treatment . . . . . .364 Cerebral Meningitis, Acute — Cases IV. to VI. .... 367 Pathology and treatment ...... 370 Chronic — Cases VII. and VIII. . . . 373 Cerebritis, Acute — Cases IX, and X. . . . . .376 Chronic — Cases XI. to XIV. . . . . .380 Pathology and treatment . . . . . .387 Cerebral Disease from Obstruction op Arteries — C ases XV. to XVII. . 390 Pathology ........ 396 Cerebral Hemorrhage — C ases XVIII. to XXIX. . . . 400 Pathology and treatment . . . . . .416 Cancer OF the Brain — C ase XXX. . . . . . .421 Dropsy op the Brain — C ase XXXI. ..... 424 Structural Diseases op the Spinal Cord — C ases XXXII. to XL. . . 427 Acute spinal meningitis ..... 427 Acute myelitis . . . . . . .428 Paraplegia and chronic myelitis — Cases XXXIV. to XXXIX. . 430 Facial neuralgia, from cancerous disease of the cranium — Case XL. . 441 Functional Disorders of the Nervous System — C ase XLI. . . 445 Classification of functional nervous disorders . . . 447 Pathology of functional nervous disorders .... 449 Treatment of functional nervous disorders . . . .453 Delirium tremens — Cases XLII. to XLV. . . . . 455 Poisoning by opium — Cases XLVI. and XL VII. . . . 458 Poisoning by hemlock — Case XL VIII. .... 460 Poisoning by lead — Case XLIX. ..... 464 SECTION V. DISEASES OF THE DIGESTIVE SYSTEM . . 466 Diseases of the Mouth, Pharynx, and (Esophagus — Cases L. to LIV. . 466 Functional Disorders op the Stomach — Cases LV. to LVIII. . . 472 General pathology and treatment of dyspepsia . . .475 Vomiting of sarcinae — LVIII. . . . . .479 Organic Diseases of the Stomach ...... 481 Chronic ulcer of the stomach — Cases LX. and LXI. .. . . 481 Chronic ulcer of the stomach, with perforation — Cases LXII. and LXIII 483 Pathology and treatment ...... 488 Cancer of stomach — Cases LXIV. and LXV. . . .489 Poisoning by oxalic acid — Case LXVI. .... 495 sulphuric acid — Case LXVII. .... 496 corrosive sublimate — Case LXVIII. . . 496 CONTENTS. . xm Diseases op the Liver ....... Acute congestion — Case LXIX. ..... Acute jaundice — Case LXX. ...... , Abscess — Case LXXI. ...... Jaundice — Case LXXII. . . * r. ’ t 'tr-trxTT 1 Jaundice from cancer compressing the ducts — Cases LXXIII. and LXXIV. Enlargement of the liver — Case LXXV. . . . . Fatty enlargement — Case LXXVI, ..... Cirrhosis — Cases LXX VII. and LXX VIII. .... Cancer of the liver — Case LXXIX. ..... Hydatid cyst of the hver — Case LXXX. .... Diseases of the Intestines . ...... Diarrhoea — Cases LXXXI. and LXXXII. .... Constipation . ....... Dysentery — Cases LXXXIII. and LXXXIV. . . . . Chronic dysentery — Case LXXXV. ..... Pathology and treatment of diarrhoea and dysentery Obstruction of large intestine from cancer — Case LXXXVI. . Strangulation of small intestine from inguinal hernia — Case LXXXVII. Intestinal Worms — Cases LXXXVIII. to XCI. .... Peritonitis — Cases XCII. to XCVI. ..... PAGE 497 497 498 501 604 606 510 511 514 518 622 624 524 525 626 627 630 634 535 642 546 SECTIO^T YI. DISEASES OF THE CIRCULATORY SYSTEM. . 557 Pericarditis — Cases XCVII. to CII. ..... 559 Pathology and treatment . . . . . .670 Valvular Diseases op the Heart — Cases CUT. to CXV. . . . 675 Enlarged foramen ovale — Case CXVI. .... 692 Pathology of valvular and organic diseases of the heart . . 694 Treatment of valvular and organic diseases of the heart . . 599 Functional Disorders op the Heart ..... 600 Aneurism — Cases CXVII. to CXXVI. ..... 601 General diagnosis of thoracic aneurisms .... 630 Physical phenomena of abdominal aneurisms . . . 630 Pathology and treatment of aneurisms .... 633 Diseases of Veins and Lymphatics ..... 634 Phlebitis of the left iliac vein — Case CXXVII. . . . 634 Angio-leucitis — Case CXXVIII. . ... 635 SECTIOlSr YII. DISEASES OF THE RESPIRATORY SYSTEM . . 637 Laryngitis — Cases CXXTX. to CXXXIII. . . . . 638 Treatment by topical applications . . . . .639 Diagnosis of laryngitis ... .... 647 Pertussis — Case CXXXFV. ...... 649 XIV CONTENTS. Bronchitis— C ases CXXXY. to CXXXVIII. Pathology and treatment On injections into the bronchi in pulmonary diseases Plehritis — Cases CXXXIX. to CXLVl. Pathology, diagnosis and treatment of pleuritis Empyema — Case CXLIV. Pneumonia — Cases CXLYII. to CLYII. . ! On the diagnostic value of the absence of chlorides from the pneumonia — Case CLllI. .... The pathology of acute pneumonia Treatment of acute pneumonia Tabular view of 129 cases of acute pneumonia Chronic pneumonia and gangrene of the CLYII. . . . . , ^ Phthisis Pulmonalis— Cases CLYIII. to CLXII. On the natural progress of phthisis pulnionalis the tendency ation — the modes of arrestment Pathology and general treatment of i luidsis pulmonahs Special treatment of phthisis pulmonaiig Cancer of the Lung — Case CLXIII. . . | Carbonaceous Lungs — Cases CLXIY. to CLXY. . i Pathology and treatment lung— Cases C Page 651 655 ' 658 660 664 671 678 urine m 686 689 692 697 LIY. to 713 722 to ulcer- 733 741 749 754 756 768 SECTION VIII. DISEASES OF THE GENITO-URINARY SYSTEM '763 Ovarian Dropsy — Cases CLXYI. to CLXIX. .... '763 Pathology of ovarian dropsy . . . . . . '775 Treatment of ovarian dropsy . . . . . ,780 Nephritis and Pyelitis — Cases CLXX. and CLXXI. . . . 782 Desquamative nephritis — Cases CLXXII. to CLXXIY. . . 785 Suppurative nephritis — Case CLXXY. . . . .791 Scrofulous nephritis — Case CLXXYI. . . . . 793 Calculous nephritis — Case CLXXYIL . . . . 795 Chronic pyelitis— Case CLXXYIII 797 Pathology of cystic kidney . . . . . .799 Persistent Albuminuria, or Bright’s Disease — Cases CLXXIX. to CXCI 801 Albuminuria with excessive amount of urine and waxy disease — Cases CLXXXYII. to CXC. .811 Pathology of Bright’s disease ...... 819 Diagnosis of Bright’s disease ...... 823 Treatment of Bright’s disease ...... 825 SECTION IX. DISEASES OF THE INTEGUMENTARY SYSTEM . 827 Classification of Skin Diseases ...... 828 Diagnosis OF Skin Diseases . . . . . . ,831 Porrigo ........ 835 CONTENTS. XV PAGE The Treatment op Skin Diseases . . . . . .836 Dermatozoa ......... 842 Acarus scabiei ....... 842 Entozoon foUiculorum ....... 846 Dermatophyta ........ 847 ' Favus — Cases CXCII. to CXCVI. ..... 847 History of favus as a vegetable parasite . . . .850 Mode of development and symptoms of favus . . . .850 Causes ......... 853 Pathology 856 Treatment ........ 862 SECTION X. DISEASES OF THE BLOOD Leucoctthemia — C ases CXCIX. to CCII. • . Pathology and treatment Discovery of leucocythemia Chlorosis and Anemia — C ase CCIII. IcHORHJEMiA OR (so-called) Py^mia — C asc CCIY. Pathology .... Glycoh^mia — C ases CCV. to CCXIII. Pathology and treatment Continued Fever .... Febricula— Cases CCXIV. to CCXYII. Kelapsing fever — Case CCXVIIL Typhoid fever treated by quinine — Cases CCXIX. to CCXXI. Typhus fever treated by quinine — Cases CCXXII. to CCXXVI Typhus fever treated without quinine — Cases CCXXVII. to . CCXXXII Diagnosis of continued fevers . Morbid anatomy of the Edinburgh fever during the winter 1847-8 Pathology and etiology of continued fever Typhoid succeeded by typhus fever — Case CCXXXIII. Typhoid fever— CCXXXIV Table of typhoid and typhus fevers, 1862-63 — Cases CCXXXV. t CCL. .... Propagation of fever . Treatment of continued fever . Iniantile Remittent Fever — Can it be separated from Acute Hydro CEPHALUS? — C ase CCLI. .... Intermittent Fever — CCLII. .... Pathology and treatment .... Eruptive Fevers ... ... Scarlatina — Cases CCLIII. and CCLXI. Erysipelas — Cases CCLXII. and CCLXIII. Variola — Cases CCLXI V. and CCLXV. The ectrotic treatment of variola — Case CCLXYI. Vaccination ...... Pathology of variola .... Diphtheria— Cases CCLXYH. and CCLXYIH. Syphilis and Mercurial Poisoning — C ases CCLXIX. to CCLXXI. Forms of syphilis ..... Diagnosis of syphilis ..... Propagation of syphilis .... Pathology of syphilis ..... 867 867 880 892 900 902 904 907 909 918 921 923 924 927 930 931 934 937 937 938 940 942 946 949 951 952 953 964 961 962 963 965 967 968 971 974 975 976 977 XVI COKTENTS. Treatment of syphilis ....... Rheumatism and Gout . . . . General pathology and treatment ..... Treatment of acute rheumatism by nitrate of potash — Cases CCLXXII. toCCLXXV. Treatment of rheumatism by lemon juice — Cases CCLXXVI. to CCLXMX. Diaphragmatic rheumatism — Case CCLXXX. .... Rheumatic iritis — Case CCLXXXI. Chronic gout — Case CCLXXXII. Scorbutus — Cases CCLXXXIII. and CCLXXXIY. Pathology and treatment Polydipsia — Cases CCLXXXV. and CCLXXXVI. PoLYSARCiA OR Obesity — Case CCLXXXVII. Conclusion — The ethics of medicine Table of Cases ..... General Index ..... PAGE 980 982 982 984 988 989 990 991 993 993 995 997 999 1005 1013 LIST OF ILLUSTRATIONS. Fig. 1. View of internal organs after removal of the thoracic and abdominal parietes 2. Deep-seated view of same . . . . • . . 3. Remarkable displacement of organs, in consequence of intestinal obstruction 4. Spatulae for depressing the tongue, one-third the real size 5. Extreme case of follicular pharyngitis .... 6. Mode of using the laryngoscope and tongue-depressor 7. View of the healthy larynx with the laryngoscope 8. Another view of the healthy larynx during ordinary breathing 9. Another view during deep inspiration .... 10. Complete closure of the glottis as in the act of swallowing . 11. Transformation of the right (inferior) false vocal cord 12. Cicatrices and loss of substance of the larynx . 13. Polypus attached to the right vocal cord . . 14. Large muriform polypus of an epithelial character in the larynx 15. Mode of inspecting the posterior nares 16. Voltolini’s mirror and shield for depressing the tongue 17. Septum, posterior orifices of the nasal fossie, etc. 18. The stethometer of Dr. Quain, half the real size 19. Mode of applying the instrument when the string is used 20. The chest-measurer of Dr. Sibson, natural size 21 and 22. Modes of applying the chest measurer 23. Stetho-goniometer, for measuring the inclination of the walls of the thorax 24. The pleximeter ....... 25. The percussion hammer of Winterich .... 26 and 27. Anterior and views of the limits and intensity of dulness 28. View of percussion in phthisis, atrophied heart and liver, and abstine 29. View of percussion in pleurisy ..... 30. View of percussion in pericarditis, pneumonia, and loaded rectum 31. View of percussion in hypertrophy of liver and heart 32. View of percussion in hypertrophied liver and spleen — Enlarged heart 33. View of percussion in enlarged spleen — pushed somewhat upwards . 34. View of percussion in dropsy of the abdomen, enlarged heart, and aneurism Page 34 34 35 38 38 40 40 40 40 40 41 41 41 42 42 42 43 45 45 46 46 48 48 49 54 55 56 57 58 59 59 61 35 and 36. Anterior and posterior outlines of the trunk for marking results of percussion 62 37 to 41. Various kinds of stethoscopes 42. Flexible stethoscope 43. Can man’s stethoscope 44. Differential stethoscope of Dr. Scott Alison 45. Hydrophone of Dr. Scott Alison . 46- Oberhaeuser’s microscope made for medical men 47. Gruby’s compound pocket microscope . 48. The same microscope mounted, ready for use 49. Beale’s clinical microscope 50. Spaces equal to 1-lOOOth and l-500th of an inch magnified 250 diameters linear 51. Salivary corpuscles, epithelial scales, etc., as seen in a drop of saliva . 52. Minute confervoid filaments springing from an altered epithelial scale 53. Confervoid filaments and sporules, in exudation on the mouth and gums 54. Fringe-like epithelium, from the surface of an ulcer on the tongue . 55. Globules of cow’s milk ........ 66. Colostrum of the human female, containing milk globules greatly varying in size 57. Blood-corpuscles, drawn from the extremity of the finger 68. Blood-corpuscles altered in shape from exosmosis XVlll LIST OF ILLUSTRATIONS. Fig. Page 59. Blood-corpuscles altered in form, and aggregated together, in thickened blood 92 60. The same united together in chaplets by coagulated fibrin . , . 92 61. Altered blood corpuscles in the fluid of an haematocele . . . 92 62. Appearance of blood once observed in a case of cholera ... 92 63. Colorless corpuscles slightly increased in number .... 93 64. Appearance of a drop of blood in leucocythemia .... 93 65. The same, after the addition of acetic acid ..... 93 66 and 67. Pus corpuscles in healthy pus, and after the addition of acetic acid . 94 68. Pus corpuscles, surrounded by a delicate cell-wall .... 94 69. In egular-shaped pus corpuscles, in scrofulous pus .... 94 70. Mass, consisting of minute molecules, frequently seen in disintegrated tubercle 95 71 and 72. Masses composed of molecules and oily granules varying in size . 95 73. Mass partly composed of the debris of a fibrous structure ... 95 74. Mass composed of tubercle corpuscles ...... 95 75. Fragments of phosphate of lime occasionally found in the sputum . . 95 76. Fragment of elastic tissue of the lung, in phthisical sputum ... 96 77 and 78. Fragments of areolar and elastic tissue, from phthisical sputum . 96 79. Fibrinous coagula in sputum, exhibiting moulds of the bronchi . . 96 80. Fibres, with corpuscles, in a fibrinous coagulum from a bronchus . . 96 81. Epithelial cells, embedded in mucus, expectorated from the fauces . . 97 82. Another portion of expectorated mucus from the fauces, acted on by acetic acid 97 83 and 84. Cells loaded with pigment in the sputum of a collier . . . 97 85. Appearance of starch corpuscles after partial digestion in the stomach . 98 86. Flake in the rice-water vomiting of a cholera patient .... 98 87. Structures observed in certain rice-water vomitings from a cholera patient. 98 88. Sarcina ventriculi ........ 98 89. Portions of the uredo in bread partly digested and disintegrated . . 99 90. Structure of confervoid mass passed from the bowels ... 99 91. The same magnified 500 diameters linear ..... 99 92. Rounded masses of earthy matter ...... 100 93. Structure of flakes in a rice-water stool, from a cholera patient . . 100 94. Corpuscles seen in a chronic leucorrhoeal discharge .... 101 95. Structure of gelatinous mucus from the os uteri .... 101 96. The same, after the addition of acetic acid ..... 101 97 and 98. Two specimens of cancerous juice squeezed from the uterus . . 101 99. Viscid greyish-yellow sputa of pneumonia, treated with dilute acetic acid . 102 100. Spermatozoids as observed in the fluid of spermatocele . . . 103 101. Cells in fluid, removed from an ovarian dropsy .... 103 102. Lozenge-shaped and rhomboidal crystals of uric acid . . . 104 103. Aggregated and flat striated crystals of uric acid . _ . _ . . 104 104. Urate of ammonia, in a granular membranous form, and in spicular masses 104 105. Triple phosphate, with various forms of urate of ammonia . . . 104 106. Octahedral and dumb-bell shaped crystals of oxalate of lime . , 105 107. Flat and rosette-like crystals of cystine ..... 105 103. Bodies observed in the urine of a scarlatina patient, 24 hours after being passed 105 109. Cast of a uriniferous tube ....... 105 110. Fatty casts, at an early period of formation ..... 106 111. Fragments of fatty and waxy casts ...... 106 112. Tyrozin masses in urinary sediment of a man with atrophy of the liver . 106 113. Leucin in a drop of the same urine allowed to evaporate . . . 106 114. Pure tyrozin from the same urinary sediment .... 106 115. Epidermic cells from crust of psoriasis . ..... 107 116. Thalli of the fungus found in the ear by Mr. Grove .... 108 117. The fungus {Achorion Schonleini) from a favus crust . . . 108 118. The same magnified 500 diameters linear ..... 108 119. Epithelial cells from the surface of an ulcer of the lip ... 108 120. The same, after the addition of acetic acid ..... lOg 121 and 122. Epidermic cells from a softened epithelioma .... lOg 123. Appearance of section of cancerous ulcer of the skin .... 109 124. A pocket-case, containing a spirit-lamp, two stoppered bottles, etc. . 112 125 to 129. Development of vibriones ...... 119 130. Nuclei embedded in a molecular blastema ..... 121 131. Young fibre cells formed by aggregation of molecules round the nuclei . 121 132. Cancer cells, one with a double nucleus ..... 121 133. Histolytic, or so-called granule cells, breaking down from fatty degeneration 121 134. Remarkable atrophy of the left side of the face .... 155 135. An exact copy of a portion of the web of a frog’s foot inflamed . . 157 136. Appearance of cartilage on each side of an incision made into the patella . 163 137. Vertical section of cartilage from the surface of the patella . . . 163 LIST OF ILLUSTRATIONS. XIX Pig. 138, 13y 141 143, 144, 145, 146 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158 159 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 1 « 0 . 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 200 . 201 . 202 . 203. 204 207. 208. 209. 210 . 211 . and 140. Portions of recent lymph from the pleura Portion of firm pleural adhesion ..... Another portion of the same, further developed The last, acted on by acetic acid . . . Pus cells. Four cells have been acted on by acetic acid . Pus celts containing fatty molecules, after adding acetic acid and 147. Scrofulous pus cells after the addition of acetic acid . Granular exudation and granular masses, from cerebral softening . Granular cells and masses from cerebral softening Two vessels coated with exudation from softening of the spinal cord Vertical section of a granulating sore ..... Moist gangrene, following compound fracture Dry gangrene from debility ...... Three air vesicles of a pneumonic lung with pus forming in them . Layers of lymph in pericarditis, presenting the form of large villi . Structure of the villi in pericarditis ..... Corpuscles from firm tubercular exudation into the lung . Corpuscles, granules, and debris, from soft tubercular exudation into cerebellum 179 180 180 180 188 189 189 189 189 189 189 190 190 190 192 192 192 192 192 192 192 192 193 193 193 193 193 193 194 195 195 196 196 197 197 198 198 198 199 200 200 201 201 201 201 202 202 202 203 203 The same, from tubercular infiltration of a mesenteric gland Section of a firm miliary tubercle of the lung .... Section of a grey granulation in the lung .... Molecular structure of a calcareous pulmonary tubercle Sti-uctures in hypertrophied heart ..... Fibrous structure of the uterus . . . . . . The same, hypertrophied from great increase in size of its fusiform cells Cell fibres and fibre cells from a fibro cellular growth in the stomach Fusiform cells from a sarcomatous growth in the kidney Fibro nucleated structure from a so-called medullary sarcoma of the humerus Fibrous stroma of a tumor acted on by acetic acid Fibres from induration of the stomach, with embedded nuclei Fibrous tissue, with free nuclei and cells, from a white peritoneal patch The same, after the addition of acetic acid .... Cells in the soft part of a fibrous tumor removed from the neck by Mr. Syrae The same, after the addition of acetic acid ..... Fibres in various stages of development from a harder nodule of the same tumo: Perfect fibrous tissue from another nodule of considerable density . Corpuscles scraped from the surface of a fibro-uucleated growth of the thigh The same, after the addition of acetic acid Appearance of a thin section of the tumor Another section, treated with acetic acid Soft polypi growing from the Schneiderian mucous membrane Fibre cells and fibres from the pulpy interior of a polypus . The same, after the addition of acetic acid Ciliated epithelial and pus cells from the exterior of the tumor The same, after the addition of acetic acid Section of a dermoid fibrous tumor embedded in the uterine walls Section of a dermoid fibrous tissue from the uterus, acted on by acetic acid Section of hard uterine polypus, boiled in dilute acetic acid and dried Section of Neuroma connected with three nervous trunks Thin section of a subcutaneous tubercle composed of fibro-cartilage Fibrous structure of a neuromatous swelling .... Lobulated Lipoma of the nose . . ' . Smooth Lipoma, removed from under the tongue, one-half the natural size Two layers of voluminous fat cells, varying in size, from a Lipoma . Fat cells from the same, dried, showing crystalline bundles of Margaric acid Section of a Fibro-Lipomatous tumor . Simple cyst of the broad ligament of the uterus, with very vascular walls 199. Diagrams of compound cystic growths .... Compound cystic sarcoma of the mamma .... Colloid cystic growths in three lobules of the thyroid gland . Delicate oval corpuscles in transparent colloid matter of the ovary . Round and oval corpuscles with filaments in colloid matter in the ovary to 206 . Of an ovarian cyst showing the epithelial cells, etc. . Cells from the interior of a simple cyst .... Structure of cholesteatoma ...... Encysted tumor, with fatty steatomatous contents Contents of a large atheromatous cyst ..... Adipose cells, from a steatomatous encysted tumor of the ovary XX LIST OP ILLUSTRATIONS. F’g. Page ‘J12. Cysts in cystic sarcoma of the mamma, filled with molecular matter . 203 213. Fibrous tissue from a sarcomatous encysted growth in the kidney . . ^ 204 214. Cystic osteoma of the femur ....... 204 215. Cystic osteoma of the tibia . . . . . . . 204 216. Cysts in cystic sarcoma of the mamma, crowded with cells . . . 205 217. Fibrous stroma from another part of the same tumor . . . 205 218. Structure of a cystic glandular tumor of the neck .... 206 219. 220, and 221. Structure of a glandular tumor removed from the mamma . 207 222. New formed tissue in a follicle of the thyroid gland . . . ^ . 208 223. Cells in fluid squeezed from a mesenteric gland, in a case of typhoid fever . 209 224. The same in another case ....... 209 225. The same cells, after the addition of acetic acid .... 209 226. Warts on the penis ........ 211 227. Summit of a papilla from a wart . . . . . . 211 228. Perpendicular section of a papilla, after adding acetic acid . . . 211 229. Transverse section of the base of a condyloma .... 212 230. Ulcerated epithelioma of the lip ...... 212 231. Section of an ulcerated epithelioma of the tongue .... 213 232. Muscular tissue immediately below the epitheliomatous ulcer . . 213 233. Concentric laminae of condensed epithelial scales .... 213 234. Epidermic scales, in mass and isolated, from the scrotum . . . 214 235. Group of deep-seated cells, in the same case ..... 214 236. The same, after the addition of acetic acid ..... 214 237. Fragments of the concentric masses figured Fig. 212, from a lymphatic gland 215 238. Epithelial cells, in yellow cheesy matter, of the same gland . . . 215 239. Cells in white matter, from soft fungoid epithelioma of the urinary bladder 215 240. The same, after the addition of acetic acid ..... 215 241. Horn from an old preparation in the Edinburgh University Museum . 216 242. True saccular aneurism of the aorta, nearly filled with coagulated clot . 217 243. Remarkable spontaneous varicose aneurism ..... 217 244. Aneurism of the coronary artery, completely filled with coagulated clot . 218 245. Section of erectile tumor ....... 218 246. Varicose cutaneous vessels of the anus ..... 218 247 to 250. Of umbilical artery of calf, eight inches long .... 219 251. Common carotid artery of an embryo calf, showing directions of the fibre cells 219 252. Stellate cells in the tail of the tadpole, developing into capillary vessels . 220 253. Capillary vessels in different stages of formation, from the eye of foetal calf 220 254. Branched cells in lymph exuded on the peritoneum .... 220 255. Vessels in an early stage of formation, from a colloid tumor of the back . 220 256. Enchondroma of the hand and fingers ...... 221 257. Structure of a firm nodule in an enchrondroma of the humerus . . 221 258. The same, after the addition of acetic acid ..... 221 259. The cartilage cells and fibrous tissue separated, with numerous molecules . 221 260. Small cartilage with round granule cells in SoLanoma . . . 222 261. The same cartilage cells, after the addition of acetic acid . . . 222 262. Thin section of a firm portion of the same tumor . ... 222 263. Fine filaments which interlaced the cells, these having been washed out . 222 264. Thin section of an enchondroma, with a bony capsule . . . 222 265. Separated cartilage cells from a softened portion of the same tumor . 222 266. The same, rendered more opaque, after the addition of acetic acid . . 222 267. Diseased articular cartilage ....... 223 268. Similar alteration in costal cartilage of the dog .... 223 269. 270. Two fibrous projections, from the surface of a diseased human cartilage 223, 224 271. Lateral view of an exostosis ....... 224 272. Part of a section through one of the prominences of the tumor . . 224 273. Section of a portion of the tumor ...... 224 274. Spicular growth of bone, in an osteo-carcinomatous tumor of the tibia . 226 275. Epulis removed from the upper jaw ...... 226 276. Cells with many nuclei in epulis ...... 226 277. Fibro-cartilage between the separated portions of a fractured cervix femoris 227 278. Spiculum of bone projecting from the choroid membrane . . . 228 279. Section from the centre of the crystalline lens .... 228 280. Loose membranous matter in the anterior chamber of the eye . . 228 281. Ossified excrescence on the arachnoid of the thoracic portion of spinal cord 228 282. Bony laminae arranged concentrically ...... 228 283. Section showing the arrangement of cells and fibres in scirrhus of the mamma 229 284. The same, after the addition of acetic acid ..... 229 285. Isolated cancer-cells, from the same growth ..... 229 286. The same, after the addition of acetic acid ..... 229 LIST OF ILLUSTRATIONS. XXI Fig Page 287. Young cancer-cells from the lung ...... 230 288. The same, after the addition of acetic acid ..... 230 289. Somewhat older cells from the testicle ..... 230 290. The same, after the addition of acetic acid ..... 230 291. Still older cancer-cells from a tumor in the duodenum . . . 231 292. The same, after the addition of acetic acid ..... 231 293. Highest development of cancer cells from a tumor of the toe . . 231 294. Simple and compound cancer-cells from the duodenum . . . 231 295. Colloid tissue, with the loculi filled with molecular matter . . . 232 296. Colloid cancer-appearance of the fibrous areolae filled with cancer-cells . 232 297. The same, after the addition of acetic acid ..... 232 298. Some of the cells isolated ....... 232 299. Fibrous stroma deprived of the cells bv pressure and washing . . 230 300. Section of small cancerous nodule in the mucous coat of the stomach . 234 SOI. Cartilage cells from a velvety articular cartilage of the condyle of the femur 235 302. Cells from a cancerous tumor of the brain ..... 236 303. Fibre of the sterno-mastoid muscle, in the neighborhood of a cancerous growth 240 304. Fasciculi of muscle, forming the flap in an amputation of the thigh . . 240 305. Granules, nuclei, and granule cells in a nerve ..... 240 306. Structure of the soft part of tumor removed by Mr. Page of Carlisle . 241 307. 308. Structure of the more indurated parts ..... 241 309. Structure of a fungoid growth of the leg ..... 242 310. The same, after the addition of acetic acid ..... 242 311. Structureless membrane formed by heating the clear fluid of pemphigus . 246 312. Edges of albuminous laminae, in a case of hydrocele .... 247 313. Dense fibrous structure, with naked nuclei from coats of the stomach . 248 314. The same, after the addition of acetic acid ..... 248 315. Diaphanous albuminous bodies, with fatty cancer cells from the diaphragm 248 316. Groups of blood corpuscles surrounded by an albuminous layer . . 248 317. A similar albuminous layer, round groups of bird’s blood-cells . , 248 318. Substance of nerve tube, broken across, forming globules . . . 249 319. Cells of the liver, in waxy degeneration of that organ . . . 249 320. Section of the thyroid body, with its glandular sacs filled with colloid matter 251 321. Radiated colloid masses from a cyst in an atrophied kidney . . . 251 322. Fatty molecules in groups ....... 253 323. Granular corpuscles and masses from cerebral softening . . . 253 324. Granular corpuscles acted upon by pressure ..... 254 325. Early stage of fatty degeneration of voluntary muscle . . . 254 326. Advanced stage of fatty degeneration in the muscular fasciculi of the heart 254 327. Another example of advanced fatty degeneration of voluntary muscle . 254 328. Fatty degeneration of the psoas magnus muscle of a lad with morbus coxarius 255 329. Other fasciculi of the same muscle, after the addition of ether . . 255 330. Enlarged fatty fusiform cells of the pregnant uterus after delivery . . 256 331. Atheroma of a blood-vessel ....... 256 332. Fatty granules, oil drops, granule cells, and cholesterine in atheroma . 256 333. Transverse section through the coats of the popliteal artery of an aged wmman 256 334. Cerebral vessels of an aged individual who died of apoplexy . . 257 335. Vessels from softening of the corpus striatum, coated with granule masses 257 336. Villi from the placenta of a six months’ foetus . .... 258 337. Fatty granules coating the blood-vessels, within the placental villi . . 258 338. Groups of fatty granules scattered through the substance of a placental villus 258 339. Fatty granules coating the vessels, and in the villous substance . . 258 340. Cells in fatty tracheal cartilage . . . . . . . 25J 3-il. Horizontal section of the occipital bone in a case of syphilis . . . 260 342. Thin section of the same bone, showing one of the ca'ncelli . . . 266 343. Thin section of the outer table of the same bone .... 260 344. New cells formed in malacosteon ...... 260 345. Retrograde cells, granules, and granular masses, in the reticulum of cancer 261 346. Fatty and broken-dowm cancer-cells in reticulum of cancer of the liver . 261 347. Fatty granular matter from the softened reticulum of a cancer of the breast 261 348. Liberated and altered nuclei in the reticulum of cancer of the testicle . 261 349. Crystals of hematoidine ........ 263 350. Wartlike brown of the female mamma . . . 264 351. Atrophied bronchial cartilage, with deposition of brown pigment . . 264 352. Placental villi, containing brown pigment from an aborted foetus . . 264 353. Black pigment masses and molecules round a tubercle of the peritoneum . 266 354. Transveise section of a necrosed tibia ...... 266 355. Black pigment molecules from the lung ..... 266 356. Black pigment irregular masses, from an intestinal aggregate gland . 266 XXll LIST OP ILLUSTEATIONS. Fig. 357. 358. 359. 360. 361. 362. 363. 364. 365. 366. 367. 863. 369. 370. 371. 372. 373. 374. 375. 376. 377. 378. 379. 380. 381. 382. 383. 384. 385. 386. 387. 388. 389. 390. 391. 392. 393. 394. 395. 396. 397. 398. 899. 400. 401. 402. 403. 404. 405. 406. 407. 408. 409. 410. 411. 412. 413. 414. 417. 418. 419. 420. 421. 422 423. 424. 425. 426. 427. Polygonal cells loaded with pigment, from the surface of the pericardium Cells loaded with pigment, from a melanotic tumor of the horse Cells in a melanotic cancer of the cheek .... Cells in the black sputum of a collier ..... Calcareous incrustation of the small vessels of the brain Structure of mineral degeneration of the walls of an aneurism Mineral degeneration of the nerve-cells and tubes of the spinal cord Mineral masses in a degenerated cancerous tumor of the omentum The same, in a degenerated cancerous mass in the liver Cancer-cells infiltrated with cretaceous molecules, in a mesenteric gland Mineral masses in a cretaceous tubercle of the lung . Section of an amorphous mineral mass .... Longitudinal section of an albuminous concretion Portion of one of the concentric lamellae of an albuminous concretion Transverse section of the edges of the concentric lamellae Section of the nucleus of an albuminous concretion . Longitudinal section of an albuminous concretion magnified . Various forms of biliary concretions ..... Vertical section of renal tubuli filled with urate of ammonia. External view of a remarkable renal calculus .... Section of the same calculus, with nucleus of uric acid and oxalate of lime Calculus with lithic acid nucleus ..... Triangular formed calculus of lithic acid .... Oval calculus of lithic acid ...... Oval calculus of uric acid ...... The triple phosphate surrounding a mulberry concretion of oxalate of lime Nodulated mulberry calculus . . ... Phosphatic calculus formed round a fragment of uric acid calculus . Phosphatic calculus formed round a piece of slate pencil Sections and external appearance of the calculi in Mr. Mackenzie’s case Prostatic calculi ........ Mass of hair found in the human stomach . _ . Section of a remarkably shaped intestinal concretion Section of an intestinal concretion ..... Hairs from the caryopsis of the oat, in an intestinal concretion Amyloid bodies embedded in a seemingly amorphous matter The same, after dilution with water ..... The same, after the addition of acetic acid .... The same, after the addition of nitric acid .... Small corpora amylacea, in the auditory nerve of a deaf individual . Variously shaped and sized corpora amylacea^ from the human pancreas Longitudinal plan of the arteries of the trunk .... Transverse plan of the arteries of the abdomen opposite to the liver The same, lower down ....... Structure of inflammatory exudative softening of the spinal cord Structure of a tubercular exudation in the cerebellum Structure of the softened cerebellum ..... Structure of the softened cerebral substance .... Structure of the softened pons varolii ..... Amyloid bodies with fragments of nerve tubes, from the optic thalamus A blood-vessel from the substance of the brain coated with exudation Another blood-vessel also coated with exudation Structure of a chronic grey softening of the cerebral hemisphere Section of the capsule and coagulum of an old apoplectic clot Granular corpuscles and masses in an old apoplectic clot Peculiar vascular stroma with villi in cancerous masses of the brain Gland-like expansions of stroma in other portions of the same mass 415, 416. Lateral, vertical, and front views of a hydrocephalic head . Appearance of the gastric glands in recent catarrh of the stomach . Commencing cystic formation in a gastric follicle A cyst in the pyloric portion of the stomach .... Fatty degeneration of gastric glands in chronic catarrh of the stomach Chronic catarrh of the stomach with hypertrophy of fibrous tissue Fatty degeneration affecting the upper layer of gastric follicular epithelium The gastric and pyloric glands hypertrophied in a cancroid tumor Disintegration of the hepatic structure following obstruction of the biliary ducts 505 Hepatic cells in various stages of fatty degeneration .... 512 Structure of a thin section of liver in the last stage of cirrhosis . . 516 Peri-lobular fatty or nutmeg liver ...... 517 Page 266 266 267 267 270 270 271 271 271 271 272 272 273 273 273 274 274 274 275 276 276 276 276 276 276 27-7 277 277 277 278 278 279 280 280 281 282 282 282 282 283 283 310 810 310 354 354 354 355 356 381 388 388 389 417 418 423 423 424 493 493 493 494 494 494 495 LIST OF ILLUSTRATION'S. XXlll Fig. 428. 429. 430. 431. 432. 433. 434. 435. 436. 437. 438. 439. 440. 441. 442. 443. 444. 445. 446. 447. 448. 449. 450. 451. 452. 453. 454. 455. 456. 457. 458. 459. 460. 461. 462. 463. 464. 465. 466. 467. 468. 469. 470. 471. 472. 473. 474. 475. 476. 477. 478. 479. 480. 481. 482. 483. 484. 485. 486. 487. 488. 489. 490. 491. 492. 493. 494. 495. 496. Pigmented nutmeg liver ... Remarkable carcinomatous cyst in the liver ... Vascular congestion and sugillation of the small intestine in cholera Granular mass, in recent exudation on the intestinal mucous membrane . An enlarged Payerian sac from the colon of a child .... Flaccid pericardium with small amount of fluid .... Distended pericardium, of a pyriform shape ..... Excessive distension of pericardium ...... Conjoined attachment of two of the aortic valves .... Aortic orifice with one valve of a funnel-shape .... Two valves of the aortic orifice, with a rudimentary one interposed Congenital malformation of the aortic valves ..... Four valves at the aortic orifice from the adhesion of one Five valves formed from adhesion and production of the septae in two valves Button-hole contraction of the mitral orifice ..... Mi-tral orifice, greatly constricted, forming an oval aperture . Fibrinous vegetations, and atheromatous degeneration of the aortic valves . Rough sketch of innominatal aneurism and adjoining parts . Diagram of an aneurism of the arteria innominata .... Aneurism of the thoracic aorta and superior mesenteric artery Appearances in acute laryngitis and oedema glottidis . Plug of mucous or coagulated blood in a bronchus Remains of pleural abscess ....... Relative position of the thoracic and abdominal viscera in A. Brown’s case Vertical section of a lung affected with pleuro-pneumonia Two moulds of coagulated exudation in red hepatisation of the lung Fragment of chicken- bone found in the right bronchus, in Neal’s case Fluid in the chronic abscess of the right lung, in Neal’s case Part of the left lung with clots occupying branches of the pulmonary artery Section of a lung in the first stage of phthisis pulmonalis Section of a lung in the second stage of phthisis pulmonalis . Section of a lung in the third stage of phthisis pulmonalis . Section of the summit of the right lung in arrested phthisis . The section of the upper portion of the lung in Keith’s case seen from within Chyle from the thoracic duct of a dog, three hours after eating a meal . Corpuscles in cancerous juice squeezed from the thyroid body The same after the addition of acetic acid ..... Vertical section through the wall of an ovarian cyst .... Subsequent formations proceeding in the walls of simple c^sts Section of the wall of an ovarian cyst, with epithelial cells in situ . Polygonal epithelial cells from the same lining membrane Oval epithelial cells from the lining membrane of an ovarian cyst . Cells in fluid removed from an ovarian dropsy .... Groups of columnar epithelium, etc., in encephaloma of the ovary . Diaphanous celloid bodies, naked nuclei, and granule cells in the same The nuclei after the addition of acetic acid ..... Structures occasionally seen in cysts of the kidney .... Waxy degeneration of a rnalpighiau body, with a few granule cells . Structures in a fatty kidney ....... Portion of fatty renal tube ....... Longitudinal section of a fatty kidney ...... Transverse section to the former one ...... Exudative casts of renal tubes ....... Desquamative casts, with blood corpuscles, naked nuclei, and cells . Fatty casts of renal tubes with granule cell ..... Waxy casts of renal tubes of various sizes ..... Dorsal surface of the female Acarus Scabiei ..... Ventral surface of the same ....... Ventral surface of the male Acarus ...... Three follicles of the skin of the dog containing entozoa Cul-de-sac of a sebaceous follicle, with entozoa and ova Hair and its follicle, with entozoa ...... Crusts of favus in different stages of development .... Branches of the Achorion Schosnleini, in an early stage of development Fragments of the branches more highly developed .... A light hair, containing branches of the Achorion Schosnleini Sporules developing on the surface of an apple, after three days The same, after four days ....... The same, more fully developed on the human arm, after inoculation Page 518 522 531 532 533 571 571 572 594 595 595 595 596 596 596 596 697 615 615 623 654 654 666 674 691 691 720 720 721 734 735 736 788 740 743 755 755 776 776 777 777 777 777 779 779 779 800 821 821 822 822 822 824 824 825 825 842 842 842 845 845 846 851 856 856 856 859 859 859 XXIV LIST OP ILLUSTRATIONS. Fig. Page 497. Thalli, mycelia, and sporidia, of the Achorion Schanleini . . . 860 498. Thalli and sporules from chronic pityriasis of the scalp . . . 865 499. Microsporon Furfur, in pityriasis versicolor . . . . . 865 500. Portion of the root of a hair plucked from a crust of chronic eczema . 866 501. Portion of clot from the vena cava in leucocythemia . . . 869 602. Posterior surface of the aorta and vena cava in leucocythemia . . 869 603. Appearance of the cerebral hemispheres in a case of leucocythemia . . 870 504. Colorless corpuscles, mingled with a few colored ones . . . 871 605. The same bodies, mingled with a larger number of yellow blood corpuscles 871 506. Change produced on the colorless corpuscles on the addition of acetic acid 871 507. Cells in the fluid squeezed from the lymphatic glands . . . 871 508. Blood-vessels giving oif a capillary from the pia mater . . . 871 509. Appearance of a drop of blood in leucocythemia .... 874 510. The same after the addition of acetic acid ..... 874 511. The same after the blood has stood for twenty-four hours . . , 875 512. Colorless corpuscles slightly increased in number .... 881 613. The same after the addition of acetic acid . . . . . 881 514. Colorless corpuscles increased in number, and of small size . . . 882 515. The same after the addition of acetic acid ..... 882 516. Colorless blood-cells observed in leucocythemia .... 882 517. Development of the nucleus in colorless blood-cells .... 883 518. Cells of various sizes, in the blood of a haddock, frog, and turkey . . 884 519. The nuclei of the blood-cells of the haddock, frog, and turkey . . 884 520. Fluid chyle, mingled with water ...*.. 885 521. The same, after the addition of acetic acid . . . , , 885 522. Numerous naked nuclei of the colorless corpuscles in the blood . . 887 523. The same after the addition of acetic acid ..... 887 524. Cells with single and multiple nuclei ...... 890 525. Structure of a decolorised mass in spleen ..... 934 526. The same after the addition of acetic acid ..... 934 527. Appearance of exudation and epithelial cells in the typhoid lung . . 935 528. Another portion of the same lung, after the addition oi acetic acid . . 935 529. Portions of normal epithelium separated from the air vesicles . . 935 530. A clinical ward of the Royal Infirmary, with fever beds, in 1817 . . 944 631. Clinical ward. No. XL, 1858, with present arrangement of fever beds . 945 532. Mr. Weir’s scarificator for vaccination ..... 966 533 and 534. Dr. Husband’s tubes charged with vaccine lymph . . ♦ 966 535. Skeleton of a dog poisoned by mercury . . . . .978 .536. Exostosis of do^s femur . . . . , . .979 537. Internal view of the same .... . 979 CLINICAL LECTURES INTRODUCTION. ^ 1,1 '//;_//. Gtentlemen, — Medicine, as a subject of study, must be/ ^egaft’deyd in, a, two-fold aspect, as a science and as an art — it has its theory / ayd^ iti practice; its principles and their application. We can trace the germs/ of theory and practice in medicine to a very early period. At first, indeed, the art must necessarily have been founded upon experience and observation alone. Hippocrates first added philosophy and reasoning to experience, and introduced those discussions which led to the overthrow of empiricism, and the final triumph of dogmatism, six hundred years later, in the time of Galen. Since then, although the medical profession has uniformly conjoined the results both of reasoning and experience, each of these two methods has had its special supporters. Even at the present day you will find persons who complacently call themselves prac- tical men, and who sneer at all modern advances in pathology. Others are apt to attribute too much importance to theory, and regard with feel- ings approaching to contempt him whom they denominate a routine practitioner. Hence, unfortunately, it too often happens that practical men are comparatively unacquainted with physiology and pathology; while those who dedicate themselves to the latter studies are very scep- tical as to empirical remedies. On this subject Cullen made a remark eighty years ago which applies at present : — Every one now-a-days pretends to neglect theory, and to stick to observation. But the first is in talk only, for every man has his theory, good or bad, which he occa- sionally employs ; and the only difference is, that weak men who have little extent of ability for, or who have had little experience in reason- ing, are most liable to be attached to frivolous theories ; but the truly judicious practitioners and good observers are such as have the most extensive views’ of the animal economy, and know best the true account of the present state of theory, and therefore know best where to stop in the application of it.” If these observations were correct when Cullen wrote, they are far more applicable now, when almost every advance that has been made in the art of medicine since his day has been owing to the result of scientific investigation. But in order to make this proposition clear, allow me, in. the first place, to point out what I conceive to be 1 2 TNTKODUCTION. The Relation of the Science to the Art of Medicine. If we regard the whole field of human knowledge, and reflect on the differences which exist among the various sciences, we must insensibly be led to classify them into two great divisions, viz., the exact and the in- exact. All the sciences belonging to the first class are characterised by the possession of a primitive fact or law, which, being applicable to the whole range of phenomena of which the science consists, renders its dif- ferent parts harmonious, and the deductions of its cultivators conclusive. Thus, the physical sciences possess a primitive fact in what is called the law of gravity. It was Sir Isaac Newton who demonstrated, by a happy effort of genius, that all the planets in our system gravitate towards the sun by the same law, and in consequence of the same principle, as that by which bodies on the earth gravitate towards its centre. This theory was subsequently found applicable to a vast number of circumstances, and by it the philosopher now explains many of the material phenomena of the universe, and the astronomer calculates the movements of the heavenly bodies. This law applies to all the facts of which physical science is made up. In the same manner, chemistry possesses a primi- tive fact in what is called the law of affinity, discovered later by Lavoi- sier. If we mix two salts which mutually decompose each other, a third salt is formed by the union in definite proportions of their constituent elements. This, in the language of •chemists, is brought about by chemical affinity. If we repeat the experiment a thousand times, the same result takes place, and the law, which applies in one case, is found universally applicable to every phenomenon in chemical science. The possession of this primitive fact, then, communicates the greatest accu- racy and precision to the sciences which possess it, and on this account they are called the exact sciences. But there are other sciences which are altogether destitute of a pri- mitive fact ; which consist of groups of phenomena, each of which may or may not be governed by a particular law. Such a one is agriculture. No man, however skilful, can till the ground or cultivate the soil, and be certain of the same result on every occasion. Numerous circum- stances, over which he has no control, may destroy his anticipations and show the fallacy of his calculations, and this, after every known condition has been fulfilled, and every possible degree of prudence and sagacity has been exercised to ensure success. The same means, appa- rently, which operate at one time fail to do so at another. Such sciences, then, are denominated inexact sciences, and it is to this class that medi- cine belongs. Now, the cultivators of medicine always have been, and are still endeavoring to render the science exact ; and hence at various times individuals have brought forward what they conceived to be a law or primitive fact, and have tried to show that it was applicable to all vital phenomena. Some have placed the law in the physical condition of the solids, and others in the physical condition of the fluids. Hence the terms soUdisis and fluidisis. A third party have sought it in the func- tional conditions of the body, viz., an alteration in the living force. Tliey have been called vitalists. If, for instance, we could constitute the RELATION OF THE SCIENCE TO THE ART OF MEDICINE. 3 vital property, excitability, a primitive fact, it would serve the same pur- pose in physiology that gravitation does in physics. But we cannot do this. It is true that the stomach is excited by the food, in order that digestion may be produced, and that the lungs are excited by the air during the process of aeration. But in the performance of these func- ti )ns, excitability plays a secondary part; it is only one of the elemen- tary properties necessary for their completion, and is utterly insufficient 10 account for their production. In the same manner, neither the mechanism of the solids nor of the fluids can explain every known fact; so that it becomes necessary to take all three doctrines, — solidism, humoralism, and vitaLsm, — into consideration, if we wish to escape fallacy. Of late years it has been contended that, as far as structure and development are concerned, we do possess a law in the doctrine of cyto-gcnesis, that is, of the growth of those minute vesicles or cells, of which we find all plants and animals, at one period of their existence, to be composed. It has been argued that if a theory of organization can be shown to apply to all animated nature, to the vegetable as well as to the animal kingdom ; if it can be demonstrated that the humblest and minutest tribes of plants possess the same original structure as is to be found in the most gigantic trees of the forest ; if it become evident that the same principle of formation is discoverable in animals, whether so minute that thousands may be contained in a drop of water, or, on the other hand, so enormous as the elephant or whale ; nay, more, if it admit of demonstration that the organic diseases to which they are subject, that the formation of new growths and the reparation of tissues are explicable by the same theory as applies to the development of healthy structure, — then, it is contended, we are surely approaching to something like a great primitive fact, which may ultimately communicate exactitude to physiological science. And yet, notwithstanding the flood of light which has been thrown upon all departments of our science by the beautiful generalisation of Schleiden and Schwann, recent researches have exhibited its insufficiency to ex- plain all known phenomena of growth. Medicine, then, in its present state, possesses no primitive fact. But is it not very possible that it may do so at some future time? During the many ages that existed before Newton, physical science was as inexact as that of physiology is now. Before the time of Lavoisier, chemistry, like physiology, consisted of nothing but groups of pheno- mena. These sciences went on gradually advancing, however, and accumulating facts, until at length philosophers appeared who united these together under one law. So medicine, we trust, is destined to advance, and one day another Newton, another Lavoisier, may arise, whose genius will furnish our science with iU primitive fact, and stamp upon it the character of precision and exactitude. Although it must be confessed that we have not yet arrived at such a happy consummation, it cannot be denied that we are making rapid strides towards it. Notwithstanding those principles which Bacon intro- duced into the study of science, it is only lately, from the advance of collateral branches of knowledge, that we have been enabled to catch 4 INTRODUCTION. glimpses of a correct pliilosophy as applied to physiology. A truly scientific medicine is yet to be created — for all the processes of life, both in its healthy and diseased conditions, are really owing to the structures which have been only lately made visible by the improvement in optical instruments. W e know also, that these processes are connected with physi- cal and chemical changes, the importance of which we are just commenc- ing to estimate. But now, assured of what is really necessary, and guided by rigid observation and experiment, rather than by a vague hypothesis, physiology and pathology are advancing with such rapidity that every year improves or modifies the ideas which sprang up in the one which preceded it. Moreover, it has been satisfactorily shown that the branch of science which refers to vital phenomena bears such a relation or correlation to various branches of physical science, that the whole is gradually becoming more simple, instead of more complex. Instead of physiology being isolated under the idea that its laws are peculiar, it is every day becoming more evident that vegetable and animal life are de- pendent on conditions which, strictly speaking, are elucidated by the geologist, botanist, zoologist, chemist, and natural philosopher. In short, the intimate union of the natural sciences seems to be near at hand. But you do not cultivate these sciences as barren, however interest- ing, subjects of medical study. With you, I apprehend, as with myself, the knowledge so acquired constitutes a groundwork for the practice of an art. It is in this point of view I am especially anxious you should consider physiology and pathology. For, gentlemen, I trust that, in studying these subjects, you will never lose sight of the important fact that you are medical students, and that, as such, your ultimate object is to acquire an art; in other words, skill in the employment of all those means which are directed to the prolongation of life and the cure of diseases. Now, in order that you may successfully accomplish this great object, it is necessary that you should appreciate properly the importance of theory in its bearings on practice, so that, when you are called upon to treat the sick, you may be ready to take advantage of all the knowledge which you may have obtained. Hence the importance of knowing how to distinguish between the nature and object of science and art respec- tively. We may consider science, then, to be a collection of theories; art, a body of rules. Science says, this is or is not ; this is probable or improbable. Art says, do this, avoid that. The object of science is to discover facts and determine laws ; the object of art is to accomplish an end, and determine the means of effecting it. Science is inductive, and reasons ; art is imitative, and exemplifies. Science is steady, certain, and progressive ; art is vacillating, doubtful, and limited. Hitherto it has been imagined that the chief, if not the only method of obtaining skill in art is by practising it ; that is, obtaining experi- ence. In medicine this is proverbial, and every practitioner is more apt to boast of his experience than of his scientific knowledge. In the infancy of science, indeed, we can readily understand that its hasty generalisations must have been continually overthrown and rendered ridiculous tlie moment they were applied to practice. Hence the reason why art for many ages preceded science — why dogmatic rules were more RELATION OF THE SCIENCE TO THE ART OF MEDICINE. 5 attended to tlian ingenious theories — and why the accomplishment of an end, even when that end was limited, was more regarded than the dis- covery of a new fact, or the determination of a law capable of extensive application. But in recent times this state of things is gradually be- coming reverseJ. Science, in numberless instances, has advanced beyond art ; nay more, science herself has worked out all the details, and made an art obedient to her commands. Thus it was that the theory of achro- matism, worked out by Euler, led opticians to make perfect telescopes and microseopes. Thus it was that Le Verrier and Adams, by calcula- tions in their observatories in Paris and London, discovered a planet which they had never seen, but which, when looked for, according to their directions, from Stockholm and St. Petersburg, was immediately proved to exist in fact, as it had previously been proved to exist in theory. Tims it was that the electric telegraph, perfected in the closet of the man of science, flashed ready-made on the astonished gaze of an admiring world ; and thus it is that at the present moment we see the artizan in his workshop, the explorer in the mine, the agriculturist in his farm — nay, even the sculptor in his studio — abandoniiig the rules and wise saws handed down to him from ancient tradition, and accommodat- ing himself to the revolutions which science has dictated, and those laws whereby blind experience is made to yield to an enlightened knowledge. We may therefore receive it as an established law, that the more any particular science is advanced, the more is the art to which it leads rendered perfect, and that true theory in the one produces never-failing rules in the other. The art of navigation, for instance, is certain, in so far as it is based on the science of astronomy, which admits of exact calculation. In like manner, the only way of improving the art of medicine is to advance the science of physiology ; and all that has been accomplished during the last fifty years has been brought about in this manner. In that short time have been discovered the independent pro- perties of the nerves, the reflex functions of the nervous centres, the chemical balance of organic nature, the functions of cells and their in- fluence on nutrition and secretion, the laws regulating the development of the ovum, the significance of the sounds produced by the heart and lungs, and numerous other doctrines which have tended to improve the art of medicine. But while the modern cultivator of medicine loses no opportunity, and employs all the means with which the improved state of science furnishes him, for investigating morbid anatomy and the causes of dis- eas •, he carefully corrects the theoretical conclusions to which these alone might lead him by practical experience and observation. Our active and our speculative powers should go hand in hand, so that, by a union of tiieoretical knowledge and practical skill, we may advance both to their farthest limits. It is by cultivating medicine in this spirit that the clinical school of Edinburgh has rendered itself so famous. Those who taught the theoretical branches of medicine from their chairs in the University were those who taught the practice in the wards of this Infirmary. They were thus enabled to demonstrate how, on the one hand, correct observation leads to just deduction, and on the other, how a knowledge of general principles causes accuracy and acuteness in 6 INTRODUCTIOX. observation. Indeed, it is impossible to estimate too highly the advan- tages which have resulted from such a system, which has been carried on uninterruptedly by the Professors of this University, for one hundred and ten years. This leads me to speak of The Mode of Conducting the Clinical Course. Your principal object, gentlemen, in coming into this Hospital, is, I presume, to observe disease for yourselves. Now, to observe with advantage two things are necessary: 1st, The correct appreciation of actual facts, as communicated to the senses of the practitioner or of his patient,- 2d, The deduction from these of a correct judgment as to the nature of the disease, and the proper mode of its treatment. Both these processes are very difficult of attainment, and some men have a natural aptitude for the one and some for the other. They are also frequently confounded together, some observers considering those to be facts which are only theories, and others imagining that to be theoretical which is truly fact. Thus the assertion that a man is laboring under apoplexy, pneumonia, pericarditis, and so on, is only stating the opinion or theory the practitioner holds with regard to his case, although such assertion is generally received as a fact. Again, when it is said that porrigo favosa consists of vegetable fungi growing on the scalp, the statement, though generally received as mere theory, is truly a fact, inasmuch as the vege- tation may actually be demonstrated, and rendered as visible to the eye as trees growing in a plantation. Indeed, the just distinction between theory and fact is a matter which has excited lively discussion, and hence the celebrated saying of Cullen, that there are more false facts than false theories in medicine. If, in the field of medical observation, we define a fact to be any- thing which is obvious to the well-cultivated senses of the observer, we perhaps approach as near accuracy as is possible. Bemark, I say well- cultivated., because the senses require to be educated before they can receive proper impressions. In this lies the great difficulty in teaching practical medicine, for what is obvious to the sight of an experienced practitioner is overlooked by the student ; the sound which is heard b}^ the one is inaudible to the other ; what the first feels distinctly is not perceived by the second. Now, this instruction of the senses constitutes a kind of information which cannot be obtained from others; you must acquire it for yourselves. Of late years, however, the detection of facts has been greatly facilitated by the appropriate use of instruments, whereby what at one time was conjectural is now rendered certain. Thus, the existence of many diseases, which could formerly be detected only by a happy speculation or by a rare sagacity, is easily demonstrated by those who know how to employ judiciously chemical tests, micro- scopes, stethoscopes, pleximeters, specula, etc. To carry observation, then, to its utmost extent, we must learn how to avail ourselves of all these means in the examination of the signs and symptoms of disease. On the other hand, gentlemen, a sound and correct judgment is equally necessary, in order that the cultivation of the senses may lead to MODE OF CONDUCTING THE CLINICAL COURSE. 7 a proper end, and indicate the direction in which you must act for the benefit of the patient. For this purpose a certain degree of preliminary instruction is absolutely essential before you can be qualified to attend an hospital with advantage. Indeed, I must take it for granted that before coining here you are tolerably well acquainted with anatomy and diemis- try ; that you have studied the institutes of medicine — that is, the present state of histology, physiology, and pathology; and that you have a know- ledge of the materia medica, and of the effects of remedies on the economy. Thus prepared, you commence a series of visits to the bedsides of those who are laboring under disease ; in other words, you enter upon a course of clinical instruction. What should we understand by clinical instruction ? It is not attendance on the lectures only — it is not merely learning the opmioiis of your teacher— it is not simply deriving know- ledge from others. It is acquiring "medical information for yourselves — it is the learning how to observe — it is that education of the senses to which I have alluded ; and, in addition, the formation of that sound judgment which will enable you to act for the benefit of your patients. This can only be learned by continual practice and experience ; and it has always appeared to me that the great aim of clinical instruction should be to teach the student to acc^uire that kind of tact and readiness to do^ which we have seen constitutes art. How are all arts acquired ? A young mechanic, when he makes a chair, follows exactly the same process as those who study what are called the fine arts ; that is, he learns how to do what his master did before him. He imitates his plan of proceeding. His first attempts are rude and uncouth ; his subsequent ones are more perfect, until at length, by continual practice, he is enabled to equal or surpass his instructor. In painting, sculpture, and music there are principles which must be attended to, and which are learned from others ; but no man can become a painter, a sculptor, or a musician without obtaining practical skill as an artist in the way now alluded to. It is thus, and thus only, that art de- scends from the old to the young. And so in medicine ; it is not enough to obtain general views of health and disease, or to study what is known of the nature and treatment of individual maladies. It is absolutely essential to watch diseases for yourselves, to see the altered countenance and form, to feel the variations in the pulse and temperature of the sur- face, to hear the changes which the sounds of the heart and lungs undergo, to learn the employment of stethoscopes, microscopes, and other mechani- cal aids in investigation, and to adapt those remedies which are in use to the special case before you. It is only by a combination of such training in a hospital for the sick, with the varied scientific knowledge you have obtained elsewhere, that you can hope to prepare yourselves conscientiously for the responsible duties of a medical practitioner. The best hospital arrangements for clinical teaching are those which exist in Italy. All the cases admitted are first placed in a receiving ward (depositorium), and immediately visited by the clinical professor or his assistant. From these he selects daily such as he thinks best fitted for clinical instruction. He has seldom above thirty beds himself, a number amply sufficient if he possesses the right of choice. Thereby he is enabled to bring before his students examples of nervous, cardiac, pul- 8 INTRODUCTION. monary, renal, or other diseases, multiplying illustrative cases of each in his wards as he requires them. The result is, that when lecturing on phthisis or any other malady, he is enabled to direct the attention of his pupils to groups of cases presenting the various stages and complications which characterise it. He can thus demonstrate the physical signs and symptoms of the disease in all its forms; point out the numerous varieties it exhibits, and show the differences in treatment which are necessitated by varied circumstances. I need not say that the proper selection of cases for clinical instruction is a matter of great importance, because, if not sufficiently varied, the student cannot, in the limited time at his dis- posal, take a sufficiently extensive grasp of medical practice.* In many schools, especially abroad, there are separate professorships of clinical medicine ; whereas in others clinical teaching is carried on by the professors of other branches of medical education. Of the two sys- tems I have no hesitation in preferring the latter. Those practical phy- sicians who teach annually the theoretical and systematic branches of medi- cine ought to be those best qualified for giving instructions in an hospital, and this for the obvious reason, that they are obliged to keep on a level with the advancing knowledge of the day in at least one department of science. They may, it is true, bring different kinds of knowledge to bear on the subject, but that knowledge will be the best in its way, and the students will have the advantage of observing diseases treated by each in turn. This system has been found, on the whole, to answer well, al- though it must be admitted that periods of three mouths are too short for a clinical teacher and his pupils to work together in the course of a twelvemonth. On the other hand, a single professor is too apt to pass into a system of routine, to dwell only on his own peculiar views, and, not being required to teach any science, gradually to fall behind, and then lose sight of scientific advancement altogether. Now it is the union of science and art which stimulates both to reach their highest degree of perfection. The physician who teaches the former systematically in the university is the man who will correct and enlarge his th'eory in the wards of an hospital, and he who possesses a large practice and great ex- perience will extend his resources by keeping himself an couroni with the state of science, as is necessitated by his duties in the university. I be- lieve that these are the reasons which have rendered the clinical school of medicine in Edinburgh so celebrated. As to the methods of teaching, they essentially consist of two kinds. In one the professor gives lectures to the students suggested by the cases under treatment, to which are occasionally added, during his visits at the hospital, observations at the bedside. In the other the student is encouraged to talk to the teacher ; to examine the case tor himself, form his own diagnosis, and suggest a treatment. Both systems have their advantages and disadvantages. An experienced teacher pointing out the difficulties and peculiarities of particular cases, and enriching the whole with the results of his own * The Medical Faculty of the University, in surrendering several years ago the same choice as is still possessed by the Italian clinical professors, were guilty of an injudicious liberality which has much weakened the efficiency of its hospital instruc- tion. MODE OF CONDUCTING THE CLINICAL COURSE. 9 observations made in a large field of hospital and private practice, cannot but communicate to bis hearers most useful information, that in after years should prove of the utmost value to them. Unfortunately the students who hear such lectures are seldom prepared to benefit by them. The difficulties of the experienced, and the methods by which they are to be overcome, cannot be entered into by those who have no experience at all. Nay, more ; the very facts and language on which descriptions are based in the class-room are often unintelligible to the student. I remember myself listening to a most able lecture on the diagnosis of pleurisy, the whole of which depended on knowing whether friction sounds and certain modifications in the vocal resonance did or did not exist. But as I had no clear idea — indeed was profoundly ignorant — of what these sounds and vocal modifications were, I was not much the better for the information communicated to me. In this manner it too frequently happens that, at the end of a series of clinical lectures, though the student has heard and seen much, he in truth knows very little, and has in fact all his real practical knowledge to acquire. The other mode of clinical teaching I first became acquainted with in the wards of M. Bostan in Ibiris in 1887, and subsequently saw it carried to a high degree of perfection in the great Cliniques of Germany — especially under Schunlein, Wolf, and Barez, in the Charite Kranken- haus of Berlin. It consists in calling upon a student to examine the case before the class, in the presenco of the teacher, according to a well- understood plan. At the termination of the examination, he is asked to give his opinion or diagnosis as to its nature. Those who stand round, and who have followed all the steps of the examination, are also invited to give their opinion. This gives an opportunity to the teacher of pointing out the error of this view or the correctness of that, until a sound conclusion is arrived at. Then the student is asked to suggest a treat- ment. Again, suggestions on this point are solicited, and the one con- sidered best is adopted by the physician fur such and such reasons. Finally, the student is requested to prescribe, and taught how to do so correctly. In Germany, the examining pupil is further requested to write out the case, and to keep a record of it, which is subsequently corrected as an exercise by the professor. It must be apparent that in this manner a student will acquire a large amount of practical informa- tion. On the other hand, instruction entirely carried on in this manner deprives the student of much that is valuable, because there are many topics which obviously cannot be carefully considered at the bedside, and others which a sense of propriety should prevent being discussed in the patient’s presence. In fatal cases, a most important part of clinical instruction consists in carefully examining the dead body, and from the appearances observed determining how far the diagnosis and treatment have been correct. This evidently cannot be carried on in the wards, and is practically useless to those who have not previously seen the case. The system of instruction, therefore, I have carried out for the last seventeen years in this infirmary is one in which I endeavor to adopt the excellences and avoid the defects of both systems. On Tuesdays and Fridays I lecture in the hospital theatre, in which I give a resume 10 IXTRODUCTIOJS'. of the facts of special cases; dwell on any difficulties of diagnosis or treatment that have presented themselves ; refer to the experience of other physicians; discuss pathological doctrines; and, above all, exhibit the morbid parts of fatal cases, and connect the changes observed in the organs after death with the phenomena we have studied in the living. On Mondays, Wednesdays, and Thursdays I visit with you all the cases in the wards, and call upon such of you as wish to examine for your- selves to do so, according to the plan which you will find detailed in this little book, “ An Introduction to the Study of Clinical Medicine.” You will then try and form your own diagnosis, and propose a treatment. In doing this, numerous opportunities will present themselves which will enable me to give you practical instruction in percussion, ausculta- tion, the use of the microscope, and of chemical tests at the bedside. You also will gradually learn how to put questions, and so conduct the inquiry as to arrive at an exact result with as little fatigue to the patient as possible. On Saturdays and Sundays only the more urgent cases will be visited. Gentlemen, I am happy to say that this system has met with the highest aj^proval from the large classes I have had the honor to instruct. In 1849, the gentlemen then attending informed me in this memorial that, “ Being aware how every divergence from the regular medical routine is very generally regarded at first with suspicion, we feel it our duty to express the conviction that, in our experience, the system alluded to has operated most beneficially, and to hope that future students may enjoy its advantages.” In 1850, a numerous class spontaneously pre- sented me with this testimonial, in which they say — “ We do not hesitate to inform you that we have learned more of practical medicine by your mode of teaching than by any other mode in use ; and though objections have been raised against it, we feel certain that the records of these last few months will tend to remove them. The general decorum of the class at the bedside; the great interest exhibited in the cases; and last, though not least, the never varying good attendance, all speak loudly in its favor, and will, we trust, encourage you in your zealous exertions to promote the science of medicine by the sound instruction of its youthful votaries in its theory and practice.” Encouraged by these marks of approval, I have continued my method of clinical instruction up to this time, generally devotiog two hours to my practical teaching in the wards, and have never heard from pupil or patient the slightest objection. The latter, indeed, is uniformly con- tented, being wise enough to know, even by instinct, that a careful and minute examination of his case can only be productive of benefit to him. Strange to say, however, objections have recently been made from a quarter whence I least expected them ; ridicule and misrepresentation have not been wanting to give point to the attack ; and another system of clinical instruction has been brought forward, which is considered preferable to any other. The chief objection is, that the examination of a patient before a large class and by an inexperienced student is cruel to the patient. ‘‘ There could not, I think,” says the objector, “ be any procedure more shocking than propping up a poor creature sufiering from disease of the MODE OF CONDUCTING THE CLINICAL COURSE. 11 lungs, and hammering his chest for the recognition of diagnostic sounds as an academic exercise.” This passage, which I copy from the Edin- burgh Evening Courant for December l3th, 1863, may have a formi- dable appearance to the public who read it in the newspapers, but will certainly not prevent physicians and intelligent students from practising percussion in diseases of the chest. The reference to this class of diseases also is singularly unfortunate; for it is just in consequence of the exactitude with which we now arrive at a knowledge of them by the “ shocking ” process referred to that those, formerly so fatal, are now almost always subdued. The “hammering” of every case of acute pneumonia in my wards is followed by the rapid recovery of the patient. Even phthisis — that formerly hopeless disease — is now much disarmed of its terror. Besides, in the system of teaching I am advocating, the professor is always present to check any unnecessary trouble or incon- vience that might be given to the patient ; and in all acute cases, such as of fever or acute inflammations, no examinations not absolutely re- quired are allowed. The plan of clinical instruction which has been proposed as “ prefer- able and as worthy of general adoption” is as follows — viz., “ to bring the cases one by one into a room where the students are comfortably seated, and if the patients have not been seen previously by the surgeon so much the better. Then ascertain the seat and nature of their com- plaints, and point out the distinctive characters. Having done this so that every one present knows distinctly the case under consideration, the teacher, either in the presence or absence of the patient, according to circumstances, proceeds to explain the principles of treatment, with his reasons for choosing the method preferred, and, lastly, does what is re- quisite in the presence of his pupils.” Without denying, as before stated, that a large amount of instruction may thus be communicated, I still venture to doubt whether those who are taught in this way will ever be enabled to grapple with the realities of practice. I remember, when myself a surgical student in this infir- mary, looking at the brilliant operations of Messrs. Liston, Syme, Lizars, and Fergusson. Legs and arms flew off with the rapidity of lightning, as if by magic; and what the bewildered student mainly occupied him- self with was his watch, to determine in how many seconds the opera- tion was completed. But as to performing such an operation him- self, the thing was never thought of nor inquired into. Further, if it be “ shocking ” to examine medical patients physically in their own beds, what term ought to be applied to dragging persons with fractures, dislocations, wounds, and sores from their beds, into a room where the students are comfortably seated ? Indeed, it is easy tp understand how those who receive instruction in a practical art after this fashion — who seldom visit the wards or follow the progress of disease there, and who only see just so much of a case as the teacher places before them in the manner above-mentioned — must be very liable to present those appear- ances so well described by Dr. Parkes, when subjected to a practical ex- amination.* * See report oi Speech made to the Medical Council April 80th, 1864, in all the weekly journals. He contended that the medical corporations were admitting men 12 INTRODUCTION. The only method of giving a stimulus to the practical education of students in the hospital wards is to institute practical examinations for their diplomas or licenses. Those, however, who are opposed to practi- cal teaching, and in favor of the comfortable looking-on system, are, as a matter of course, opposed to practical examinations. The institu- tion of the latter would necessarily cause the breaking down of the former. The truth is, there is no difficulty either in the one or the other. I have found a large class no impediment. On the contrary, it adds interest to the proceedings ; and as I have never yet had to com- plain of want of decorum or absence of gentlemanly conduct on the part of my students, so I have no fear for the future. The Commis- sioners for the Universities of Scotland have enacted that the examina- tions in Medicine and Surgery shall be conducted “ in part by clini- cal demonstrations in the hospital.” The regulation comes into opera- tion this session (1864-05), and will, I trust, be the means of inciting you to that kind of study which, you may depend upon it, is, after all, the one best qualified to fit you for the responsible duties of the medi- cal profession. I am satisfied that you will not cultivate practical medicine very long iu this way without noticing a fact, which is every year becoming more and more evident — viz., that the art has of late years been under- going a great revolution. It is daily becoming apparent to those who observe in a spirit of sincerity and of truth, that much of the practice of our profession, which has resulted from what is called experience, is altogether incompatible with the existing state of our knowledge — that in consequence it requires a thorough revision — that the systems and nosologies of our forefathers, though useful in their day, no longer apply — and that a new field of labor is now open to the cultivation of those zealous clinical students who are anxious to identity themselves with the progress of medicine. It cannot fail to strike all those who have paid any attention to modern medical education, that whilst physiology and pathology have been making rapid advances, our previous impressions of the action of drugs, and of various modes of treatment, have become altogether changed. Whilst we were ignorant of the structure and functions of an organ or tissue, so long as we confounded together causes and results, so long we were especially apt to be led astray by tentative efforts at cure. But once that we have established on indisputable data v*4iat is really fact — what is the true law governing the progress of a disease — in how many instances does it then become evident that the means employed for its removal are feeble or altogether inert ? This has now occurred so extensively — systematic works on medicine are so at vari- ance with books on physiology and pathology — the practice of the pro- who could not practise with safety ; and as long as this was the case, so long must the army medical department examine for itself. Further, “ In regard to the general question of examination, he could not consider the present system satisfactory, Avhen it allowed men to obtain licenses who could not make a chemical examination of water, or who did not know the skeleton, or who could not put up a fractured limb or pass a catheter.” POLITICAL STATE OF THE MEDICAL PKOFESSION. 13 fession is so discordant with its theory — that many intellectual inquirers among us take refuge in a universal scepticism as to the action of drugs, leave everything to nature, and merely adopt what is called in France an expectant treatment, and in Germany the practice of “ Nihilismus.” Nay, it has been even Contended that our remedies, so far from doing good, in many instances do positive injury, and that it is safer to trust to nature than to the physician. The only method of escape from this state of things, it appears to me, is by an earnest effort on the part of those who sincerely desire the improvement of our art, to establish the science of medicine upon some- thing like a solid foundation. Let us, at all events, endeavor to realise our position, and to separate what is known from what is unknown. Among the known, let us determine what we have derived from scientific generalization, and what from blind experience ; and in the vast field of the unknown, let us, if possible, agree as to the direction and manner in which we ought to work, in order to explore its extent and contract its boundaries. The propriety of this procedure is admitted. Why, then, is it not carried out ? — why cannot we co-operate in the resolve to prosecute our noble profession with a simple desire to advance it towards its true end — the cure of disease ? I will answer these questions by endeavor- ing to show what are, as I think, the circumstances which, at the outset of every honest attempt, discourage our endeavors to improve medical practice. They seem to me to be connected, as far as this country is concerned — 1st, With the political; i^d, With the social; and 3d, With the practical status of our profession. On each of these subjects a vol- ume might be written, but I shall endeavor to place their leading as- pects before you in a few words. The Political State of the Medical Profession. When we regard all the other professions and pursuits of life in this great country, we find there are none of them, except medicine, whose cultivators are excluded from the high offices of state, or forbidden to aspire to any rank below that of royalty. The eminent lawyer or divine — the successful admiral or general — the popular author — or the heads of our great commercial houses, may become peers of the realm, are commonly seen taking an active part in the Legislature, and frequently receive reward or distinction, conferred upon them by a nation grateful for their services. It is a fact well calculated to excite astonishment, that a class of men who have dedicated themselves to the well-being of the public health should be comparatively neglected. In this respect we suffer with men of science in general, who, however much they may be respected individually, are but slightly encouraged by the state. The hackneyed phrase of our legislators with regard to all men of science, including medical men, is, in the words of Sir Kobert Peel, that “ science is its own reward; ” or in the words of the Duke of Argyle, “ that in the main it must depend for its advancement on its own inexhaustible attractions, and on the delight which it affords us to study the constitu- 14 IXTEODUCTION. tion of tlie world around us.” But in every civilised country except Great Britain it has been thought a matter of good policy to encourage, by marks of honor, those who, by their scientific labors, have contri- buted to the public weal. The French reproach the profession in this country for having achieved for itself no adequate honor or reputation. It has been said that “ in France, during the last half century, there is no council-board, no administration, no society, in which the medical profession has not found itself represented, whether at the court of the sovereign, or among the peerage, or in the legislature. Physicians of the Institute take their place naturally among the first of the land. Their views, their discoveries, their cures, their professional ideas and sugges- tions, must be listened to, cannot be neglected, and may never be treated as intrusion; nor had Napoleon fewer physicians and surgeons for friends, councillors, and dignitaries of state, than he had of any other profession. But in England all such interests find themselves either misrepresented, or not represented worthily ; and the best of their physicians is good only to amass money, or at the highest, get a baronetcy.” — (Examiner.)'^ All this, gentlemen, would be of little importance, did it not, as I shall point out immediately, greatly afiPect our social position, and through it lower the true objects for which medicine ought to be cultivated. Much of the evil arises from the fact, that the medical profession in this country possesses no national organization. Unlike the other pro- fessions, so far from there being a bond of union among its members they are irreconcilably divided by chartered medical institutions. These amount to about thirty in number, each having different powers conferred upon them by past sovereigns or governments, and an interest in ag- grandising itself at the expense of its neighbors. These various insti- tutions, though they were all established professedly to support the hon- or and dignity of medicine and its cultivators, are so discrepant in pow- er, and so conflicting in interest, that they have led to little but confu- sion and disunion among the members of the profession at large. Such, of late years, have been the clashing interests, the conflicting privileges, the injuries inflicted on the student and on medical education, the discreditable prosecutions in our courts of law of well-educated medical men, whilst the ignorant pretender is allowed to escape, and a host of other evils, that a universal cry has been raised for what is called medical reform — that is, a re-arrangement of the affairs of the profession by an Act of the legislature. It would be curious to analyse the different measures which have been proposed for this purpose. But it was to be anticipated that our medical corporations would look after their own in- terests — oppose everything that encroached upon them — and in cases where there existed few or no privileges, that efforts would be made to obtain them, even at the expense of sister institutions. * As a public manifestation of this state of things, I may refer to the fact that, in 1858, I witnessed with pride and gratification the statue of Jenner placed in Tra- falgar Scpiare, London, in the presence of Prince Albert, Lord Lansdowne, and other distinguished men. But I have never seen it since, as, on my next visit to the me- tropolis, it had been removed to some obscure corner — fur removed from monuments to the other great men of the country. POLITICAL STATE OF THE MEDICAL PROFESSION. 15 At length, however (1858), an Act passed the Legislature which abolished the territorial privileges of the corporations, and permitted every medical man to practise, according to his qualification or qualifica- tions, throughout the kingdom. It empowered a Council to be formed of delegates from the various universities and corporations — a sort of medical parliament — which was to settle the details of all vexed ques- tions. It ordered the preparation and publication of a Register of legally qualified practitioners, and of a national Pharmacopoeia ; and provided that the licentiates and fellows of a college in one part of the country, who might desire to join another in a different part of it, might do so on the payment of a small sum (£2). In this manner the evils resulting from local privileges and jurisdiction were to a great extent removed. Other disputed points as to the natare of qualifications, what should constitute a national and uniform medical education, instead of the vexatious curricula of so many medical boards, and a variety of im- portant but minor considerations, were to be determined by this Medi- cal Council. Since the Act has become law, a Register of qualified practitioners, for the information of the public, and h.aving absolute authority in courts of law, and a national Pharmacopoeia, have been published ; but as to the other points we have still to wait for further deliberations of the Council. While these efforts to regulate the medical profession, or what has been called Medical Reform, were proceeding, other attempts were being made to extend and improve the advantages of our national Universities, or what has been called University Reform. It became generally felt that the system sanctioned by long usage in these ancient institutions required modification to meet the altered demands of the times ; that the great end of all education was not to acquire abstract learning or science, but to render knowledge useful in life ; and that the value of that education ought to be tested by its fitness to prepare men for the various professions and administrative offices of the country. It was maintained that a university education, therefore, should make not merely a learned man, but also a practical man, and that academical de- grees should not be regarded only as marks of honor — to be crowned, as in the Olympian games, with chaplets of barren leaves — but should be considered as proofs of proficiency, and rewarded with branches on which, like those from the garden of the Hesperides, we might look for golden fruit. In short, the spirit of our time, and the most obvious good policy, pointed to the support and extension of the Universities as the true source of professional knowledge for the youth of our country. It is there that intimacies are formed between men of different classes and professions; it is there that the narrow tone of mind, fostered by mere professional schools, is counteracted ; it is there that the associated students learn the value of general information and enlarged ideas when brought to bear upon distinct pursuits ; and it is there that the preju- dices of caste and of corporate exclusiveness are merged in the catholic desire to render education as general as possible for the good of the country at large. Great changes, in consequence, have been gradually made in the government and regulations of the English and Irish Universities. A new University was established in London, a second in IG INTRODUCTION. Durham, and another with three colleges in different cities of Ireland, each having a complete medical faculty. And, lastly, the Scottish Unh versities have been made the subject of an Act of Parliament, whereby, as you are aware, this University obtained a new constitution, which is now in full operation, and which gives students, graduates, and profes- sors a share in its government. It would be evidently premature to speak of w'hat is likely to be the result of all this legislation with regard to the welfare of the medi- cal profession. But already events have taken place with which, as ma- terially influencing your future position, you should be acquainted. The Medical Act provides that two or more corporations may unite for the purpose of constituting one examining board, and thereby securing at once an efficient examination in two or more of their especial depart- ments — the successful candidate receiving the licenses of the different corporations who so unite. This plan, if conscientiously carried out, cannot but be of the greatest service, and, without depriving these bodies of their privileges, abolishes one of the great evils to which I have pre- viously alluded. Thus in England, a union of the Colleges of Physicians and Surgeons would enable those distinguished bodies to appoint able physicians and surgeons in every way qualified to carry out the important duties of examiners, and what seem to be the purposes of the Act. Such would appear to be the reason why the English Poor- law and Army Medical Boards insisted that their medical officers, who are required to practice both medicine and surgery, should possess what is called the double qualification. In other words, they demand to be satisfied that such candidates have been carefully examined in medicine by physicians, and in surgery by surgeons, which is obviously the only way of ensuring that the examination has been a hona fide one. But in Scotland, the fellows of the E-oyal Colleges of Physicians and Surgeons are, with few exceptions, parties who practise both branches of the art, and are what is called in the profession general practitioners. There is, in truth, little distinction between the one college and the Other ; so that, in forming a joint board, unless the few physicians on the one side, and the few surgeons on the other, constituted that board, there would be no guarantee of a thorough medical and surgical exami- nation, as would occur in the case I have supposed of the London Colleges. Instead of different elements being united to make a perfect whole, similar elements are brought together from the two institutions, neither medicine nor surgery being properly represented at all as dis- tinct professions. Such a plan does not fulM the object of the Medical Act, nor meet the requirements of the Poor-law and Army Medical Boards. While these powers were given by the Medical Act to the numerous corporations, the ancient large privileges granted to the Universities were confirmed. The Universities can now grant the degrees of Doctor, Bachelor, or Licentiate of Medicine, and Master of Surgery ; and their graduates, on presenting their diplomas, are enrolled in the G-eneral Register of Medical Practitioners, and are empowered to practise both in medicine and surgery, as has been the practice immemorially among the great Continental Universities. There can be no doubt that the adoption POLITICAL STATE OF THE MEDICAL PROFESSION. 17 of this course generally would be of great advantage to the public and to the profession at large. It would not only elevate the status of sur- geons, by conferring upon them academical rank, but would constitute another means of getting rid of those corporate distinctions which have created so much jealousy among medical men. The necessity of extending the preliminary studies has met with the concurrence of all parties. The conviction has gained ground, that he who wishes to understand the phenomena of the animal economy must approach them by the way of a logical and physical, as well as by that of a classical education. In future, therefore, no one can enter upon the study of medicine until his knowledge in lite- rature and arts has been more satisfactorily tested than it was former- ly. The regulations on this head, it is hoped, will tend to enlarge the attainments of medical students, and produce a favorable reaction on medicine itself. I must not overlook the circumstance, that it has already become necessary to repeal an important clause in the Medical Act, in conse- quence of an occurrence which was not anticipated. This consisted in the Royal College of Physicians of Edinburgh selling its licenses to the surgeons, apothecaries, and druggists of England, without examinaticn,. for the sum of £10 ; while many of the purchasers, to the astonishment of the profession, assumed in consequence the university title of Doctor of Medicine, which the College in question had taken no steps to prevent. I shall not venture to state any opinion of my own as to this unfortunate transaction, but give you that of an eminent physician, himself a Fellow of the College he complains of, and who spoke as follows when President of the British Medical Association : “ It is to be hoped,’’ he says, “ that the self-respect of our profession will deter its members from supporting this sale of medical indulgences, and so, by rendering the English traffic less lucrative than was anticipated, lead its promoters to remember the purpose for which their College was established. A distinction in letters, whether in medicine, law, or divinity, which may be obtained by merely paying down a few pounds, is worth precisely what it costs ; it proves pecuniary ability, nothing more. The initials of physician by purchase would correctly intimate the estimation in which the possessor of such a distinction will be held by every one but himself. There is a want of more of acknowledged authority in our profession, and not of less. And although colleges may have but little power to create this, they are not, as in this instance, without the power to lessen that which exists. I feel personally,” continues Dr. Radcliffe Hall, “ that faith is not kept with those who formerly considered it creditable to be connec- ted with the Edinburgh College of Physicians; and that, in bare jus- tice, every Fellow ought to have a vote in deciding whether or not so radical a degradation of his College should take place. Surely there is great defect in the constitution of the Medical Council of Great Britain if it cannot interfere to prevent so grave an abuse of vested authority as this.”* ^Address to the South-Western Branch of the British Medical Association. Brit, Med. Jour.^ July 9, 1859. 18 INTRODUCTION. Gentlemen, the Medical Council did interfere, and insisted on a med- ical examination ; but how far this was rendered stringent we will not inquire. No less than 356 candidates passed this so-called ex- amination between the 29th March and 20th April of 1860 ; and during twelve months, nearly 1000 persons altogether obtained the license. The result has been, that the London College of Physicians, having first remonstrated in vain, properly refused to admit this flood of licentiates to its own body on the conditions provided by the Act; and the clause which enabled a medical man on changing his residence to join a sister college at a nominal charge, has been repealed in a short bill, which, under the circumstances, all parties admit to be necessary. Thus, not only has the status of physic and physicians been lowered in ^Scotland by the institution expressly founded to elevate both, but all fellows and licentiates of every college in the kingdom have, by dts conduct, been excluded from an important reciprocal privilege, which had been long struggled for, and which was actually conferred upon them by the Legislature. As young graduates, you will naturally feel indignant that the title of Doctor should be usurped by parties who have no claim to it. Such, however, is the difficulty of legislating on this matter, and so indiscrimi- nate the manner in which the highest medical title is given by the public, that I have no other advice to offer you than this, — viz , that on all proper occasions you should at least do yourselves the justice of pointing out the distinction (not apparently understood in England and abroad) be- tween the College of Physicians and the LLiiversity of this city. I sin- cerely trust that the Loyal College before long may see it to be consist- ent with its honor to repudiate an act which has been so universally con- demned by the profession at large. Such then, is the actual political condition of the profession into which you are about to enter. Let us hope that, as the Medical and Scotch Universities Acts are brought into operation, the cause of medical education, and the improvement of the schools, will advance. Among these, that of Edinburgh has hitherto occupied a pioud position; and great indeed will be the responsibility of those who, with the pow'er of supporting and increasing her influence, are induced to cripple her re- sources and impede her usefulness in the vain hope of reconciling inter- ests and satisfying institutions which are essentially antagonistic. What W'e require is a legislation which, instead of maintaining a system of rival institutions and opposing schools, perpetuatir g disunion and re- tarding the cause of scientific progress among us, will draw these dis- cordant elements together, for the purpose of co-operation and mutual support. Nor is this impracticable, as such a constitution exists in most Continental nations, and has been found to work admirably. To this end the various universities and corporations, instead of independent and •contradictory action, should be empowered to carry out one system of education and privilege in the three divisions of the kingdom, subordi- nate to a uniform direction. Instead of numerous schools acting as rivals to and injuring one another, a machinery ought to be devised by which the talent now diffused and wasted should be concentrated under THE SOCIAL STATE OF THE MEDICAL PROFESSIOJ5". 19 a wise administration, so as to strengthen instead of weaken our national Universities. In this manner the strongest stimulus would be given to successful exertion, while ability and scientific merit might hope to meet sometliing like adequate reward. Gentlemen, believing that the interests of medicine as a science, its dignity as a profession, and its usefulness to the community, are inti- m itely associated with the manner in which public bodies carry out the spirit of their foundation statutes and charters, you will not, I trust, re- gard my having directed your attention to this important subject as un- necessary or inopportune. To explain fully the numerous intricacies of this perplexed matter time would not permit. I shall be satisfied if, on reflection, my remarks shall have led you to see the incongruity in a science like medicine, which is one and indivisible, of its cultivators being constantly opposed to one another on account of corporate distinc- tions and animosities. I would earnestly urge you to labor in the cause of union — which, proverbially, is strength — as the only method of placing the profession of medicine in a dignified position with regard to the State on the one hand, and the public on the other, and thus furthering the beneficent object for which it is cultivated. The Social State of the Medical Profession. The evils resulting from the political condition of the medical pro- fession have led to still greater ones in its social state. In consequence of the complete absence of public positions, with emoluments sufficient to satisfy the reasonable desire and ambition of scientific men — as the most skilful physician, or most successful discoverer, does not, in conse- quence, receive any dignity or honor from the State — and as the offices of our medical corporations as they are at present managed are utterly incapable of supplying the deficiency — it follows that the only prize open to the aspiring and ambitious is the wealth to be derived from an enormous practice. If, indeed, there were any necessary relation between the popularity of a physician and his real professional merit, we might recognise this as, so far, a reward and encouragement. But it is notorious that this is not the case, and that in many instances large practices are acquired by the most unblushing charlatanism. St. John Long was supposed to have received about twelve thousand pounds a year for pretending to cure consumption by rubbing an escharotic liniment into the chest, and when at length he was tried for the manslaughter of Miss Cashin, evidence in his favor was given by half the aristocracy of the metropo- lis. In all ages, indeed, the successful pretender has succeeded in col- lecting more gold than could be accomplished by honorable members of the profession ; formerly, however, the imposture was manifest, and car- ried its own shame with it. But the bane of the profession at this mo- ment is the existence of a class of medical practioners who, in arduous competition with their fellows, and pressed, perhaps, by the necessity, if not the desire, of making money, have come to the conclusion, that what they really know and can perform professionally is of much less 20 INTEODUCTION. consequence than what the public gives them credit for. The ultimate influence of this state of things on their own morals, and on the welfare of the profession, must be obvious. But let us suppose that a really able man, after years of toil and anxiety, at length reaches the full career of a metropolitan practice. Is this, after all, a suitable reward for his labors? Is this position really a desirable one, with regard to its results either on his own mind or on the honor and higher interests of his profession ? On this head I pre- fer reading the statement of another. “ Many years’ attention to all subjects affecting the profession of physic,” says an anonymous writer, “ has led us to the conclusion that large practices, the only prizes which the profession offers at present to its members, are in many ways its bane. By them the high scientific tone of the profession is depressed; its independence sunk ; a low standard of effort is fostered ; the indi- vidual who succeeds is rendered worthless ; the public cheated ; false practice authorised ; quackery promoted ; and sterling merit often de- prived of its just reward.”* The same writer goes on to observe that occasionally also, this ex- cessive practice leads to such a love of money, or desire to be thought important, distinguished, or influential, that in order to obtain it, the proper etiquette of the profession is abandoned, and every feeling of gentlemanly propriety and honor is first blunted, then destroyed. The great position a person of this kind fancies he has attained leads him to overlook the interests and just claims of his fellow-practitioners, and to tempt away their patients, who, after all, among the crowd of those he attends, are often sadly neglected. By watching the progress, and mingling in the society of certain men of this class, the professional mind is in danger of being rendered unsound, and actuated more by a desire of attaining what is conventionally received as “ success in life” — which simply means the obtaining of a large income — than by the higher incentive of public usefulness. The Present State of Practical Medicine. If the political state of the medical profession leads to the deteriora- tion of the social one, so does the latter lead to the greatest confusion in, and distrust of, the power of cure. What, indeed, is to be expected of men whose highest aim and boast are to have a large practice ? Are the statements of their wonderful cures, of their practical knowledge, and the success of remedies in their hands, and so on, to be trusted statements which, for the most part, so far from promoting, tend only to retard and obstruct the advancement of the medical art ? On the other hand, those of this class who act conscientiously (and many such, to the honor of medicine, exist) are too busy in the active duties of their call- ing, and have too little time to follow the rapid progress of the science. Hence, what they have acquired by long experience is seldom seen by * Azygos on Medical Reform, London, 1853. The author of this pamphlet will see that I have adopted some of his arguments and a little of his phraseology. PRESENT STATE OF PRACTICAL MEDICINE. 21 them to harmonise (though truth in practice always must in the end har- monise) with truth in theory. Although twenty-four years have elapsed since the cell doctrine of growth has been admitted into physiology and pathology, medical men have not yet realised to themselves its vast importance in a practical point of view. The morbid processes of inflammation, of tuberculiza- tion, and of various morbid growths, are now for the most part elucidated by this theory. But a cell pathology is no more universally applicable to the phenouiena of disease than is humoralism or solidism. Indeed, we may more correctly speak of a molecular pathology, for a molecule, and not a cell, is the first and last form of organisation. What, however, it is important to remember here is, that if there be a molecular or a cell physiology and pathology, so there is a molecular and a cell therapeutics. For it is evident that those diseases which depend on an increase or di- minution of molecules and cells can only be reached scientifically through a knowledge of those laws which govern their evolution and disinte- gration. Thus, growth (that is, the multiplication of cells) is favored by in- creased warmth, by room for expansion, and by moisture ; and it is checked by cold, by pressure, and by dryness. If, then, an exudation be poured out and coagulated near the surf^ace, as it can only disappear by its passing through the stages of cell growth, we favor suppuration — that is, the growth of pus-cells — by warm poultices or fomentations, and re- tard it by cold and pressure. Pneumonia consists of an exudation into the vesicles and tissues of the lung, which coagulates and excludes the air. It is very doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the inflamed part, or the congested capillaries in its neighbor- hood; that it can directly affect the coagulated exudation is impossible. But by lowering the strength and vital power of the individual, venesec- tion is directly opposed to the necessary vital changes which the exuda- tion must undergo in order to be removed by cell growth and disintegra- tion. Hence it is, in my opinion, that the mortality from pneumonia has diminished since large bleedings have been abandoned, and not because, as has been suggested by an eminent authority, inflammations, like fevers, have changed their types since the days of Cullen and Gregory. The absorption of a pleuritic effusion depends on the formation of new blood-vessels in the coagulated exudation which is adherent to the pleurae. These in their turn are the results of cell formation. Such formation so far from being encouraged, can only be retarded or pre- vented by large bleedings and antiphlogistics. The growth of tumors may be encouraged or retarded by the same means which influence all other kinds of cell development. But if they assume a parasitic character, as in cancerous growths — that is, if the cells possess a power of multiplication in themselves — then the only chance of cure is in their complete destruction or extirpation. But the surgeon who trusts to his naked sight, forgets that germs are infiltrated among the surrounding tissues, and are so minute that he cannot see them ; yet he employs no microscope to discover them. He cuts out a tumor, but only cuts through the disease. Need we wonder, therefore, that cancer 22 INTRODUCTION. should frequently return, or rather continue to grow, when in fact it had never been removed ? Our improved knowledge with regard to parasites, both animal and vegetable, illustrates the flood of light which the cultivation of natural science has thrown upon diseases, the pathology of which was formerly unknown. It has now been shown that an animal may live as a cystic worm in one animal — say a mouse, and as a tapeworm in another — say a cat ; and that to prevent the appearance of the last parasite, we must not allow the former one to enter the digestive organs as food. In like manner, the demonstration that favus, pityriasis, diphtheria, pyrosis, and other disorders are connected with the growth of vege- table organisms, has completely revolutionised the treatment of those affections. The beneficial changes which have taken place in our treatment of apoplexy, syphilis, small pox, phthisis, Bright’s disease, and many other diseases, might in like manner be shown either io have originated from or to be capable of being satisfactorily explained by an advanced know- ledge of physiology. Again, notwithstanding the universality with which the stethoscope and auscultation are now received as necessary means of diagnosis, how few of our medical men, comparatively, are really skilful in detecting by them the morbid changes going on in the heart and lungs. The stetho- scope, indeed, was as much sneered at when it was first introduced as was the microscope. Physicians existed who taught that a piece of stick was not likely to make us discern what was going on in the lungs, and who cautioned students against losing their time in learning auscultation, just as some now do in reference to histology. But the philosophic practitioner must see the necessity of using every means in his power for detecting disease, whether stethoscopical, microscopical, or chemical. I cannot too strongly advise you not to be influenced by the opinion of those who, educated before these means of research came into general use, speak of them as worthless, especially in the investigation and diag- nosis of disease. It is because they are ignorant of their value that they hold them out as of little benefit. I need scarcely remark that this kind of reasoning is altogether unsound, and is directly opposed to the intro- duction of all improvement in either science or art. What should we think of a modern astronomer who sneered at telescopes, and boasted that it was enough for him to examine the heavens with his naked eye ? or how should we like to trust ourselves at sea with the navigator who, as in ancient times, steered by the sun and stars, and who abused sextants and other instruments by which alone exact calculations can be made of his course ? Such, however, is precisely what those medical men do who underrate stethoscopes and microscopes, betraying an unacquaintance with the present state of their own art. At all events, in this Clinic, you will find that we seize eagerly on every means that science places in our hands for detecting the true nature of disease; that percussion, auscultation, histology, and chemistry are all pressed into our service ; that, whilst we spare no pains to make ourselves masters of observation, cultivate our senses to the utmost, study PRESENT STATE OF PRACTICAL MEDICINE. 23 symptoms, and thus endeavor to unite the knowledge of the present day with the experience of the past ; we never forget that the Medical Art is founded on science, the only guarantee of its elevated and ennobling character, and the only secure means for its future advancement. What, then, is required, in the present condition of medicine, is an attempt to bring our advanced knowledge of physiology and pathology to bear upon the treatment of disease, and by renewed observation, with all the aids which modern diagnosis gives us, to reinvestigate the action of our more important remedies. In so doing, we should not neglect past experience, but endeavor to make the truths it has taught us har- monise with scientific laws. So far from believing in the propriety of a pure expectant system or a “ Nihilismus,” I am convinced that experience has furnished us with some most precious results. No one can doubt, for instance, that quinine cures ague, and that lemon-juice cures scurvy. Why they do so we are ignorant ; and hence those remedies are given empirically — that is, as a result of blind experience. It has also been distinctly shown that sulphur ointment cures scabies. But here, I think, false reasoning has stepped in, and declared sulphur to be as much a specific for scabies as quinine is for ague. But scabies depends upon the presence of insects which lay their eggs in the skin ; and the greasy matter of the ointment is brought, by means of friction, into contact with, and asphyxiates them, just as well without as with sulphur. But to dis- cover these insects, and to determine their habits, patient and long-con- tinued scientific research was necessary, and practice now reaps the bene- fit of it. It is true that the contradictory opinions concerning medical doctrine and practice have, in all times, excited the ridicule of the weak-minded, and still constitute the ground on which Medicine is attacked by the ignorant and superficial. Yet the differences which exist no more prove that there is no foundation for Medicine as a science, than the varieties of religious sects show that there is no truth in religion, or than the opposing dicisions of our courts of law prove jurisprudence to be a farce. All these contradictions depend upon imperfect attempts at cor- rect theory ; and this latter once rendered perfect, it will be seen that both health and disease are governed by laws as determinate as the motion of the planets and the currents of the ocean. But notwithstanding the discouragements which knowledge has re- ceived and will ever suffer from the indolent or narrow-minded, at no period has the tendency to cultivate scientific medicine been more strongly manifested than it is at this moment. Everywhere in Europe do we observe a noble effort to enlarge the foundations on which its practice is based. Everywhere we see Natural Philosophy advancing; enthusiastic chemists pushing forward organic analyses ; anatomists unwearied in their researches concerning development and the structure of tissues; physiologists experimenting and concentrating all the re- sources of modern science in order to elucidate organic laws ; and patho- logists busy in connecting the symptoms observed in the living, with alterations in the minutest tissues and atoms of the dead. At this time Medicine is undergoing a great revolution, and to you gentlemen, to the 24 INTRODUCTION. rising goneration, do we look as to the agents who will accomplish it. Amidst the wreck of ancient systems, and the approaching downfall of empirical practice, you will, I trust, adhere to that plan of medical education which is based on Anatomy and Physiology. If you resolve to follow in the legitimate path of improvement to which all reason and experience invite you, be assured that the toil of mastering what is no»w known of correct generalization will not be in vain. Everything pro- mises that before long a law of true harmony will be formed out of the discordant materials which surround us ; and if we^ your predecessors, have failed, to you^ I trust, will belong the honor of building up a system of Medicine which, from its consistency, simplicity, and truth, may, at the same time, attract the confidence of the public, and command the respect of the scientific world. SECTION I EXAMINATION OF THE PATIENT. It is absolutely necessary that an examination of patients at the bed-side should be conducted with order, and according to a well-understood plan. I have observed that some students, on being called upon, in their turn, to interrogate a case, feel great embarrassment, and are unable to proceed. Others put their questions, as it were, at random without any apparent object, and wander from one system of the economy to another, vainly searching for a precise diagnosis, and a rational indication of cure. But continual practice, and the adoption of a certain method, will remove all difficulty. No doubt, questioning a patient, to arrive at a knowledge of his condition, requires as much skill in the medical practitioner, as ex- amining a witness does in counsel at the bar. They make it an especial study, and you must do so likewise. You should remember that, in proportion as this duty is performed well or ill, is the probability of your opinion of the case being correct or incorrect ; and not only will the re- putation you hold among your colleagues greatly depend on your ability in this matter, but the public also will promptly give its confidence to him whose interrogations reveal sagacity and talent. The method of examination difters greatly among practitioners, and must necessarily vary in particular cases. Men of experience gradually form a certain plan of their own, which enables them to arrive at their object more rapidly and securely than that adopted, with perhaps an equally good result, by others. In a clinical class, however, and in order that every one present may follow and understand what is going forward, the method adopted must be uniform. I hold it to be a matter of great importance, that every one standing round the bed should take an equal interest in what is proceeding, and this he cannot do unless he is fully aware of the manner and object of the examination. The plan which appears to me the best, and which we shall follow, is the one I learnt when myself a clinical student in the wards of Professor Rostan of Paris. Its object is to arrive, as quickly as possible, at a knowledge of the ex- isting condition of the patient, in a way that will insure the examiner that no important organ has been overlooked or has escaped notice. For this purpose, we search out, in the first instance, the organ principally affected, and ascertain the duration of the disease, by asking two questions, “ Where do you feel pain ? ” and, “ How long have you been ill ? ” Let us suppose that the patient feels pain in the cardiac region^ 26 EXAMIN'ATION OF THE PATIENT. we immediately proceed to examine the heart functionally and physically, and then the circulatory system generally. We next proceed to those organs which usually bear the nearest relation to the one principally affected — say, the respiratory organs — and we then examine the lungs functionally and physically. We subsequently interrogate the nervous, digestive, geuito-urinary, and integumentary systems. It is a matter of little importance in what order these are examined — the chief point is, not to neglect any of them. Lastly we inquire into the past history of the case, and thus we arrive at all the information necessary for the for- mation of a diagnosis. The following is the arrangement of symptoms and circumstances demanding attention under each of the seven heads into which the ex- amination is divided ; — I. Circulatory System — Heart. — Uneasiness or pain; its action and rhythm ; situation where the apex beats ; extent of dulness deter- mined by percussion ; its impulse ; murmurs — if abnormal, their character, and the position and direction in which they are heard loudest. Arterial pulse — Number of beats in a minute; large or small, strong or feeble, hard or soft, equal or unequal, regular or irregular, intermittent, con- fused, imperceptible, etc. If an aneurismal swelling exist, its situation, pulsations, symptoms, extent, and sounds, must be carefully examined. Venous pulse — If perceptible, observe position, force, etc. II. Respiratory System. — Hares. — Discharges; sneezing. Larynx and Trachea — Voice, natural or altered in quality, hoarse, difficulty of speech, aphonia, etc. ; if affected, observe condition of epiglottis, tonsils, and pharynx, by means of a spatula. Lungs — State of respiration ; easy or difficult, quick or slow, equal or unequal, labored, painful, spasmodic, dyspnoea, etc. ; odor of breath. Expectoration, trifling or profuse, easy or difficult ; its character, thin or inspissated, frothy, mucous, purulent or muco-purulent, rusty, bloody ; microscopical exami- nation. Haemoptysis, color, appearance, and amount of blood discharged. Cough, rare or frequent, short or long, painful or not, moist or dry. External form of the chest, unusually rounded or flattened, symmetrical or not, etc. Movements — regular, equal, their amount, etc. Resonance, as determined by percussion, increased or diminished, dulness, cracked- pot sound, etc. Sounds determined by auscultation, if abnormal, their character and position. III. Nervous System. — Brain — Intelligence — augmented, per- verted, or diminished ; cephalalgia ; hallucinations ; delirium, stupidity, monomania, idiocy ; sleep, dreams, vertigo, stupor, coma. Spinal cord and nerves — Pain in back ; general sensibility, increased, diminished, or absent; special sensibility — sight, hearing, smell, taste, touch, their increase, perversion, or diminution ; spinal irritation, as determined by percussion ; motion, natural or perverted, fatigue, pain on movement, gait; trembling, convulsions, contractions, rigidity, paralysis. IV. Digestive System. — Mouth — Lips, teeth, and gums; taste in the mouth, saliva. Tongue — Mode of protrusion, color, furred, coated, fissured, EXAMINATION OF THE PATIENT. 27 condition of papilloo, moist or dry. Fauces^ ionsils^ pharynx^ and oRsopha- gus — Deglutition — if impeded, examine the pharynx with a spatula ; the cervical glands, neck, etc. ; regurgitation. — Appetite, thirst, epigastric uneasiness or pain, swelling, nausea, vomiting, character of matters vomited, flatulence, eructations. Abdomen— measurement and palpation ; pain, distension or collapse, borborygmi, tumors, constipation, diarrhoea, character of dejections, haemorrhoids. Liver — Size, as determin- ed by percussion, pain, jaundice, results of palpation, 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, leucorrhoea, etc. If there be long-continued pain, or much leucorrhoeal discharge, examine os and cervix uteri with the finger, and, if necessary, with the speculum ; uterine or ovarian tumors ; pain in back ; difficulty in walking, or in defoecation ; functions of mammae. Kidney — Lumbar pain ; micturition ; quantity and quality of urine, color, specific gravity ; tube casts and precipitates, as determined by the microscope, and by chemical tests; ac- tion of heat; nitric acid, etc.; action on test papers ; stricture; discharges from urethra; spermatorrhoea; etc. (See use of Chemical Tests.) VI. Integumentary System. — General posture; external surface; color ; expression of countenance ; hue of lips ; obesity ; emaciation ; rough or smooth ; dry or moist ; perspiration ; marks or cicatrices ; eruptions (see diagnosis of skin diseases) ; temperature ; morbid growths or swelling; 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 ; kind of lodging, drainage, water, smells, etc. ; irregularities 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 — pre- vious 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 you that no very important circumstance has been overlooked. At first, in- deed, it may appear to you that such a minute examination is unneces- sary ; but we shall have abundant opportunities of proving that, whilst a little extra trouble never does harm, ignorance of a fact frequently leads to error. It is surprising, also, how rapidly one thoroughly con- versant with the plan, is able to examine a patient so as to satisfy him- self that all the organs and functions have been carefully interrogated. Remember that the importance of particular s3^mptoms 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 dis- cover them. 28 EXAMINATION OF THE PATIENT. In carrying out the examination, the following hints may be attended to ; 1. It should never be forgotten that you are examining a fellow- creature who possesses the same sensitiveness to pain, and the same feelings that you do, and that everything that can increase the one and wound the other should be most carefully avoided. Prudence, kindness, and delicacy, are especially enjoined upon those who treat the sick, and no levity ought to be tolerated among those who are determining the value and duration of life. 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 intelligence 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. Eostan 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 sufiiciently plain, it is often difficult to determine the period of com- mencement of many diseases. In acute inflammatory or febrile disorders, we generally count from the first rigor. In chronic affections, a length- ened 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 headache. These symptoms are commonly preceded by a period of indisposition, 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. 7. During the physical examination of a case, the temperature of the apartment should be considered, and the doors and windows shut, so that the patient be guarded against cold. For the same reason exposure of the surface should not be continued longer than is necessary. Silence must be maintained not only amongst those who surround the bed, but generally throughout the ward. When the patient is weak the physical examination should be shortened, or altogether suspended. 8. In endeavoring 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 alive to the possibility of imposition on the other. Sometimes, with all our endeavors, 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. 9. In forming our diagnosis — that is, in framing a theory deduced EXAMINATION OF THE PATIENT. 29 from tbe facts elicited by examination — we should be guided by all the circumstances of the case, and be very careful that these are fully known before we hazard an opinion. Even then it is not always possible to come to a satisfactory conclusion, and in such cases the diagnosis should be deferred until further observation has thrown new light upon the nature of the disease. 10. 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 healthy, 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 — when 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. 11. All mention of size should be according to its exact measurement in feet and inches. Situation is often referred 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 anato- mical 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. It is useless to speak of the pulse or of the respiration as being quick or slow, whereas by saying that the first is 60 or 120, and the second 12 or 40 in the minute, a correct statement is given at once. In recording cases, dates and references should always be stated in the day of the month, or still better, of the disease, and not in the day of the week. The authority formgny statements should be given ; such as, the patient, the nurse, or the friends, say, etc. 12. 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 a diseased heart we should speak of cardiac hypertrophy, or of insufiiciency of the mitral or aortic valves, etc. In a witness-box, before a jury, it is right to use the common familiar names of things, and instead of cranium to say skull, instead of axilla to say arm-pit, instead of abdomen to say belly, etc. There, the object is to instruct the uneducated ; here, the educated in medicine, while, at the same time, we avoid alarming or causing anxiety to the patient. 13. In prescribing for the patient, many circumstances should be taken into consideration, such as, the probable time of your next visit, the form in which medicine is most easily taken by the patient, his means, etc. The prescription should be written in Latin, and the quantities denoted by the usual pharmaceutical signs, but the directions for administration should be written in English. 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 30 EXAMIiJ^ATION OF THE PATIENT. which may occur in the signs and symptoms previously noticed, the effect 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 importance 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, has formed a leading feature of the Edinburgh system of clinical instruction, and constitutes the only trustworthy method of drawing up 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 demonstrated 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 m.n direct their attention to a certain class of diseases, and are apt to attribute too much importance to a particular lesion. It has frequently happened to me, when pathologist to the Boyal Infirmary, to observe, that after the physician has examined this or that organ, to which he has attributed the death of his patient, and left the theatre, that after examination, according to the routine I always practised, has revealed important lesions that were never suspected. Thus a person supposed to die of Bright’s disease of the kidney, may have a pneumonia that was latent and overlooked. Large caverns and tubercular deposits in the lungs may satisfy the physician, and he may leave the body when intense peritonitis may be subsequently found, arising from intestinal perforation. A man has hypertrophy, with valvular disease of the heart; he dies suddenly, and everything is referred to the cardiac lesion. On opening the head, an apoplectic extravasation or yellow softening may be discovered. I cannot too strongly, therefore, impress upon you the ne- cessity of always making a thorough post-mortem examination, and for this purpose you should, if possible, obtain permission to inspect the body and not any particular cavity. The object of a post-mortem examination is threefold : — 1st, The * I have arranged a note-book for taking cases, according to the system of exami- nation here recommended, which may be procured of Mr. Thin, medical book-seller, close to the Infirmary. EXA.MINATION OF THE PATIENT. 31 cause of deatli ; 2d, An appreciation of the signs and symptoms; 3d, 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 satisfied, 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 possibility of error, for how can any conscientious man form an opinion, that an abdominal disease has been fatal, if he be not satisfied by inspection that the chest and brain are healthy ? Again, it often occurs that a particular sign or symptom is unusual or mysterious, and this, if explained by the examination, is sufficient for 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 very earliest period that can be detected. Hence we must call in the micro- scope to our assistance, 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 gives 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 you will have in view in examining dead bodies. At all events, such are the views that I shall constantly endeavor 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. General aspect and condition of the body; peculiarities of person; marks on the surface ; sugillation ; amount of decomposition. In cases of suspected death by violence, great minuteness in the external examination is neces- sary. In unrecognised bodies the probable age, the color of the hair, and any peculiarity connected with the teeth, should be especially noticed. 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. III. Spinal Column. — Integuments over spine ; vertebrae ; men- inges; cord; nerves. IV. Neck. — Thyroid gland; larynx and its appendages ; trachma; tongue; tonsils; fauces; pharynx; oesophagus; large blood-vessels; nervous trunks ; cervical vertebrae. V. Chest. — Thymus gland ; position of thoracic viscera ; lining membrane of bronchi; bronchial glands; pleurae; contents of pleural cavity; parenchyma of lungs; do diseased portions sink in water? large thoracic veins; pericardium, its contents; general aspect and posi- tion of the heart; its weight; amount and condition of blood in its various cavities ; right auricle ; coronary veins ; auricular septum ; right 32 EXAMINATION OF THE PATIENT. 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 ; thoracic aorta, its structure and calibre. VI. Abdomen. — Peritoneum and peritoneal cavity; omentum; position of abdominal viscera ; omenta ; stomach ; duodenum ; small and large intestines ; liver, its weight, form, and structure — its artery veins, and ducts; gall 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, vagina; 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 portae, etc. ; congulated 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 : 1. As I have already said, the head, chest, and abdomen should always be examined, but the spinal cord and neck need not be disturbed unless the symptoms indicate some lesion there. In special cases, par- ticularly judicial ones, however, every part should be carefully inspected, and in them it may be further necessary to investigate a variety of cir- cumstances connected with the external or surgical lesion, such as frac- tures, wounds, and burns; injury to the large vessels; alterations of the organs of sense ; signs of maturity and viability in new-born children, etc. etc. 2. Great care should be taken never 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 invari- ably 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 contents, whether gaseous, fluid, mucous, bloody, faecal, or containing foreign substances, 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 justice 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 EXAMINATION OF THE PATIENT. 33 out the viscera, etc. Nothing is more painful 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, so that the surrounding parts are deluged with blood ; or the cardiac valves cut through, instead of being simply exposed ; or awkward incisions made into the intestines, whereby faeces escape ; slipping of ligatures, etc. etc. Coolness, method, knowledge of anatomy, and skilfulness in dissection, are as necessary when operating on the dead as on the living body. 5. In examinations made at private houses, it is not always necessary to remove the viscera. The heart, lungs, liver, kidneys, etc., may be readily examined in situ. But in this Infirmary, where every facility exists, the viscera are invariably taken out, and after describing the morbid 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 texture or product microscopically, until experience has made you perfectly familiar with its minute structure. 7. Notes of the examination should always be made at the time. The methodical report may be drawn up afterwards. 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, color, odor, position, etc. ; and avoid all theoretical language, such as its being inflamed, tubercular, cancerous, gangrenous, and the like, as well as such indefinite description as small and large, narrow and wide, increased or diminished, 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 chemical 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 necessary 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 *For an excellent guide to the examination of the dead body, I would recommend the practitioner and student to a work entitled, “ What to Observe,” published under the authority of the London Medical Society of Observation. 3 34 EXAMINATION OF THE PATIENT. surgical anatomy, is every day felt to be more necessary. I would earnestly therefore recommend the student of Clinical Medicine to study the excellent work of Dr. Sibson on Medical Anatomy, in which this sub- ject is admirably treated and illustrated. From his work I have borrowed the two accompanying figures, which exhibit at a glance the posifioii of the Fig. 1. Fig. 2. 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 vessels retract, an 1 the abdominal organs follow the diaphragm somewhat upwards.” — [Sibson.) The remarkable changes which occasionally occur in the natural position of the internal viscera may be judged of from a ease 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 faeces in the lower end Fig. 1. Superficial view of internal organs after removal of the thoracic and abdo- minal parietes. Fig. 2. Deep view. — (Sibson.) EXAMINATION OF THE PATIENT. 35 of the colon, at length produced enormous distension of the sigmoid flexure, the ascending portion of which measured thirteen, and the ' descending twenty-five inches in circumference. The spleen and dia- phragm were forced high up to the left side, compressing tlie lung and displacing all the neighboring organs, so that, on elevating the ster- num and removing the ribs after death, the appearances represented Fig. 3 were ex- hibited.'* In the case of Allan Brown, recorded under the head of Pleuritis, in a sub- sequent part of this work, another singular transposi- tion of viscera occurred. As the result of empyema of the left thoracic cavity ,the heart was forced over to the right side. From drinking effer- vescing lemonade shortly before death, the stomach was distended with gas, and caused to twist round par- F:g. 3. tially on itself at the cardia, so that nothing could escape. The distend- ed stomach was found to occupy nearly the whole of the abdomen, and air was forced between its coats, causing emphysema of the organ. 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 functional symptoms. But as these — being often only the sensations of the patient — may vary from hour to hour according to accidental circumstances, while the pathological lesions which occasion them remaiu 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 different lesions have the same symptoms ; and that, occasionally, most important and even fatal organic diseases have no symptoms at all. Cases of fatty heart, and atheromatous degeneration of the cerebral blood-vessels, often give rise to no symptoms whatever until death suddenly supervenes by * Monthly Journal of Medical Science, Dec. 1850, p. 494. Fig. 3. Remarkable displacement of organs, in consequence of intestinal obstruc- tion. a. Caput coli ; 6, ascending portion of sigmoid flexure ; c, descending portion ; i/, gravid uterus turned a little (ffwn. — {Easto7i.) 36 EXAMINATION OF THE PATIENT syncope or coma. Hence, whenever physical 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 thi& respect that medicine has made such great advancement during the present century. INSPECTION. Inspection of a part or of the whole surface of the body in various positions 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 counte- nance, of the thorax, of the abdomen, of the pharynx, of the larynx, and of the posterior nares. Inspeciion cf ilie general posture of the patient in repose and in motion is often highly diagnostic. Thus the position and attitude assumed by the body in cases of fever, in acute inflammations, in hemi- plegia or paraplegia, in hydrothorax and asthma, in colic or spasmodic diseases, and even in various forms of insanity, are very characteristic. The description of these, however, belongs to the consideration of indi- vidual diseases. As a general rule, the supine position denotes muscular debility — quick and forcible changes of position indicate excitement of the nei-vous 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 condition of the patient. A thorough knowledge of the indications so presented to the physician is only to be attained by long experience in the observa- tion 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 subcutaneous 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, in whom they are not under the control of the will. Inspection of the Chest . — This refers to the form and configuration of the entire thorax, or its various parts, and to a careful comparison of the two sides when at rest and when in motion. It is often difiicult, in cases where changes are not well marked, to determine them by mere BY INSPECTION. 37 inspection. To do so, a good light and 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 unsym metrical, from dis- tortions, congenital or acquired, in the bones of the vertebral column or of the thoracic wall?. Various portions of it may be expanded or bulge out, as in cases of empyema or thoracic tumors ; or it may be retracted and depressed, as occurs in chronic phthisis. A case presented itself to the late Dr. Spittal at the Royal Dispensary of this city, where the re- traction 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 prom- inence there was indicative of a tumor. The motions of the chest bear reference to inspiration and expiration,* which 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 abdominal. In disease these motions are altered in various ways — 1st, By general excess or diminu- tion, 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. Inspection 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 sym- metrically, as in dropsies, or partially, and irregularly, from ovarian, hepat- ic, splenic, and other tumors ; 2d, it may be retracted — generally, from ex- treme emaciation, or partially, from local intestinal obstruction. The su- perficial abdominal veins are sometimes greatly enlarged, and at others dis- tinct pulsations are visible, dependent on deep-seated cardiac or arterial disease. The abdomen, like the chest, is in constant movement in connec- tion with the act of respiration, being more prominent during inspiration. * “ 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 converge ; the upper cartilages form a more obtuse angle with the sternum, and the lower carti- lages 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 abdomen. 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 downwards, and that, consequently, viewed in relation to the ribs, the descent of the internal organs appears to be greater than it really is.” — {Sihson.') 38 EXAMINATION OF THE PATIENT and flattened during expiration. These respiratory movements of the ah' domen bear a certain relation to those of the chest, being often increased when the latter are arrested, and vice versa. Thus, in pleurisy, the re- spiratory movements are mostly abdominal, whereas in peritonitis, they are altogether thoracic. The variations observable in the disturbed rela- tions of the respiratory movements in the thorax and abdomen are often highly instructive, especially in cases of dyspnoea from hydrothorax, spasmodic asthma, anaemia, ascites, abdominal tumors, etc. Inspection of the Pharynx . — For this purpose a broad spatula firmly mounted in a handle at right angles is necessary to depress the tongue. Such spatulas are now easily procurable of diflerent forms in all surgical- instrument makers’ shops, the most convenient being those here figured, (Fig. 4). The greatest difference exists in various persons as to the freedom with which they can bear pressure on the dorsum of the tongue. In some that organ can be readly depressed, and the top of the epiglottis brought into view without causing any inconvenience. In others this cannot be done without exciting cough, or sensations of suffocation or sickness. In a few, the parts are so sensitive that the slightest touch induces spasms. These latter cases are rare, and reiterated efforts in the vast majority of instances, by educating the parts as it were to submit to interference, en- able the practitioner, after a shorter or longer time, easily to bring into view the tonsils, pillars of the fauces, uvula, back of the pharynx, and upper edge of the epiglottis. In this manner enlargement or ulcerations ot the tonsils or uvula can be readily seen, as well as the various morbid ulcerations of the mucous membrane. Among these, follicular pharyngitis Fig, 4. Spatulse for depressing the tongue — one-third the real size. Fig. '. Extreme case of follicular pharyngitis, shown by the tongue-depressor. — {After Horace Green.) Fig. 4. Fig, 5. BY INSPECTION. 39 is the most common, red circular swellings, in the form of split peas, being scattered more or less thickly over the surface. Occasionally these are aggregated together, as in the extreme case now figured (Fig. 5). Inspection of the Larynx — The idea of illuminating and rendering the larynx visible bj’^ means of a reflector has been more or less attempted by Liston, Warden,* Avery, Garcia, and others, but abandoned as impractica- ble in medicine, until successfully revived in recent times (1858-59) by Professor Czermak, of Pesth. For the examination of the larynx he employs, 1st, a perforated mirror, by means of which a powerful light is thrown from a lamp into the back of the mouth, and through which the operator gazes in the direct axis of the illuminating rays. This mirror may be attached to a bent stalk, the end of which can be held firmly by the teeth, but is far more conveniently attached to the framework of a pair of spectacles, or to a band passing around the head. 2d, A laryngeal - mirror of glass or steel, varying in size, attached to a stem at one of its corners, which having been previously warmed to prevent condensation of the breath upon it, is placed against the uvula, and reflects the image of the rima glottidis to the eye of the observer. The following directions are given by Czermak : — “ The person ex- amined places his hands upon his knees, the upper part of the body is advanced forwards, the neck bent onward, the nape slightly inclined backwards, the mouth widely open, the tongue flattened and held a little without. The observer is seated in front of the person to be examined; he places in his mouth the handle which supports the illuminating mirror, and looks through the central opening ; the laryngeal mirror, introduced into the back part of the mouth with the right hand is illuminated by the light which is projected from the illuminating mirror ; the left hand can be placed upon the shoulder of the person examined, and steadies the chin and the nape, or holds a tongue- depressor, which he can often trust to the patient himself. In the first place, the illumination of the back part of the mouth and the mutual position are regulated ; then the laryngoscope is heated, and its temperature regulated by the touch. After these pre- liminaries are gone through, we request the patient to open the mouth wide, and alternately to inspire deeply and to pronounce the sound ah ; during this we endeavor to place the back of the laryngoscope against the uvula and the velum palati, to sustain these parts a little, and to give the mirror a convenient inclination ; at times it is impossible to avoid touching the posterior wall of the pharynx ; the examination is directed by the image we thus obtain. In this way we commence each laryngoscopic ex- amination. Practice and reflection will bring each observer to compre- hend the modifications to which he ought to submit this proceeding, ac- cording to the special circumstance ; whether, for instance, he is in some degree to advance or to withdraw the laryngoscope, to bend it, to lower or to elevate it, to change the position and attitude of the individual un- dergoing examination, raise his chair, etc.” The method which I have found most convenient for examining the larynx with these instruments is seen in the accompanying diagram. When * Dr. Warden of Edinburgh distinctly showed the larynx in 1845 by means of a spatula and a reflecting prism invented for the purpose. — Edinburgh Monthly Journal of Medical Science, 1845, p. 552. 40 EXAMINATION OF THE PATIENT direct sunlight cannot be obtained — which is always the best method of illumination — a brilliant gas jet, the glare of which is screened from the eyes of the operator by a shade, answers very well This should be placed near the ear of the patient, on the side opposite to the eye employed of the observer, in order to diminish, as much as possible, the inclination of the reflector forwards. A brilliant light is absolutely essential, and is readily obtained by a globe of glass, six inches in diameter, filled with water, as recommended by Dr. Walker.* Instead of the tongue-depressor, the tongue may be drawn forward and held by its tip with the hand and a towel, and if the patient can do this himself the examination is facilitated. The appearances of the larynx when closed moderately and fully dilated, Fi^, 9. Fig. 10. as shown in himself or in others, are represented by Czermak in a state of * The Laryngoscope, 1864, p. 13. Fig. 6. Mode of using the laryngoscope and tongue-depressor. The light is ob- tained from a movable gas jet, the glare of which is screened from the observer by a shade mounted on a stand. BY INSPECTION. 41 health, in the accompanying figures. When widely dilated, and the neck straightened, the cartilaginous rings of the trachea and bifurcation of the bronchi have been made visible. These appearances are greatly modified in disease, when oedema, ulcerations, cicatrices, morbid growths, or irreg- ularities in the form of the glottis and mucous membrane, are readily detected, of which several interesting cases have already been published. Fig. 11. Fig. 12. Fig. 13. Fig 14. As the use of the laryngoscope extends these will of course become more numerous. The rendering ulcers and morbid growths visible by the laryngoscope, not only establishes an exact diagnosis, but permits of the direct application of means for their cure or removal. Fig. Y. View of the healthy larynx with the laryngoscope, when the vocal cords are closed as in sounding high notes. — {Czermak.) Fig. 8. Another view of the healthy larynx during ordinary breathing. — ( Czermak^ Fig. 9. Another view during deep inspiration, with the trachea straight, showing the glottis widely dilated, and through it the rings of the trachea and bifurcation of the bronchi. — {Czermak.) In the three last figures the numbers indicate the following parts : — 1, Base of the tongue ; 2, Posterior wall of the pharynx • 3, Entrance of the oesophagus, the line of demarcation between the wall of the pharynx and the posterior surface of the larynx ; 4, Epiglottis ■ 5, Arytenoid cartilages ; 6, Cushion of the epiglottis ; 7, Aryteno- epiglottic ligament ; 8, Tubercle corresponding to the cartilage of Wrisberg ; 9, Tuber- cles of the cartilages of Santorini ; 10, Tubercle which sometimes exists between the two preceding ; 11, Process of the arytenoid cartilages ; 12, Inferior vocal cords ; 13, Superior vocal cords ; 14, Ventricles of Morgan!; 15, Anterior wall of the trachea; 16, Posterior wall of the trachea ; 17, Right bronchus ; 18, Left bronchus. Fig. 10. Complete closure of the glottis as in the act of swallowing. — {Czermak.) Fig. 11. Transformation of the right (inferior) false vocal cord into a hard, rough, and ulcerated mass. — ( Czermak.) Fig. 12. Cicatrices and loss of substance of the larynx. — {Czermak.) Fig. 13. Polypus attached to the right vocal cord, the real cause of a supposed nervous aphonia. — ( Czermak.) Fig. 14. Large muriform polypus of an epithelial character. — {Czermak.) 42 EXAMINATION OF THE PATIENT Inspection of the Posterior Nares . — If instead of directing the mirror downwards, it be carried behind the uvula and directed upwards, a pos- terior view of the nares may be seen with the openings of the Eustachian canals. The laryngoscope then becomes a rhinoscope. In this case it may be necessary to draw the uvula forwards by a small blunt hook or bent spatula (Fig. 15, K). Here, as in the case of the larynx, morbid alterations, polypi, etc., can be seen and distinguished from a healthy state of the parts. Dr. Voltolini of Breslau has also pointed out the great advantage of this mode of exploration in the diagnosis and treatment of diseases of the ear. He recommends, instead of a spatula for depressing the tongue, a shield of gutta percha, a portion of which is raised up to Fig. 15. 1 — 6, section of the six upper cervical vertebrae; o, a section of the basilar process of the occipital bone ; a section of the body of the sphenoid bone and sinus ; y, a section of the crista galli of the ethmoid bone ; /, a section of the frontal bone and sinus ; w, os nasi of the left side ; m, the palate process of the superior maxillary bone separating the mouth from the nasal fossae ; v, the posterior or pharyngeal edge of the vomer ; d, the opening of the Eustachian tube ; pu\ a sec- tion of the soft palate and uvula, indicating the normal position of these parts ; the soft palate and uvula drawn forwards and upwards by the hook {K ) ; ph, the pharynx ; the tongue ; a section of the inferior maxillary bone ; A, a section of the hyoid bone ; c, X, a section of the epiglottis and larynx ; tr^ the trachea. The external wall of the left nasal fossa is indicated by dotted lines ; a, 6, c, the tur- binated bones ; x, x\ two different positions of the rhinoscopic mirror ; jcy, x'y\ two different directions of the light and sight. — {Czermak.) Fig. 16. Mirror and shield for depressing the tongue, useful in the examination of the posterior nares and orifices of the Eustachian tubes ; half the real size. — ( Voltolini.) BY PALPATION. 43 admit the passage under it of the handle of the mirror strengthened for that purpose. In this manner the mirror can he directed upwards and the tongue depressed with one hand,"^ a matter of great importance, as the other hand must be employed in pulling forward the uvula. Even when the patient depresses his own tongue, which is seldom done by him efficiently, it will be found difficult, unless the hand which manipulates the rhinoscope be kept low, as in depressing the tongue, to pre- vent its interfering with the rays of light The application of these instruments management of the light, and overcoming the irritability of the parts concerned, often require the exercise of patience and perseverance in the practitioner. In this also, as in every other method of physical exploration, practice and dexterity of manipulation are required. Perse- verance and skill in their employment, however, cannot fail, in appropri- ate cases, to improve our means of arriving at an exact diagnosis, and thereby of extending the domain of medical science. f PA.LPATION. Palpation also is a necessary mode of examination, and is sometimes practised by simply applying the tips of the fingers, at others by placing the hand on the part affected, and not unfrequently by employing both hands, and pressing with them alternately. This latter method is most applicable in endeavoring to judge of tumors, 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. The horizontal posture is best to judge of deep-seated pulsations and vibra- tions, but sometimes the erect posture, or even leaning forward, becomes necessary, as when the heart is being examined. When feeling 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 the head and neck forwards. In this manner palpation affords information — 1st, As to the increased or diminished sensibility of various parts ; 2d, Of their altered form, size, density, and elasticity ; and, 3d, Of the 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, Wt relieved if neuralgic. Not unfrequently pressure causes pain or tenderness where otherwise * Virchow’s Archiv., Band. 21, s. 45. f For full details and numerous interesting cases, see Czennak on the Lar>'ngo- scope in the “Selected Monographs” of the New Sydenham Society for 1861, Also the works of Drs. Gibb and Walker. Fig. 17. Septum, posterior orifices of the nasal fossae, turbinated bones, and orifices of the Eustachian tubes. The posterior arched surface of the velum covers the inferior part of the nasal cavity. — {Czermak.) 44 EXAMINATION OF THE PATIENT neither are experienced. Thus deep pressure in the right iliac region causes pain in typhoid fever, which, however, must be judged of from the expression 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 sensibility can only be ascertained by feeling or pinching the part, and the limitation of anaesthesia is best arrived at by pricking the sur- face 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 percussion, as in cases of hypertrophied liver and spleen, or when some tumor 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. Occasionally organs are diminished in size, and cannot be felt in their normal positions, as when the inferior margin of the liver cannot be detected in this way, from atrophy. The natural elasticity of parts may also be increased or diminished. Thus the abdomen is more elastic when air is in excess in the intestines, and less so when the peritoneum 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 tedema, when they pit on pressure, from diminished elasticity. 3. Certain motions in the thoracic and abdominal cavities, 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 sternum 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 motioLS below the integument, and to determine the existence of vibrations, frictions, gratings, and crepi- tations. Kostan relates a case where all the symptoms of acute intercos- tal 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 perceptible 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 vibration 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 displacement of their con- tained fluids. A modification of it is known under the name of succussion, which is effected by shaking the patient — a proceeding, however, which »is seldom necessary. BY MENSURATION. 45 MENSURATION. The 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 processes 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. 20), or the stethoraeter of Dr. Quain (Fig. 18). Both instruments are composed of a brass box, having a dial and 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 necessary, when making observations on the respiratory movements, whether of the chest or of 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 shown in Fig. 19, and the mode of using Dr. Sibson’s chest-measurer by placing the pinion on the nail of the observer’s finger, Fig. 18. The stethoraeter of Dr. Quain — half the real size. Fig. 19. Mode of applying the instrument when the string is used. — {R. Quain.) 46 EXAMINATION OF THE PATIENT moving with the chest, is seen Fig. 21. if held in the hand, as in Figs. 19 and 21, 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 ]. The upper arm is movable, and admits of elongation by means of a split tube, so that in this way great steadiness is arrived at, while the instrument itself can be carried Fig. 20. Fig. 21. to any part of the chest or abdomen, without disturbing the position of the patient, as seen in Fig. 22. There is, however, considerable variation even in health in different 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 rib indicates that of the diaphragm. The pressure of the stays in the female exaggerates the thoracic and diminishes the abdominal movements. Fig. 20. The chest-measurer of Dr. Sibson, natural size. Fig. 21. Mode of applying the chest-measurer. — (Sibson.) BY MENSURATIOIY. 47 According to the observations of Dr. Sibson, naade with this instru- Fig. 22. 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. . . . right left Lower end of sternum 6th Costal cartilages near the rib. . . 6th Rib at the side 10th Rib ( right ] left j right 1 left right left Abdomen ( centre i right [left Involuntary tranquil respiration boy man 3 to 6 3 “ 7 3 “ 7 2 “ 6 3 “ 6 2 “ 5 6 3 10 9 25 25 to 30 9 8 Voluntary forced I'espi ration about 100 110 110 95 95 85 70 60 65 60 90 100 In disease it may be observed as a general rule, that if the respira- tory 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 di- minished movements on one side of the chest in pleuritis, pneumonia, and incipient phthisis, can be determined and compared with the ex- aggerated motion on the opposite. Thus in phthisis, instead of the indicator 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 employment of all other instruments. It enables us to arrive at great accuracy, and constitutes an extra means of exploration, without, how- Fig. 22. Mode of application of the chest-measurer, attached to brass rods, bent at right angles, when the patient is in the horizontal posture. — (Sibson.\ 48 EXAMINATION OF THE PATIENT ever, 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 paying attention to the muscular force and other circumstances, so inter- feres with the correct conclusions to be derived from this mode of ex- ploration, as to render it valueless in the examination of cases gene- rally. 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 invented an instrument for measuring the an- gles of the chest. It will also enable us to judge approximatively of the curves under various altered conditions. He calls it stetho-goniometer, a term derived from three Greek words, signifying chest, angle, and measUl’€. Dr. S. Alison believes that it will afford data not to be ob- obtained by other means, and assist in the diagnosis of disease in its early 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 me- dium 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 edu«» cate the ear, or the sense of resistance. This preliminary education in the art of percussion requires a certain dexterity, which some find it very difficult to obtain. The difficulty seems to depend, in * Beale’s Archives of Medicine, vol. i. p. 60. F:g. 23. Stetho-goniometer, for measuring the inclination of different parts of the walls of the thorax in cases of disease, aa, The arms ; 6, the arc of a circle graduated ; c, the vernier, with an arrow, also graduated ; c?, vernier arm ; e, joint . — {Scott Alison.) BY PERCUSSION. 49 some cases, on an alteration in the proportions usually existing 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 pleximcter fairly with the tips of the 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 rea- son to believe that could this be surmounted, accu- rate percussion would become more universal and better appreciated. Without entering into the nu- merous discussions which have arisen as to the supe- rior advantages of one plan as compared with another, or of using this or that instrument, I may mention,, that for the last twenty-three 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. 24). The hammer is the invention of Dr. Winterich of Wurzburgh. The advantages it possesses are, — 1st, That the tone produced by it, in clearness, pene- trativeness, and quality, far surpasses that which the most practised percusser is able to occasion by other means. 2d, It is especially useful in clinical instruc- tion, 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 dexterity (Fig. 25).^ With the assistance of the instruments I now recommend to you, every student acquainted with the relative situations of the different thoracic and abdominal organs, is himself enabled, without other preliminary education, to detect the different degrees of sonoriety they possess in a state of health and’ disease. I may say, that by means of these instru- ments, after one hour’s practice on a dead body, he Fig. 25. is placed on a par (as regards the art of percussion) * The hammer and pleximeter are carefully made by Mr. Young, cutler, North Bridge, Edinburgh — in a neat case, price 7s. 6d. 4 50 EXAMINATION OF THE PATIENT with the generality of experienced practitioners in 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. I have tried a smaller and lighter hammer kindly sent to me by Br. Winterich, as well as balls surrounded by thick rings of caoutchouc, and attached to elastic pieces of whalebone. But a certain weight is neces- sary to obtain a penetrative sound, and rigidity of the handle is necessary to judge of the sense of resistance. In my opinion, no better hammer has been invented than the one figured on the preceding page. Of the Different Sounds produced 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 num- ber 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,, pulmonal^ intestinal,, stomacal, osteal, humo- rique, and hydatique.’''' 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, — 1st, 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, therefore, may bo termed the tympanitic, the humoral, and the paren- chymatous. 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 occasion the metallic and the crached-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, intes- tines, and stomach. ISo description will suffice to convey proper ideas of the various alterations of tone occasioned by percussing over the different 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 sufficient 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 in- testines may give out different sounds according to the nature of their 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 faeces. BY PERCUSSION. 51 A study of the ditferent 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 parenchy- matous sound, from enlargement of the uterus or an ovarian tumor ; or a dull humoral sound, from the effusion of fluid into the cavity of the peritoneum. Of the Sense of Kesistance produced by Percussion. By the sense of resistance is understood the peculiar sensation re- sulting 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 a child is elastic, whilst that of the adult is un- yielding. Of all the thoracic and abdominal organs, the liver presents the greatest degree of resistance, and the stomach the least. The pres- ence of fluid in the hollow viscera offers an amount of resistance between the parenchymatous organs on the one hand, and those containing air on the other. But air much condensed, or fluid contained within the rigid walls of the thorax, may offer 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 individual, 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 consider- ing it perfectly useless to. describe that in words which may be learnt in half an hour, by the use of the pleximeter and hammer on a dead body, or the living subject, I shall now proceed to describe the General Kules to be followed in the Practice of Mediate Percussion. 1. The pleximeter should be held by the projecting handles between the thumb and index finger of the left hand, 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 expe- riment 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 vibra- tion 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. 52 EXAMINATION OF THE PATIENT 2. Great care must be taken that no inequality exist between the inferior surface of the plexirneter and the skin. Firmly pressing it down will always obviate this when the abdomen is examined. As re- gards the thorax, the groove over the anterior mediastinum, the promi- nence of the clavicles and of the ribs, in emaciated subjects, may allow a hollow to exist under the instrument, by which a deceptive tympanitic sound is occasioned. By a little management, however, with the small and oval plexirneter I have recommended, this may readily be avoided. 3. The hammer should be held, as advised by Dr. Winterich, be- tween 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 in- strument. 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 sufficient to hold it by the extremity of the handle, merely in such a manner as will enable the practitioner to strike the plexirneter lightly, or with force, as occasion may require. 4. Care must be taken to strike the plexirneter fairly and perpen- dicularly. Unless this be done, vibrations are communicated to textures in the neighborhood 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 resist- ance is thus communicated to the hand of the operator from the muscu- lar 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 abso- lutely 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. When percussion causes pain, the force of the blow must of course be diminished. Under such circumstances, however, it will often be necessary to distrust the results. 10. The position in which the individual examined should be placed, BY PERCUSSION. 53 will vary according to the organ explored. In percussing the thoracic organs and the liver, a standing or sitting position is most convenient. The stomach, intestines, uterus, bladder, and abdominal tumors 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 examined, he should lie on the breast and abdomen. In cases of effusion into the serous cavities, a change of position furnishes most valuable indications. 11, In percussing any particular organ, the pleximeter should be first applied over its centre, where the sound and sense of resistance it may furnish are most characteristic. Two blows with the hammer are gene- rally 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 lightly, 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 difference 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 exactly, after having deter- mined whereabouts the line of separation is, by placing the long diameter of the pleximeter transversely across it, and striking, first one end of the instrument, and then the other, till the precise spot is determined. This spot should now be marked, by placing with a pen a dot of ink on the skin, or employing for this purpose a very soft black-lead pencil. The oppo- site and then other portions of the margin of the organ should be limited in the same manner, and these in turn should be marked until the whole organ be completely examined. Then by uniting all these marks with a line of ink or pencil, we have the exact form of the organ drawn upon the skin. When it is thought necessary to render the first line permanent, 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 carrying lightly over the ink line a stick of nitrate of silver previously moistened. Special Rules to be followed in Percussing Particular Organs. Before proceeding to percuss individual organs in persons laboring under 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 26 and 27) will enable you to compare with readiness the altera- tions 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 54 EXAMINATION OF THE PATIENT 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 cir- cumstance must be the same before it is possible to determine, in delicate Fig. 26. Fig. 27. cases, either from the tone or sense of resistance, whether change of den- sity exist in the lungs. When circumscribed alterations are discovered in the pulmonary tissue, their limits may be marked out on the surface of the skin, in the manner previously indicated. In this way I have fre- quently succeeded in determining with accuracy the size and form of cir- cumscribed 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 determine 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 in- spiration. 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 Fig. 26, Anterior, and Fig. 27, posterior view of the normal 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 tolerably free from air, except CO, colic sound, from distended colon. The descending colon and rectum are filled, and sound dull. HU, humoral soimd, over a distended bladder ; M, mus- cular, and 0, osteal sounds. — {Piorry.) BY PERCUSSION. 55 only slight dulness and increased resistance, which, however, may occa- sionally 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 impres- sion of hardness and solidity commu- nicated to the hand. When, however, the lung is infiltrated with tubercle, the induration is most intense, and the greatest degree of resistance commu- nicated. Partial indurations from apoplexy or simple cancerous and tubercular ex- udation, may be detected by percus- sion, even when deep-seated and cov- ered by healthy portions of the lungs. In this case, by pressing with the plex- imeter, and striking lightly, a tympan- itic sound only is heard ; but by press- ing the pleximeter down firmly, and striking with force, the dull sound may be elicited and circumscribed. When indurations, however, exist in- feriorly in those portions of the lungs which overlap the liver, it requires great practice to detect them with certainty. Caverns in the lungs, when large and filled with air, induce a tympanitic sound (Fig. 28, 3) ; but they are generally more or less full of viscous and fluid matters, and give rise to dulness. Two or three ounces of fluid may be detected in the pleural cavity, by 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 effusion be only on one side, the increased dul- ness 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 cavity, when the space which was previously dull becomes clear (Fig, 29). When the effusion entirely fills the pleural cavity, no limit, of course, can be detected ; but, even then, the dulness 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 caus- ing 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 Fig. 28. Phthisis — Atrophied heart and liver — Prolonged abstinence. 1, Atrophied heart ; 2, Infiltrated tubercle on left side ; 3, the same on right side with a cavity ; 4, Atrophied liver ; 6, Spleen ; 6, unusual dulness over abdomen, from prolonged absti- nence. — {Piorry . ) 56 EXAMINATION OF THE PATIENT 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 frequently be elicited a sound, which Laennec first likened to gently striking a cracked pot. It may be very closely imitated by crossing the 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, pneumonia, and phthisis; of congested, apoplectic, and emphy- sematous lungs, and even when these organs were quite healthy, if, as in young subjects, the ribs are very elastic. The conditions which seem favorable for the production of this sound are, 1st, A certain amount of confined air rendering the tissue of the lung tense; 2d, The sudden com- pression of this air by a solid body in its neighborhood ; 3d, Communication of this air with the external atmosphere. Hence it is not diagnostic of any particular disorder, or pathological state, such as a 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 diseases.* Heart . — To mark out the precise limits of the heart constitutes the first difficult lesson in the art of percussion. M. Piorry commences by determining the clear sound at the upper end of the sternum, and bring- ing the pleximeter gradually downwards till the dull sound of the heart be heard. 1 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 towards the heart, we shall readily distinguish the line where cardial dulness commences, and thus limit the superior margin of the organ. The same method is to be followed in determining the situation of the lateral margins, only carrying the pleximeter outwards or inwards, strik- ing more and more forcibly with the hammer, until the clear tympanitic sound of the lung only be heard. It is more difficult to determine the * See the author’s “ Clinical Investigation into the diagnostic value of the cracked- pot sound .” — Edinburgh Medical ^Journal for Marc\ 1856. Fig. 29. 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.) BY PERCUSSION. 51 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 distin- guished from them. The size of the heart, however, may be pretty accurately estimated, by limiting its superior and lateral margins. In females, the left mammary gland should be drawn upwards and out- wardsby an assistant. In the natural position of the organ (Figs. 1 and 2) it is well to remember that the auri- cles are on the right, and the ventri- cles on the left side The normal size of the heart differs in different persons. As a general 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. (Pi- orry.) In hydropericardium, the dul- ness has been remarked to exist rather at the superior part of the sternum, than on one side or the other. (Pior- ry, Reynaud.) In pericarditis it bulges out inferiorly (Fig. 30, 1). In hypertrophy and dilatation of the right auricle, the increased extent of the dulness stretches toward the median line, and sometimes passes over it (Fig. 31, 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. 31, 1, and Fig. 32). 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 tumors pressing upon, or in the neighborhood of, the organ ; hypertrophied liver, extensive empyema, etc., etc., may render the mensuration of the extent of its dulness difficult or impossible. The changes in position of the heart produced by a pleurisy on one side push- ing it towards the opposite one, or by the pregnant uterus, or an ovarian tumor or ascites thrusting it upwards, may also be determined by per- cussion, especially if the impulse can be distinguished by palpation or auscultation. Liver . — Limitation of the size of the liver should^ be commenced by placing the pleximeter over the organ on the right side, where the dul- ness and resistance are greatest. It should then be carried upwards un- til the clear sound of the lung be distinguished, when it ought again to be brought down and the limit marked. This limit, however, may indi- cate 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 Fig. 30. Pericarditis^ 'pneumonia.^ and loaded rectum, 1, Pericarditis; 2, Pneu- monia separable from the extreme dulness of the liver ; 3, Loaded rectum. — {Piorry.) 58 EXAMINATION OF THE PATIENT necessary to determine where the tympanitic sound ceases inferiorly, by striking gently with the hammer, and where the parenchymatous sound ceases superiorly, by striking forcibly, so that vibrations may be commu- nicated to the organ through the layer of lung. The space bkween these two lines thus marked on the surface is wider in some individuals than in others, and deeper and more extensive posteriorly, than anteriorly. By carrying the pleximeter from the right side anteriorly, and then pos- teriorly 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 de- tected. 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 de- scends on the right side over the intes- tine. It is, therefore, necessary to be cautious in determining the inferior margins, for a tolerably strong blow with a hammer may give rise to a tym- panitic sound from the intestine, heard through the liver. The lower margin must be percussed in an inverse man- ner 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 pre- sent, contrasted 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, abscesses, hydatids, tumors, atrophy, etc., etc., may often be exactly de- termined by means of percussion. In icterus, the increase and diminu- tion of this organ, as evinced by lines marked on the skin, will generally be found to bear a proportion to the intensity of organic disease. When tumors 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 fluid effusion exists in the pleura, the increased density of Fig. 31. Hypertrophy of liver and heart 1, Hypertrophied liver, which may be still further enlarged to the dotted lines over the abdomen ; 2, Distended gall-bladder ; 3, Hypertrophied right auricle — 1 , Hypertrophied ventricles ; 4, Loaded coecum ; 6, Loaded rectum and descending colon. — {Piorry.) BY PERCUSSION. 59 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 (thg. 32). 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 un- der the inferior margin of the liver, anteriorly and somewhat laterally, may be marked off (Fig. 31, 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 stomach and intestines causes the margin readily to be distinguished. Posterior- ly, however, where the organ approaches towards the kidneys, this is more difficult. Its superior and inferior margins may be made out by striking the instrument with some force, and following the rule (No. 10) previously given, p. 53. This organ offers great resistance on percussion. In health the spleen never projects below the false ribs, even during a deep inspiration. Its general size is about four inches long and three inches wide. (Piorry.) In diseased states it may be atrophied 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 dotted lines in Fig. 33. A pleu- ritic effusion, ascites, pneumonia, or tubercular de- position in the inferior lobe of the left lung, may of this organ difficult or impossible. If the Fig. 32. Hypertrophied liver and spleen in leucocythemia — Enlarged heart. 1, , Hypertrophied heart with dilatation; 2, Great dulness over the larger part of abdomen from enlarged liver on the right side; and enlarged spleen on the left. — [Partly from Piorry . ) Fig. 33. 1, Slightly enlarged spleen, pushed somewhat upwards. The dotted lines indicate how the organ may be enlarged in various diseases. 7, Elongation downwards in leucocythemia. — [Slightly modified from Piorry.) 60 EXAMINATION OP THE PATIENT dulness cannot be detected, we may infer that its dimensions are small. (Mailliot.) S'omach ayid Intestines . — The sounds elicited by percussion of the stomach and intestines are of the greatest service to the practitioner: — 1st, As furnishing him with the means of determining the form of other organs, as the liver, spleen, or bladder; 2dly, As enabling him to dis- tinguish the presence or absence of fsecal or alimentary matter; and, 3dly, As the means of diagnosing abdominal tumors. Hence it is in- cumbent on every physician 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 corre- spond. 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, strik- ing it all the way, now hard, now gently, with the hammer. The differ- ent tones which the stomach, colon, and small intestines furnish, will thus be distinctly heard. The pleximeter should then be carried late- rally, alternately to the one side, and then to the other, till the whole surface be percussed. In this manner the different tones produced by the coecum 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 resist- ance will be modified according as the different viscera are full or empty, 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 by which they may readily be dis- tinguished 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 BY PERCUSSIONo 61 tumors, peritoneal adhesions and effusions, may all frequently be di- agnosed, and their limits determined, by a careful examination with the plexirneter and hammer. By means of percussion, even the nature of the tumor may often be arrived at ; as, for instance, whether it be fungus hematodes, scirrhous, encysted, osseous, etc., by the different degrees of resistance they possess. Care, however, must be taken not to confound with tumors an enlarged spleen or liver, a distended uterus or bladder, stomach full of alimentary matter, etc. It should also be remembered that when tlie patient lies on his back the percussion 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 pur- gative 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 faeces, and an enema is indicated. If, on the other hand, the left iliac fossa sound tympanitic, and the right sound dull, an enema is of little service, as it will not extend to the coecum, and purgatives by the mouth are indicated (Figs. 30 and 31). Effusion of fluid into the peritone- um may be determined with great ex- actitude by means of percussion, and the height of the fluid marked, as in the case of pleuritic effusion. In the same manner, a change of po- sition furnishes similar results. Abdominal distension from accumulation of air may also be determined. If it be within the intestine, the tym- panitic note is partial and limited, if in the peritoneal cavity more equa- ble and diffused (Fig. 34). Kidneys . — To percuss the kidneys, the patient should lie on the abdomen and chest; a position which allows any ascitic fluid that may be present to gravitate downwards, whilst the intestines float upwards. The dulness and great resistance offered by the renal organs are, under such circumstances, at once determined (Figs. 27 and 29). Their external margins 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 calculous or scrofulous nephritis, pyelitis, or other Fig. 34. 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, es- pecially of the right auricle ; 3, Liver, pushed upwards ; 4, Ascitic fluid, gravitating inferiorly, the patient being on the back ; 5 and 6, Stomach and intestines, superiorly and anteriorly. — {Piorry.) 62 EXAMINATION OF THE PATIENT diseases, may in this manner be made out, as seen (Fig. 29) on the left side. Atrophy of these organs is more difficult to determine with ex“ actitude, hut 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 dis- tinguished, and its circular margin limited, by observing the tympanitic 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 will 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 percussion. 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 percus- sion 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 foetus in utero, 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 ^ De la Percussion Mediate, etc., Paris, 1828. Du Precede Operatcire, Paris, 1831. De I’Examen Plessimetrique de I’Aorte Ascendante, et de la Crosse Aortique, etc. Archives Gen. de Med., vol. ix., 1940, 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, 1851. f Mailliot (L.) Traite de la Percussion Mediate, etc., Paris ; translated into English, with notes, by Dr. George Smith of Madras. Figs. 35 and 36. Anterior and Posterior outlines of the trunk, for marking more readily the results of Percussion and Auscultation. BY AUSCULTATION. 63 A very convenient method of recording the results of percussion, consists in filling in an outline of the trunk, with pencil, so as to mark, by different shading, the intensity or extent of the dulness. With this view I have caused the small outlines of the trunk, anteriorly and pos- teriorly, here figured, to be printed in sheets, which are gummed at the back. They can in this way be kept in the pocket of your note-book, and easily attached to the paper when required. The same outlines will serve to mark the position of sounds heard in the chest, when the upper part of the outline only may be used.^ AUSCULTATION. The object of auscultation is to ascertain and appreciate the nature of the various sounds which occur in the interior of the body. It has been found most useful when applied to the pulmonary and circulatory organs. Auscultation of the abdomen is occasionally serviceable, especially in certain cases of pregnancy, and during labor. It has also been applied to the head, although I have never been able to make out any useful results from the practice. General Rules 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 Fig. 37. Fig. 38, Fig. 39. Fig. 40. Fig. 41. to a small region, as during auscultation of the heart. In either of these * These sheets may be obtained of Mr. Thin, bookseller. South Bridge. Figs. 3Y and 38. Stethoscopes with different sized trumpet extremities, the smaller one for auscultating the heart, oi emaciated subjects. Fig. 39. Stethoscope capable of being shortened, by screwing one half into the other. Fig. 40. Stethoscope invented under the notion that its form would facilitate the conduction of sound. Fig. 41. Stethoscope invented under the idea that the spiral form, like that of a shell, would increase the intensity of sound. 64 EXAMINATION OF THE PATIENT cases a stethoscope is necessary. The instrument is also useful to confirm or nullify the existence of certain finer 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 cleanliness ; and lastly, as the most delicate method of auscultating the 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 condi- tions. The forms of stethoscopes vary infinitely : those represented (Figs. 37 to 39) are the most convenient, that having the smaller trumpet-shaped end being best for emaciated subjects, or for limiting the sounds Fig. 42. Fig 43. of the heart. Figs. 40 and 41 are two stethoscopes which were presented Fig. 44. to me by two students, both of whom imagined that the form they had given the instruments intensified the sound. This result, however, is unquestionably attained by the double stethoscope of Canman (Fig. 43) and the dilFerential stethoscope of Scott Alison (Fig. 44). In many Fig. 42. Flexible stethoscope. Fig. 43. Canman’s stethoscope. Fig. 44. Differential stethoscope of Dr. Scott Alison. BY AUSCULTATION. 65 cases, where sounds were doubtful with the ordinary instruments, they have been rendered at once appreciable and positive by the differential stethoscope. Dr. Scott Alison also found that water enclosed in a flat circular bag of caoutchouc, still farther increased the sound, when flexible stethoscopes were employed, and I have satisfied myself, that when with these instruments no sound (friction or crepitation) is audible, they are at once rendered so by employing this bag or hydrophone (Fig. 45). Although these flexible stethoscopes have hitherto seldom been used, I have frequently, during the last four or five years, met with cases in which the differential instrument of Dr. Scott Alison has been of great service.^ 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 pressed down with tolerable firmness, whilst with the second, third, and fourth fingers, you ascertain whether the circular edge be perfectly applied, which is abso- lutely essential. 4. The position of the patient will vary according to the part examined. In auscultating the lungs anteriorly, the erect or recumbent positions may be chosen, the Fig. 45. two arras being placed in a symmetrical position by the side. If the- chest be examined posteriorly, the individual 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. Grenerally speaking, the beds in the Infirmary here are too low, and ren- der auscultation very fatiguing to the physician. In young children or infants we should place our ears on their backs. 5. Whenever individuals are thrown into such a state of agitation as to iuterfere 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 * See his valuable work, “ The Physical Examination of the Chest in Pulmonary Consumption, etc.” London, 1861. Fig. 45. The Hydrophone of Dr. Scott Alison. 5 66 EXAMINATION OF THE PATIENT r order of sequence as has been made appa- 138 PRINCIPLES OF MEDICINE. rent among the nutritive processes, it will be necessary to describe them in a different manner. General Anatomy and Physiology 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, vary- ing greatly in size and shape, mingled with a greater or less number of nerve tubes, also varying in calibre. One important fact with regard to these corpuscles is, that many of them may be demonstrated to throw out prolongations, which may be seen in well-preserved preparations to be in direct communication with the central band or axis of Remak and Purkinje within the fibres. The so-called fibres, indeed, may be shown 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 cylindrical, 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 through- out, as in the nerves. There are also bundles of gelatinous or flat fibres, the nature of which is much disputed, very common in the olfactory nerve and sympathetic system of nerves. 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 situated below this great commissure, consisting of the corpora striata, optic thalami, corpora quadrigemina, cerebellum, pons varolii, medulla oblon- gata, and medulla spinalis. In this way, we have a cranial and a verte- bral portion of the spinal cord. In the cerebrum, or brain proper, the ganglionic or corpuscular structure is external to the 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 grey substance has been appropriately called the hemispherical ganglion (Solly). In the cranial portion of the spinal cord, the grey matter exists in masses, constituting a chain of ganglia at the base of the encephalon, more or less connected with each other and with the white matter 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 in- ternal 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 ante- HEALTHY AND DISEASED INNERVATION. 139 rior and middle ones may be seen to decussate there with each 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 off a bundle of fibres, which passes below the olivary body, and is lost in the cerebellum— land of Solly). The principal portion of the tract passes through the corpus striatum, and anterior portion of the optic thalamus, and is ultimately lost in the white sub- stance of the cerebral hemispheres. The middle column, or olivary tract, maybe traced through the substance of the optic thalamus and corpora qua- drigemina, to be in like manner lost in the cerebral hemispheres. Tlie pos- terior column, or restiform tract, passes almost entirely to the cerebellum. In addition to the diverging fibres in the cerebral hemispheres which may be traced from below upwards, connecting the hemispherical ganglion with the structures below, the brain proper also possesses bands of transverse fibres, constituting the commissures connecting the two hemispheres of the brain together, as well as longitudinal fibres connecting the anterior with the posterior lobes. In the posterior columns of spinal cord it results from the investigations of Lockhart Clarke, that there is a decussation of various bundles of fibres through- out its whole extent. It is now also determined, that many of the fibres in the nerves may be traced directly into the grey substance of the cord — a fact originally stated by Grainger, but confirmed by Budge and KoHiker. Further, it has recently been shown, that b}^ means of these fibres an anastomosis is kept up between the various columns, even tho.m on both sides of the cord, through the medium of nerve cells in the grey matter, an important fact principally demonstrated by the labors of Stilling, Remak, Van der Kolk, Lockhart Clarke, and others. / These later observations, indeed, render it certain that the numerous actions hitherto called reflex are truly direct, and are carried on by a series of nervous filaments running in different directions through the cord ; and hence the term diastaltic^ proposed by Marshall Hall instead of reflex, is in every way more appropriate. Functions of the Nervous System. — The great difference in structure existing between the grey and white matter of the nervous system, 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 in- fluences which are sent or originate there. Cerebrum. — This portion of the nervous system consists of that mass of grey and white matter situated above and outside the corpus callosum, composing what are denominated the two cerebral lobes. On carefully examining a thin section of this structure, prepared after the manner of Lockhart Clarke, and steeped in carmine, the white substance in the adult may be seen to be composed wholly of nerve tubes. These become more and more minute as they reach the grey matter of the convolutions, and are gradually lost in it. The layer of grey matter consists of a finely molecular substance, in which are embedded minute nerve cells, varying in shape and size. The cerebral lobes furnish the conditions necessary for the manifesta- 140 PRINCIPLES OF MEDICINE. tion of tlie intellectual faculties properly so called, of the emotions and passions, of volition, and are essential to sensation. That the evolution of the power especially connected with mind is dependent on the hemispherical ganglion, 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 defective ; so much so, indeed, that the convolutions are, as it were, in the first stage of their formation, being only marked out by superficial fissures almost confined to the surface of the brain. As the cirieritious substance increases, the intelligence becomes developed. 3. The results of experiments by Flourens, Rolando, Hertwig, and others, have shown 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 grey matter, therefore, evolves that force or quality which is essential to mind, and the conditions necessary for this are evidently connected with the molecular and cell structure. The white matter, on the other hand, conducts the influences originating in, and going to, the grey matter. These may be said to travel in four directions — 1st, Out- wards to the circumference of the body along the nerve tubes; 2d, In- wards and upwards to the hemispherical ganglion; 3d, From one hemi- sphere to another by the commissures ; and 4th, From the anterior to the posterior lobes, and vice versa, by the so-called longitudinal fibres of the hemispheres. This power of conducting mental influences in various directions is probably subservient to that combination of faculties which characterises thought. By the term sensibility I understand the peculiar vital property possessed by nervous substance of conducting the influence generated by impressions made upon it. By sensation I understand the mental con- sciousness of such impression. Now the experiments of Flourens, Hertwig, Longet, and others, have shown that on removing the cerebral lobes from animals, the mental faculties, including, of course, conscious- ness and volition, and therefore sensation and voluntary motion, are abolished, while the creature can stand when put on its legs, fly when thrown into the air, and walk when pushed. Hertwig has kept pigeons in this condition for three months, deglutition and all other reflex acts being perfect, the mental faculties only absent. Longet and Dalton have recently maintained that sensation may exist without the cerebral lobes. The former says, when the cerebrum was removed from a pigeon, and a light suddenly brought-- near its eyes, there was contraction of the pupil, and even winking. Further, when a rotatory motion was given to the candle at such a distance that no heat could operate, the pigeon made a similar movement with its head. But of these facts I would observe that the pupil will contract on the application of light when the eye has been cut out of the head, and a sunflower follows the course of the sun. HEALTHY AND DISEASED INNERVATION. 141 It cannot, therefore, be said that under such circumstances the eye and the flower possess sensation or can see. Dalton’s description of what occurs after removal of the cerebrum is as follows ; — “ The effect of this mutilation is simply to plunge the ani- mal into a state of profound stupor, in which he is almost entirely in- attentive to surrounding objects. The bird remains sitting motionless upon his perch or standing upon the ground, with the eyes closed and t'ae head sunk between the shoulders. . . . This state of immobility, however, is not accompanied by the loss of sight, of hearing, or of ordi- nary sensibility. All these functions remain, as well as that of voluntary motion. If a pistol be discharged behind the back of the animal, he at once opens his eyes, moves his head half round, and gives evident signs of having heard the report; but he immediately becomes quiet again, and pays no further attention to it. Sight is also retained, since the bird will sometimes fix its eye on a particular object and watch it for several seconds together. Ordinary sensation also remains after removal of the hemispheres, together with voluntary motion. If the foot be pinched with a pair of forceps, the bird becomes partially aroused, moves uneasily once or twice from side to side, and is evidently annoyed at the irritation.” From the observed facts Dalton concludes that “ the animal is still capable, after removal of the hemispheres, of receiving sensations from external objects. But these sensations appear to make upon him no lasting impression. He is incapable of connecting with his perceptions any distinct succession of his ideas. He hears, for example, the report of a pistol, but he is not alarmed by it ; for the sound, though distinctly enough perceived, does not suggest any idea of danger or injury. There is accordingly no power of forming mental associations, nor of perceiving the relation between external objects. The memory, more particularly, is altogether destroyed, and the recollection of sensations is not retained from one moment to another. The limbs and muscles are still under the control of the will, but the will itself is inactive, because apparently it lacks its usual mental stimulus and direction.” I think the facts may be interpreted differently and more correctly. The turning round of the animal’s head on the explosion of a pistol, and many other movements, may be altogether reflex, dependent on irritations communicated to the cranial portion of the spinal cord through the tympanum. Again, that the pigeon should open its eyes with a vacant stare, or apparently fix them on an object, is no proof of sight. We constantly do these things ourselves with the brain entire, and see nothing. Lastly, that the limbs and muscles are under the control of the will, while the will is inactive, appears to be contradictory language. One of the most active operations of the will is to direct motion; and to say of a bird which flies away on the production of the slightest noise in health, but does not move on the discharge of a pistol, that in the latter case its limbs and muscles are still under the control of the will, appears to be a most unfounded conclusion. The truth evidently is that there is no will, no sensation in such a case, any more than there is in a sensi- tive plant, which shrinks on being touched, but which surely cannot be said to exercise either the one mentnl faculty or the other. With regard to the relation existing between mind and brain, two 142 PEINCIPLES OF MEDICINE. views are contended for : one, that the brain originates ; the other, that it is only the instrument of thought. The discussion is metaphysical rather than physiological, because the phenomena observed in either case are the same, and these depend upon the structure and quality of the organ itself. In this respect the brain is exactly similar to a nerve or muscle. It possesses properties and functions which it is our duty to study. AVhy it does so we are ignorant, and are content to regard them as ultimate facts in our science. In the same way, therefore, that con- tractility is a property of muscle, sensibility of nerve, growth of tissue, and secretion of gland, so we regard thought as a property of the brain. But to avoid metaphysical subtleties, we are quite willing to say that it furnishes the conditions necessary for the manifestation of mind. From the various facts now known, I think it may be concluded that the cortical substance of the cerebral lobes furnishes those conditions which are necessary for thought, including all mental operations, sensa- tion, and volition. . I do not think that in the present state of science we are warranted in proceeding further, for the same facts entirely negative all those theories which have been advanced having for their object a localization of the different faculties into which the mind has been arbi- trarily divided. Some have maintained that volition is seated in one place, memory in a second, sensation in a third, and so on ; but we have no sufficiently extended series of facts to establish any of these or of similar propositions. There can be no doubt that the relation between the molecular, nuclear, and cell elements of the hemispherical ganglion, as the instru- ment of mind, must be most important ; and yet I am not acquainted with any one, who, having first qualified himself for the task by a pro- longed and careful study of histology, has investigated the brain in cases of insanity. Psychologists content themselves with repeating well-known clinical observations, with the ordinary morbid anatomy or density of the brain, and with the metaphysical speculations which have been pushed as far as, if not further than, human intellect can carry them. Need we feel surprised that the true pathology of insanity is unknown ? What we desiderate is a careful scrutiny of the organ. Hitherto the difficul- ties of such an investigation have been insurmountable, in consequence of our imperfect methods of research. But let any one possessing a com- petent knowledge of histology and the use of our best microscopes, with the opportunities our large asylums offer, only now dedicate himself to the task, and he may be assured that while extending the bounds of science he will certainly obtain an amount of fame and honor that few can hope to arrive at. The molecules on which muscular contractility depends are, as we have seen, visible molecules, and so I believe are those in the hemispherical ganglion, so essentially connected with the functions of the brain. CcreeUhim . — The ganglionic surface of the cerebellum is structurally altogether unlike that of the cerebrum. On looking at a well-made verti- cal section of the former, prepared after the method of Lockhart Clarke, and steeped in carmine, under a magnifying power of 25 diameters, the fine tubular substance in the centre is seen to be bounded externally by a granular layer, outside which is a row of nerve cells with branched pro- HEALTHY AND DISEASED INNERVATION. 143 cesses gradually terminating towards tbe margin of the exterior layer, which is finely molecular. On increasing the magnifying power to 250 diameters, we see more distinctly the relation of these various parts to one another, and recognise in the interior of each granule an included rounded body. According to Gerlach, these corpuscles are united to one another by a slender filament, which he has figured in a hypothetical diagram. Although such an appearance as he has imagined cannot be discovered in the natural structure, I have seen the tubes running between the granules, and traced them to the external margin of the granular layer. The external layer is the structure which demands the greatest attention. It is composed essentially of a finely molecular mass, containing numerous capillaries derived from the vessels of the meninges. Large ganglionic cells external to the granular layer send olF branching processes externally, which are gradually lost as they proceed outwards. Both in the external, as well as in the internal granular layer, the basis of the texture is evidently molecular — a fact which hitherto has received far too little attention. If the cerebellum be removed gradually from a pigeon in successive slices, there is progressive circumscription of the locomotive actions. On taking away only the upper layer there is some weakness and a hesitation in its gait. When the sections have reached the middle of the organ the animal staggers much, and assists itself in walking with its wings. The sections being continued further, it is no longer able to preserve its equilibrium without the assistance of its wings and tail; its attempts to fly or walk resemble the fruitless efforts of a nestling, and the slighest touch knocks it over. At last, when the whole cerebellum is removed, it cannot support itself even with the aid of its wings and tail ; it makes violent efforts to rise, but only rolls up and down ; then, fatigued with struggling, it remains for a few seconds at rest on its back or abdomen, and then again commences its vain struggles to rise and walk. Yet all the while its sight and hearing are perfect. The slightest noise, threat, or stimulus, at ouce renews its contortions, which have not the slightest appearance of convulsions. These eSects, first described by Flourens, have been confirmed by all experimenters, and occur in all animals. The results contrast strongly with those of the much more severe opera- tion of removing the cerebral lobes. “ Take two pigeons,” says Longet; “ from one remove completely the cerebral lobes, and from the other only half the cerebellum ; the next day the first will be firm upon its feet, the second will exhibit the unsteady and uncertain gait of drunkenness.” These facts induced Flourens to consider the cerebellum as the co- ordinator of motion, in which view he was supported by the late Dr. Todd and others. Foville, on the other hand, supposed it to be the seat of sensation, and argued that, as it is by means of this function that we regulate muscular motion, so, when it is destroyed, the faculty of per- ceiving the movements being lost, we cannot answer for their precision or duration. That it should be the seat of sensation generally is dis- proved by the fact that the animal is evidently conscious of impressions after its removal ; but that it should be the organ of that peculiar sense, which has been variously called “ muscular sense,” “ sen^e of resistance,” and “sense of weight,” is very probable. Accordingly we find that 144 PEINCIPLES OF MEDICINE. Professor Lussana of Parma lias recently brought together all the argu ments which exist as to this matter, along with numerous original obser- vations, confirmatory of the view that the cerebellum does indeed regulate motion, but in consequence of its being the seat of the muscular sense.* It has been suggested by Carpenter and Dunn that the corpus den- tatum in the cerebellum is the ganglion which is connected with this sense — a view rendered improbable by Brown-Sequard’s analysis of cases where the organ was diseased. I submit that the function is seated in the external layers of grey matter rather than in the corpus dentatum — a theory to which the same objections do not apply. Mind frequently remains when portions of the hemispherical ganglion are injured, although we know of no instance in which, where the whole of it has been dis- eased, intellect has been preserved. So the co-ordinating motor power may remain when parts only of the cerebellar leaflets are destroyed, but is certainly lost when the whole grey matter is diseased. That the cere- bellum, therefore, is connected with a special sense, through which it influences the co-ordinate action of the muscles, is a doctrine worthy the attention of physiologists. Its external layers of grey matter, constituting a complex ganglionic structure, has probably the same relation to the mus- cular sense as the hemispherical ganglion has to sensation in general. The spinal cord has two portions — a cranial and a vertebral. The former consists of a chain of ganglia more or less connected with one another, as well as with the cerebrum above and the vertebral part of the cord below ; the latter is composed of two lateral halves divided by an anterior and posterior fissure. Each half is subdivided into three columns — an anterior, middle, and posterior — by the two cornua of the central mass of grey matter. Through the centre runs the spinal canal, lined with columnar epithelium. The white matter of the lateral columns is composed of tubes, which, as shown by Lockhart Clarke, on being traced inwards from the spinal nerves, join the ganglionic cells in the grey matter, and, through them, keep up a communication — 1st, with the opposite lateral columns; 2d, with the cerebrum; and 3d, with the anterior and posterior roots of the nerves. The coarse of the conducting tubes, as pointed out by Clarke, shows that the views of Sir Charles Bell, though correct as to the functions of the roots of the nerves, were erroneous with regard to the columns of the cord. The few experiments Bell made on those roots confirmed the conclusions he drew from dis- section. Had he experimented on the cord itself, he might have formed juster views. What he neglected, however, was performed by Brown- Sequard, with the effect of demonstrating that a section of the anterior columns does not produce paralysis of voluntary motion, nor section of the posterior columns prevent conduction between the brain and poste- rior roots. To produce either of these results, the section must be con- tinued into the grey matter. If two sections be made, however, midway between two neighboring spinal nerve roots, then conduction between the parts above and below the sections is cut off. The explanation of this is to be found in the course taken by the nerve tubes as shown by Locklmrt Clarke, which so diverge from one another, on passing into the cord, that no one transverse section of the column can divide them, * Journal de la Physiologic, tome v., p. 418, et seq. HEALTHY AND DISEASED INNEEVATION. 145 although two at a certain distance from one another may. Thus, histolo- gical research and experimental investigation support one anotlier, and the two have now demonstrated that the conducting nerve tubes of the spinal roots of the nerves communicate through the grey matter of the cord, not only with the brain and the two sides of the body, but with each other. These facts have served also to explain more fully the nature of those actions variously denominated automatic, reflex, and diastaltic, for the true knowledge of which we are indebted to the labors of Marshall Hall. It is now clear that the influences excited by irritation of nerves run continuously through the cord in certain directions, now communi- cating with muscles to produce spasms, and now with the glands and vessels to produce secretion and vaso motor action, and this without any necessary connection with the brain, and therefore without sensation. Nerves . — The various nerves of the body consist for the most part of nerve tubes, running in parallel lines. Yet some contain ganglionic cor- puscles, as the olfactory and the ultimate expansion of the optic and audi- tory 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 maybe 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, Nerves of common sen- sation such as the greater portion of the fifth, and part of the glosso- pharyngeal. 3d, Nerves of motion, such as the third, fourth lesser division of the fifth, sixth, facial, or portio dura of the seventh, and the hypo-glossal. 4th, Senso-motory or mixed nerves, such as the pneumo- gastric, the accessory, and the spinal nerves. 5th, Sympathetic nerves. All nerves are endowed with a peculiar vital property called excita- bility, inherent in their structure, by virtue of which they may be excited on the application of appropriate stimuli, so as to transmit the influence of the impressions they receive to or from the brain, spinal cord, or certain ganglia, which may be considered as nervous centres. The nerves of special sensation convey to their nervous centres the influence of impressions caused by odoriferous bodies, by light, sound, and by sapid substances. The nerves of common sensation convey to their nervous centres the influence of impressions caused by mechanical or chemical substances. The nerves of motion carry yrom the nervous centres the influence of impressions, whether psychical or physical (Todd). The mixed nerves carry the influence of stimuli both to and from, thus combining in themselves the powers necessary for the functions of com- mon sensation and of motion. But there are doubtless numerous other individual nerve tubes pecu- liarly qualified to receive impressions connected with particular sensations — such, for example, as those of cold or warmth, of weight, of hunger, thirst, and numerous other feelings — which, although not yet actually discovered, must have relation to the special endowments of these tubes. As to the direction in which these influences travel, we now know that they pass, first, from the brain to the voluntary muscular system gen- 10 146 PEIXCIPLES OF MEDICINE. erally ; second, from the surface and the organs of sense to the brain ; third, from one side of the body to the other, through the spinal cord ; fourth, from the cerebro-spinal system through ganglia to numerous glands, non-voluntary muscles, and to the blood-vessels. There may be other directions in which nervous influence travels, but such have not yet been discovered. In the meantime we know that the nerve tubes are not only idio-motor and sensitive (general and special), but diastal- tic, nutritive, secretory, and vaso-motor. The ganglionic system of nerves consists of numerous ganglia having connecting filaments, keeping up a communication with each other and with the cerebro-spinal centres. These communications are not direct, the various nerve tubes separating in a ganglion, and, whether they do or do not anastomose with nerve cells, on leaving it form a dififerent combination of nerves. Hence every ganglion serves to break the con- ducting power of the nerves, or to modify it — probably both. In health W’e are not conscious of the actions of internal viscera principally supplied with these nerves, nor can volition act on muscular parts to which they are distributed. But let them be diseased, and they often excite excru- ciating yet peculiar pain, as in that caused by angina, by colic, or by a gall-stone. Again, mental emotions have a powerful influence on the contractions of the organic contractile tissue, as in palpitations of the heart, or as visible in blood-vessels on the production of pallbr or of a blush. In the same manner mental emotions or desires act on the vari- ous glands, exciting or diminishing their action. Such results can only be explained by the connection known to exist between these nerves and » the spinal cord. Similar phenomena may be produced by direct stimu- lation or by reflex action, each ganglion being a centre through which alferent and efferent nerves communicate — the whole constituting an excito-nutrient and excito-secretory system, as has been well described by Dr. Campbell of the United States."^ The observations as to the eflects of injuring the trunk of the gan- glionic system, more especially in the neck, have excited the attention of numerous physiologists since the days of Petit in 1727, and more espe- cially of Dupuy (1816), Breschet (1837), John Beid (1838), Bifid (1&46), Budge and Waller (1851), and finally of Bernard and Brown- Sequard (1852). Bernard discovered the remarkable increase of heat which fol- lowed section of the nerve, and Brown-Scquard showed that cold was produced on applying galvanism to it. It is now recognised that if we cut the trunk of the sympathetic, heat commences in the neighboring ])arts almost immediately, and will continue for weeks without producing inflammation, oedema, or other effect, so long as the animal remains in good condition. But if it falls sick, either spontaneously or in conse- quence of other operations, the na.sal and ocular mucous membranes of the affected side become red and swollen, and secrete pus in great abun- dance. The inflammation of the conjunctiva described by Dupuy, J. Beid, and others, is therefore an accidental phenomenon produced by the debility of the animal, and may be avoided by giving it food and sup- porting its strength. * Essays on the Secretory and Excito-Secretory System of Nerves, etc. Phila- delphia. 1857. HEALTHY AND DISEASED INNERVATION. 147 Thus in the same manner that when we irritate a sensitive nerve we . excite motion through a motor nerve, or secretion and nutrition through thi nerves distributed to glands or to the tissues, so we excite cold by iiritating the ganglionic system of nerves, and heat by destroying their action or exhausting it. These phenomena are those of fever. Sensation may be defined to be the consciousness of an impression^ and that it may take place, it is necessary — 1st, That a stimulus should be applied to a sensitive nerve, which receives an impression; 2d, That, in consequence of this impression, a something, which we designate an influence, should be generated, and conducted along the nerve to the hemispherical ganglion ; 3d, On arriving there, it calls into action that fiiculty 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 impressions; which im- pedes 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 inat- tentive, excited, or suspended. The independent endowment of nerve 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, galvanic, or other physical stimuli, when applied to the course or the extremities of a nerve, cause the very same results as may originate from suggestive ideas, perverted imagination, or psychical stimuli. Thus a chemi- cal irritant, galvanism, or pricking and pinching a nerve of motion will cause convulsion and spasms of the muscles to which it is distributed. The same stimuli applied to a nerve of common sensation will cause pain, to the optic nerve flashes of light, to the auditory nerve ringing 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 Section on General Therapeutics.) Motion is accomplished through the agency of muscles, which are endowed with a peculiar vital property, called contractility, in the same way that nerve is endowed with the property of sensibility. Contractility may be called into action altogether independent of the nerves (Haller), as by stimulating an isolated muscular fasciculus directly (Weber). It may also be excited 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 parts of iliahodiy diastaltically (Marshall Hall) — that is, through the spinal cord. In this latter case the following series of actions take place : — 1st, The influence of the im- pression is conducted to the spinal cord by the afferent or esodlc filaments which enter the grey matter. 2d, A motor influence is transmitted out- 148 PRINCIPLES OF MEDICINE. wards by one or more efferent or exodic nerves. 3d, This stimulates 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. Thus, then, we may consider that the brain acting alone furnishes the conditions necessary for intelligence ; the spinal cord acting alone fur- nishes the conditions essential for the co-ordinate movements necessary to the vital functions : and the brain and spinal cord acting together furnish the conditions necessary for voluntary motion and sensation. The following aphorisms will be found useful in endeavoring to reason correctly on the functions of the nervous system : 1. The brain proper is that portion of the encephalon situated above the Corpus Callosum. 2. The spinal cord is divided into a cranial and a vertebral portion. 3. The grey matter evolves and the white conducts nervous power. 4. ContractilUy is the property peculiar to fibrous texture, whereby it is capable of shortening its fibres. Motion is of three kinds, contractile^ dependent on muscle — diastaltic, dependent on muscle and spinal cord — voluntary, dependent on muscle, spincti cord, and brain. 5. Sensibility or excitability is the property peculiar to nervous tex- ture, whereby it is capable of receiving impressions. Sensation is the consciousness of receiving such impressions. 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 within the cranium must always be the same so long as its osseous lualls are capable of resisting the pressure of the atmosphere. There are few principles in medicine of greater practical importance than the one yre are about to consider, — the more so, as many able practitioners have lately abandoned their former opinions on this head, and on what I consider to be very insufficient grounds. On this point, therefore, I cannot do better than condense and endeavor to put clearly before you the forcible arguments of the late Dr. John Reid, with such other considerations as have occurred to myself. That the circulation within the cranium is different from that in other parts of the body, was first pointed out by the second Monro. It was tested experimentally by Dr. Kellie of Leith, ably illustrated by Dr. Abercrombie, and successfully defended by Dr. John Reid. The views adopted by these distinguished men were, that the cranium forms a spherical bony case capable of resisting the atmospheric pressure, the only openings into it being the different foramina by which the vessels, nerves, and spinal cord pa^ss. The encephalon, its membranes, and blood- vessels, with perhaps a small portion of the cerebro-spinal fluid, com- HEALTHY AND DISEASED INNERVATION. 149 pletely fill up the interior of the cranium, so that no substance can be dislodged from it without some equivalent in bulk taking its place. Dr. Monro used to point out, that a jar, or other ve.ssel similar to the cranium, with unjieldihg 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 further, we must draw a distinction between pressure on, and compression of, an organ. Many bodies are capable of sustaining 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 generally are not absolutely incompressible, yet it requires the weight of one atmosphere, or fifteen pounds on tli3 square inch, to produce a diminution equal to 2 0^00 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 circumstances, can the contents of the cranium be diminished even the 20000 ^^ part. When the brain is taken out of the cranium, it may, like a sponge, be compressed, by squeezing fluid out of the blood-vessels ; but during life, surrounded, as it is, by unyielding walls, this is impossible. For let us, with Aber- crombie, say, that the whole quantity of blood circulating 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 effused, blood extravasated, or tumors grow within the cranium, a corresponding amount of fluid must be pressed out, or of brain absorbed, from the physical impossibility of the cranium holding more matter. At the same time, it must be evident that an increased or diminished amount of pressure may be exerted on the brain, proportioned to the power of the heart’s contraction, the effect of which will be, not to alter the amount of fluids within the cranium, but to cause, usiug the words of Abercrombie, “ a change of circulation” there. This is all, it seems to me, that is shown by the ingenious experiments of Bonders, who saw venous con- gestion 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 possible the return of the blood from the brain, and one of the * Nederlandeche Lancet, 1850. 150 PEINCIPLES Of medicine. carotids was then opened. He inferred, from the whole inquiry, which was conducted with extreme care, “ That we cannot, in fact, lessen, to any considerable extent, the quantity of blood within the cranium by arteriotomy or venesection ; and that when, by profuse haemorrhages, de- structive 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, serving to maintain the plenitude of the cranium.” Dr. Kellie made other experin'.ents 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 differences between the appearances of the brain in these cases, and in those where the cranium was entire, were very great. One of the most remarkable of these diffei- encos 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 cra- nium, and a space left, which was found capable of containing a tea- spoonful of water.” It results from these inquiries, that there must always be the same amount of fluids within the cranium so long as it is uninjured. In morbid conditions these fluids may be blood, serum, or pus ; but in health, as blood is almost the only fluid present (the ce'rebro-spinal fluid being very trifling), its quantity can undergo only very slight alterations. There are many circumstances, however, which occasion local congestions in the brain, and consequently unequal pressure on its structure, in which case another portion of its substance must contain less blood, so that the amount of the whole, as to quantity, is always preserved. These circum- stances are mental emotions, haemorrhages, effusions of serum, and morbid 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 ar- teries and the presence of the cerebro-spinal fluid, described by Magendie. The views now detailed had been very extensively admitted into pathology, when Dr. Burrows, of St. Bartholomew’s Hospital, endeavored to controvert them, first in the Lumleian lectures of 1843, and subse- quently in a work published in 1846, entitled “ On Disorders of the Cerebral Circulation, and on the connections between Affections of the Brain and Diseases of the Heart.” Dr. Burrows, however, evidently misunderstood the doctrine we are advocating. Thus, he is always com- bating the idea that blood-letting, position, strangulation, etc., cannot affect the hlood m the hrain ; whereas the real proposition is, that they cannot alter t\\Q fluids within the cranium. By thus confounding blood with fluid, and brain with cranium, he has only overthrown a doctrine 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 from them that are erroneous. For the paleness which results from HEALTHY AND DISEASED INNEEVATION. 151 hseinorrliage, and the difference observable in the color of the brain, when animals, immediately after death, are suspended by their ears or by their heels, is explicable by the diminished number of colored blood particles in the one case, and by their gravitation downwards in the other. That the amount of fluid within the cranium was in no way affected, is proved by the plump appearance of the brains figured by Dr. Burrows, and the total absence of that shrunken appearance so well described by Dr. Kellie. Neither does our observation of what occurs in asphyxia or apnoea, oppose the doctrine in question, as Dr. Burrows imagines, but rather confirms.it. On this point the following observations by Dr. John Beid 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 exception of the vertebral arteries, compressed and then obstructed. These two arteries, which are protected by the peculiarity of their course through the foramina of the transverse processes of the cervical vertebras, 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 admit- ted by Dr. Burrows, although he endeavors to get rid of so troublesome a fact by a gratuitous hypothesis, which will not bear a moment’s exa- mination, but for the refutation of which I must refer to the works of Dr. Beid.^ 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 effects of bleeding are explained by the influence produced on the heart, the altered pressure 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, Kellie, and Abercrombie. But so far is this theory concerning the circulation within * Physiological, Anatomical, and Pathological Researches, No. XXV. 152 PPJJVCirLES OF MEDICINE. the cranium from being shaken by the attack of Dr Burrows, that ii may be said now to stand on a firmer basis than ever, owing to that attack having drawn forth the convincing reasoning and unanswerable argu- ments of so sound an anatomist, physiologist, and pathologist, as the late Dr. John Keid. (2.) All the functions of the nervous system may he increased, 'perverted^ or destroyed^ according to the degree of stimidus or disease operating on its various parts. — Thus, as a general rule, it may be said, that a slight stimulus produces increased or perverted action ; whilst the same stimu- lus, long continued or much augmented, causes loss of function. All the various stimuli, whether mechanical, chemical, electrical, or psychical, produce the same effects, and in different degrees. Circumstances 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 vigor and activity in the muscular system. As the stimulus augments in intensity, we see irregular movements occa- sioned, staggering, and loss of control over the limbs. Lastly, when the stimulus is excessive, there is complete inability to move, and the power of doing so is temporarily annihilated. With regard to sensibility and sensation, we observe cephalagia, tingling, and heat of skin, tinnitus aurium, confusion of vision, muscse 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, me- chanical irritation, and the various organic diseases, produce augmented, perverted, or diminished function, according to the intensity of the sti- mulus applied, or amount of structure destroyed. Then it has been shown that excess or diminution of stimulus, too much or too little blood, very violent or very weak cardiac contractions, and plethora or extreme exhaustion, will, so far as the nervous functions are concerned, produce similar alterations of motion, sensation, and in- telligence. Excessive haemorrhage causes muscular weakness, convul- sions, 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 treat- ment of these will be altogether different, according as the individual is robust or weak, has a full or small pulse, etc. These similar effects on the nervous centres from apparently such opposite exciting causes, can, it seems to me, only be explained by the peculiarity of the circulation previously noticed. A change of circulation within the cranium takes place, and, whether arterial or venous congestion occurs, pressure (3n some portion of the organ is ecpially the result. The importance of pay- ing attention to this point in the treatment must be obvious. (3.) The seat of the disease in the nervous system influences the nature of the phenomena or symptoms produced. — It is a matter of very great im- portance to ascertain how far certitude in diagnosis may be arrived at, and the seat of the disease ascertained. On this subject it may be affirmed that, although clinical observation combined with pathology has done much, more requires to be accomplished. As a general rule, it may be HEALTHY AND DISEASED INNERVATION. 153 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 remarkably rare. Besides, it has always appeared to me probable that, inasmuch as extensive organic disease, if occurring slowly, may exist without producing symptoms, whilst it is certain most important symp- toms may be occasioned without organic disease, even these few excep- tional cases are really not opposed to the general law. Then, as a general rule, it may be said that diseases of the brain proper are more especially connected with perversion and alteration of the intelligence ; whilst disease of the cranial portion of the spinal cord and base of the cranium are more particularly evinced by alterations of sensation and motion. In the vertebral portion of the cord, the intensity of pain and of spasm, or else the want of conducting power, necessary to sensation and voluntary motion, indicates the amount to which the motor and sensitive fibres are aflected. Further than this we can scarcely generalise with prudence, although there are some cases, as we shall subsequently see, where care- ful observation has enabled us to arrive at more positive results. The fatality of lesions afiecting 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. Con- vulsions and paralysis are the common results of disease of the ganglia, in the cranial portion of the cord. The same results from lesion of the pons varolii. But if the medulla oblongata, where the eighth pair originates, be affected, or injury to this centre itself occur, it is almost always immediately fatal. (4.) The rapidity or sloivness with which the lesion occurs influences the phenomena or symptoms produced . — It may be said as a general rule, that a small lesion (for instance, a small haemorrhagic extravasation), occur- ring suddenly, and with force, produces, even in the same situation, more violent effects than a very extensive organic disease which comes on slowly. This, however, will depend much upon the seat of the lesion. Very extraordinary cases are on record, where large portions of the nervous centres have been disorganised, without producing anything like the violent symptoms which have been occasioned at other times by a small extravasation in the same place. -Here again the nature of the circulation within the cranium offers the only explanation, for the ence- phalon 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 ac- cording to circumstances, wdiereby pressure is avoided. (5.) The various lesions and injarics of the nervous system produce phe- nomena similar in hind . — The injuries which may be inflicted on the ner- vous system, as well as the morbid appearances discovered after death, are various. For instance, there may be an extravasation of blood, exudation of lymph, a softening, a cancerous tumor, or tubercular deposit, and yet they give rise to the same nervous phenomena, and are modified only by the circumstances formerly mentioned, of degree, seat, suddenness, etc. Certain nervous phenomena also are of a paroxysmal character, whilst the lesions supposed to occasion them are stationary 154 PRINCIPLES OF MEDICINE. 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 com- mon ; and this, it appears to me, may consist of — 1st, Pressure with or without organic change ; 2d, More or less destruction or disorganisation of nervous texture. Further, when we consider that the same nervous symptoms arise from irregularities in the circulation ; from increased as well as diminished action ; sometimes when no appreciable change is found, as well as when disorganisation lias occurred — the theory of local congestions to explain functional alterations of the nervous centres seems to me the one most consistent with known facts. That such local con- gestions do frequently occur during life, without leaving traces detectable after death, is certain ; whilst the occurrence of molecular changes, or other hypothetical conditions which have been supposed to exist, has never yet been shown to take place under any circumstances. While such appear to me to be some of the generalisations which are important to the physician wdth regard to the nutritive and nervous functions, viewed separately, it should never be forgotten that he has constantly to do with their conjoint action. Indeed, the derangement of one order of functions exercises a constant influence over the other, so that in every disease the effects of disordered nutrition are visible in perverted innervation, and the converse. Thus an improper quantity or quality of food produces sometimes excitement, at others dulness of in- tellect. Various articles of diet have been known to cause violent head- ache 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 apoplexies 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 thoughts 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 secretions, 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 followed 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, injury of a great sympathetic trunk produces similar loss of nutrition without impairment of sensibility or motion, of which * “ Give sorrow words ; the grief that will not speak, Whispers the o’erfraught heart, and bids it break.” — Shakspeare. INFLAMMATION. 155 tlio most remarkable example I am acquainted with is recorded by Pro- fessor Komberg of Berlin. It was that of an unmarried woman, aged twenty-eight, in whom, as the result of extensive suppuration on the left side of the neck, which burst through the tonsil, the features on the corresponding side of the face gradually became atrophied, without any di- minution 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 divid- ing her hair towards the right, so as to equalise 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 of the opposite one. Further illustrations of the general principles now detailed wi.l be constantly met with under the head of special diseases. INFLAMMATION. The important morbid change in the animal economy denominated inflammation, is so intimately interwoven with the theory and practice of medicine, that it meets us at the very commencement of our patho- logical inquiries. In all ages it has been made the pivot upon which the medical philosophy of the time has revolved, and any doctrine capable of explaining the various phenomena it presents, cannot but furnish those principles on which our science and art must ultimately rest. I. — Phenomena of Inflammation. — When, with the view of deter- mining the phenomena of inflammation, we sufficiently irritate the trans- parent vascular membrane of some animal — such as the web of the frog’s foot — we observe, 1st, An increased rapidity of the circulation in the smaller vessels ; 2d, That the same x^essels become enlarged, and the current of blood is slower, although even ; 3d, That the fl^ow of blood Fir;. 184. Remarkable atrophy of the left side of the face, in a woman aged 28, without loss of sensibility or motion in the atfected parts. — {Romberc/.) 156 PRINCIPLES OF MEDICINE. becomes irregular and oscillates; 4th, That the current ceases, and the vessels are distended with colored corpuscles ; and 5th, That the liquor sanguinis is exuded through the walls of the vessels, and that occasionally, in consequence of their rupture, extravasation of blood corpuscles takes place. The first step in the process, viz., narrowing of the capillaries, is readily demonstrated on the application of acetic acid to the web of the frog’s foot. If the acid be weak, the capillary contraction occurs more slowly and gradually. If it be very concentrated, the phenomenon is not observed, or it passes so quickly into complete stoppage of blood, as to be imperceptible. Although we cannot see these changes in man under the microscope, certain facts indicate that the same phenomena occur. The operations of the mind, for instance, as fear and fright, and the application 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 wdiich con- stitutes the second step of the process. In other cases, the redness may arise primarily from certain mental emotions, or from the application of heat ; and in both instances depends on the enlargement of the capillaries, and the greater quantity of blood which is thus admitted into them.'^ The variation in the size of the capillaries, and of the amount of blood in them, is conjoined with changes in the movement of that fluid. Whilst the vessels are contracted, the blood may be seen to flow with increased velocity. After a time the blood flows more and more slowly, without, however, the vessel being obstructed : it then oscillates, that is, moves forwards and backwards, or makes a pause, which is evidently synchronous with the ventricular diastole of the heart. At length the vessel appears quite distended with yellow or colored corpuscles, and all movement ceases. Again, these changes in the movement of the blood induce variations in the relation which the blood corpuscles bear to each other, and to the * It has been asserted that instead ot 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 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 Oberhaeuser’s eye micrometer the diameter of various vessels before, during, and after the application of stimuli. The results were, that immediately hot water was applied, a vessel which measured 13 spaces of the eye micrometer contracted to 10 ; another that measured 10 contracted to V ; a third that measured 7 contracted to 5 ; a fourth, which was a capillary carrying blood globules in single file, and measured 6, 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 ad- dition 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 occur- red. The smaller veins were seen to contract as much as the arteries of the same size. INFLAMMATION. lo7 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 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 colored corpuscles are hurried forward in the centre of the vessel, occasionally mixed with Fig. 135. some lymph corpuscles. These latter, however, may frequently 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 young frogs, their number is often very great ; but then they constitute a normal part of the blood. Fig. 135. 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 running 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. а, A deep-seated vein, partially out of focus. The current of blood is of a deeper color, 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 plasma, is very apparent, containing a number of colorless corpuscles, clinging to, or slowly moving along, the sides of the vessel. б, 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 capillary vessel has produced an extravasation of blood, which resembles a brownish-red spot. At (Z, congestion has occurred, and the blood corpuscles are apparently merged into one semitransparent reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, j)artly by the action of the alcohol, partly by the exudation. This latter entirely fills up tho spaces, or only coats the vessel. 20U diam. 158 PEmCIPLES OF MEDICINE. and in no way impede the circulation. In old frogs, on the other hand, all these, and subsequent changes, may be observed, without the presence of colorless corpuscles. When the capillaries enlarge, however, the central colored column in the smaller vessels may be 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 colored 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 colored corpuscles, the original form of which can no longer be dis- covered, so that the tube appears to be filled with a homogeneous deep crimson fluid. This is congestion. If the morbid processes continue, the vessel may burst, causing haemorrhage, or the liquor sanguinis may trans- ude through its walls, without rupture, into the surrounding texture. This last is exudation. II. Theory of Inflammation. — It is of the utmost importance in pathological inquiries to separate facts from theories. Our facts may be correct, although the conclusions derived from them are wrong. This proposition, however generally admitted, is seldom adhered to in prac- tice ; for, in medical writings and statements, we frequently find fact and hypothesis so mingled together, that it often requires considerable critical and analytical power to separate the one from the other. We are, how- ever, in all cases, insensibly led to theorise — that is, to attempt an ex- planation 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 generalisa- tions of known facts, and are ready to abandon them the moment other facts point them out to be erroneous. The phenomena of inflammation, previously described, may easily be demonstrated — they constitute the facts. Let us now examine how they have been attempted to be ex- plained — in other words, what is the theory. 1. The contraction and dilatation of the capillaries are explicable, by supposing them to be endowed with a power of contractility analogous to that existing in non-voluntary muscles. John Hunter thought they were muscular, from the results of his observations and experiments; and they may be shown by the histologist to consist of a delicate mem- brane, in which permanent nuclei are imbedded. Mr. Lister has recently 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 directly. 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 muscular paralysis. The recent observations of Cl. Bernard and others as to the effects produced by dividing the large nervous trunk of the sympathetic in the neck, have singularly confirmed this theory. INTLAMMATIOX. 159 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 patholo- gists, 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 animals, 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 san- guinis, however, which is most difficult to explain ; for why, so long as there is no mechanical obstruction (and during this process none has ever been seen), should the circulation through the capillaries of a part cease ? In reasoning on this matter, observation must ultimately satisfy us that it cannot depend upon any mechanical impediment, such' as the plugging-up of the vessel by colored corpuscles (Boerhaave) ; multipli- cation of the colorless corpuscles (Addison and Williams) ; change in the specific gravity or viscidity of the blood in a part (Wharton Jones), or of the corpuscles in particular (Bruecke) ; obstruction of the venous circulation (G. Robinson) ; or adhesiveness of the blood corpuscles (Lister.) That the blood corpuscles, indeed, have a tendency to aggregate together is certain; and I have frequently seen what Mr. Lister has described — namely, a roll of them projecting from a side vessel into a larger one, and oscillating in the current without separating. But that this is produced by a viscous condition of these bodies, which causes their surfaces to stick together, as he appears to think, is negatived by the fact, that not unfre- quently I have seen one or more of them approach rapidly a vessel in the inflamed tis.sue not yet obstructed, then proceed slowly, oscillate for a while, until at length, getting beyond the diseased parts, it has again darted off with the same velocity as it came. Again, it may frequently be observed, when a vessel is so full of colored corpuscles that they can no longer be distinguished, and seem to have melted together, that on rupturing it, these bodies are extravasated, at once assume their original form, and arrange themselves just the same as they do on coming from a healthy structure. I cannot suppose, therefore, that the cause of stasis is connected with adhesiveness of the blood corpuscles ; indeed, many of the valuable observations of Mr. Lister himself only confirm what I have long maintained — namely, that they are simply drawn together and brought more closely into contact by some external force, which is excited by irritation of the surrounding tissue. The only theory which appears to me capable of explaining the well- recognised changes in inflammation, is one which attributes them to a vital force, not seated in the blood or blood-vessels, but in the tissues out- side the vessels. We have previously seen, when speaking of secretion and nutrition, that a power must exist in the ultimate molecules of the textures, whereby they attract and select materials from the blood. A 160 PRINCIPLES OF MEDICINE. modification of this power, whereby the attractive property is augmented, and the selective one diminished, at least offers us an explanation con- sistent with all known facts, and seems to be the only active agency to which we can ascribe the aggregation of the colored particles to one an- other in the inflamed part, their approach to the vascular walls, and the passage through these last of the exudation. This increased attraction, the result of irritation operating on the nearest blood-vessels, producing in vascular parts exudation, constitutes inflammation. It may cause other effects, which, as we shall subsequently see, ought to be distinguished from that morbid state. The nature and mode of operation of this attrac- tion may be illustrated by the well-known effects which an electrical current produces when passing round a piece of soft iron. Let the chemical action on the metallic plates be regarded as the irritant, the excited electrical stream as the attractive force evolved, then the adhesion of a piece of iron to the one affected by the induced current represents the effects on the blood. So long as this current influences the iron within the helix, the attractive power exists ; and so long as a certain amount of irritation operates on the tissue does inflammatory congestion continue. In both cases, also, the increased attractive force so produced must be molecular — that is, must depend upon the altered relations existing among the ultimate molecules of the iron in the one instance, and those of the living tissue in the other. III. The necessity of giving to the word “ Inflammation ” a de- finite MEANING. — On this point Andral has >vell observed : — “ Created in the infancy of science, this expression, altogether metaphorical, was destined to represent a morbid state in which the parts appeared to burn, to be inflamed, etc. Received into general language without any precise idea having ever been attached to it — in the triple relation of symptoms which announce it, of the lesions which characterise it, and of its intimate nature — the expression ‘ inflammation ’ has become so very vague, its interpretation is so very arbitrary, that it has recently 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.” Magendie says : “ One could fill an entire book with all the ideas which represent the word ‘ inflammation,’ for it is synonymous with the word ‘ disease.’ ’’ To judge of the correctness of these statements, let us for a moment attend to what has been called inflammation, and the contradictory ideas which prevail on this matter. 1. Symptoms have been supposed to constitute inflammation, and especially pain, heat, redness, and swelling. Yet the most fatal inflam- mations are now known to represent only one or two of these symptoms, and in not a few no single one of them has been recognised. For ex- ample, an old man may suddenly lose his appetite and strength ; his respirations become hurried and feeble ; his chest, on examination, is dull on percussion ; mucous rattles are heard by the ear, and he dies. On opening his body grey hepatization has attacked the lungs, which are infiltrated with pus. He has from first to last had no pain, there has been no heat, on the contrary, the temperature was diminished ; no red- ness nor swelling is anywhere detectable. Such cases have been called INFLAMMATIOX. 161 latent pneumonia, and latent inflammations of every viscus are very com- mon and very fatal. The truth is, the great writers on the subject have been surgeons, who, because phlegmonous abscesses and exte^-nal inflam- mations are usually accompanied by these signs, have supposed them to characterise all inflammations. Modern clinical investigation, however, has demonstrated that in the brain, lungs, heart, pleura, kidneys, and internal organs, inflammation frequently presents no such symptoms.* Not only, therefore, are the cardinal symptoms not characteristic of inflammation, but the idea that such is the case has led to the most mis- chievous results in practice. 2. Is irritation of texture inflammation ? This doctrine has long been formularized by the expression, uhi irritatio ihi affluxus. Irritation may, as we have seen, produce inflammation, but very often it does not do so. It may simply excite the nerves, and occasion heat and redness for weeks without causing inflammation. Even when textural irritation is excited through the nerves by reflex action, the vessels immediately in connection with such nerves are not more disturbed than those at some distance, showing that the effect must be produced through the elements of the tissue. When applied at intervals it may produce induration and hypertrophy of texture, as when a corn grows , but this is not inflam- mation. It may produce cell-growth and cell-multiplication in any texture, but this, also, is not inflammation, as it may be a fibrous tumor or a cancer. We cannot, therefore, characterise inflammation by the cause which occasions it: we must look for something significant in the parts diseased. 3. Is contraction or dilatation of the blood-vessels inflammation? We see paleness and redness of tissues, in consequence of these alterations in the vessels constantly occurring from mental emotions or exposure to cold and heat, friction, etc. ; yet no one would say of a face suffused with ablush, red with anger, or warm from exposure to heat, that it is inflamed. In the experiments of Bernard on the sympathetic nerves, intense redness and excessive heat in parts have been maintained for weeks without inflam- mation. To produce it something evidently must be superadded. Mere congestion, therefore, ought to be carefully separated from inflammation. 4. Is capillary haemorrhage inflammation ? This is a result of con- gestion and rupture of the vessel from over-distension with blood. It often accompanies, but is by no means essential to, inflammations. It may also occur under circumstances where inflammation is not to bo thought of — as, for example, in menstruation. This periodical congestion and haemorrhage from the capillaries, though frequently accompanied by all the so-called cardinal symptoms, can never be regarded as in its nature inflammatory. It is not a monthly metritis and ovaritis. Hence capil-- lary haemorrhage, like congestion, requires something more to convert it into inflammation. 5. Is serous effusion inflammation ? This constitutes dropsy, and is always dependent on venous congestion. Hence, when important organs— such as the heart, lungs, liver, or kidneys — are so diseased * See case of Edward Campbell (acute pericarditis) ; of John Young (adherent pericardium); of Peter M’Guine (acute pleurisy) ; of William Dow (pneumo-thorax), etc. 11 162 Fi:iNCIPLES OF :S[EI)ICINE. as to prevent the return of blood from the capillaries, oedema occurs. Meclianical pressure on, or internal obstructions of veins produce the same effect. This is not inflammation. The so-called serum of a blister is, in truth, an exudation, contains fibrin, and coagulates on cooling. It is not allied to the dropsies, but is truly inflammatory. 6. Is stoppage of the blood (stasis) inflammation ? On this point Mr. Norris has recently pointed out^ that stoppage of the blood, with aggregation of the corpuscles, may arise — 1st, from constriction of the arteries, atid thus shutting off the cardiac force from the capillaries; 2d, from weakening the heart’s contractions; and, 3d, in a limb, from strangulation. In neither of these cases is there inflammation. The experiments of Mr. Lister show that carbonic acid, applied locally, pro- duces such congestion, although his employment of the term “ inflamma- tory congestion ” in such cases, shows that he has not distinguished this (Condition from true inflammation. In asphyxia, the blood-vessels in the lungs are highly congested and the circulation arrested ; but there is no pneumonia. 7. Is the exudation of the liquor sanguinis inflammation ? To this I answer. Yes. It is in truth, the only morbid phenomenon — the only part of the process, which, whenever it occurs, unequivocally charac- terises an inflammation. t The late Dr. Aiison maintained, that what was requisite to give precision to the general notion of inflammation was, in addition to the four cardinal symptoms, to include in it a tendency always observed to effusion from the blood-vessels of some new products capable of assuming the form of coagulated lymph or purulent matter. But, as this tendency to a certain act can never be separated from the act itself, or be recognised in the body, it cannot give the precision which is de- sired. Indeed, it is only when the exudation has occurred that we can ever feel satisfied that even the tendency existed. It follows that no one of the preliminary phenomena, nor all of them combined, constitute an inflammation unless exudation has occurred ; so that, for all practical as well as scientific purposes, it may be said that this morbid state con- sists essentially of an exudation of the liquor sanguinis. J ^ Proceedings of the Royal Society, vol. xii., p. 258. f The term exudation lias been introduced into pathology, not only to express the act of the liquor sanguinis passing through the walls of the blood-vessels, but also to denominate the coagulation of the fibrinous portion of the liquor sanguinis itself, upon the surface, or in the substance of any tissue or organ of the body. Tlie 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 inflamma- tory, tubercular, and cancerous ; it may be associated with every form of morbid growth; it often gives rise to concretions, and frequently constitutes the soil in which grow those parasitic vegetations 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 separated from lesions of innervation. \ Mr. Norris even argues that exudation precedes the stoppage of the blood, and is the cause of it. This he denominates the primary exudation, which, by causing increased viscidity of the blood, produces what he calls homogeneous stasis. INFLAMMATION. 163 The objections to this viow are of two kinds. In the first place, it is said that epithelium, cartilage, cornea, and non-vascular parts, maybe inflamed, although they contain no blood-vessels, and consequently can have no exudation poured into them. But the morbid changes which occur on irritating these structures are so widely diflPerent from those which are produced in vascular parts that they ought never to be con- founded together. Thus, on irritating non-vascular structure, such as cartilage, we find the cells nearest the injury enlarge, the included con- tents gradually form secondary cells, and the intercellular substance be- comes opaque and soft from deposition of molecules, or from fibrillation. The first of these changes — namely, enlargement of pre-existing cells — is well shown in a section of the patella into which an incision was made by Redfern (Fig. 136) ; and the second, or molecular deposition and fibrillation, in Fig. 137. The same occurs in epithelium and cornea Nothing can be more different from such changes than that which occurs in vascular parts, where we have alteration in the blood-vessels and blood, as formerly described, always followed by exudation, and the production of new cells from a molecular blastema, rather than in the interior of old ones. In fact, the two morbid states are wholly different. To suppose, indeed, that mere irritation always produces inflamma- tion, whatever be the change effected, is to confound morbid processes widely different in character with one another. Such of the German pathologists as have adopted this doctrine, under the head of parenchy- Fig. 136. Cartilage on each side of an incision made into the patella of a dog. Thirty days afterwards the cells were found enlarged, with internal multiplication of nuclei, as seen in the figure. (Redfern.) Fig. 1.37. Vertical section of cartilage from the surface of the patella, showing at the same time cell-growth, histolytic molecular formation, and fibrillation. 250 diam. 164 PRINCIPLES OF MEDICINE. matous inflammation, sometimes include under it fatty degeneration of muscle, sometimes hypertrophy of texture, and sometimes even cancer. According to such views, the term inflammation would equally well apply to an encephaloma as to the pulpy softening of cartilages — to a corn as to a fibro-nucleated growth. We argue it should be applied to none of these, but only to that perverted alteration of the vascular tissues which produces an exudation of the liquor sanguinis. Should different results be occasioned by irritation, they are congestion on the one hand, or in- creased growth — that is hypertrophy — on the other. In the second place, it is now known that exudations occur, and are often very fatal, under circumstances where the old idea of inffammation, or an active condition attended by acute symptoms, cannot apply. In short, the modern pathologist and the senior practitioner are widely divided in thought. The former regards the essence of the process; the latter the occasional phenomena it presents. As there is no necessary relation between the two, it follows that the only escape from the con- fusion thus arising is, as Andral suggested, the removal of the word inffammation from medical nomenclature. No doubt the future employ- ment of the terms congestion, stasis, exudation, morbid growth, etc. etc., would remove much of our difficulties. Those, however, who continue to use the term inflammation can only do so with exactitude in the sense of an exudation of the liquor sanguinis. This is the only view of it which is consistent with all known facts, and it possesses the further merit of having led in recent times to the most valuable results in practice. Terminations of Inflammation. Once established, further changes occur in the exuded matter. These have been called the terminations of inflammation, and were considered by John Hunter to be adhesive, suppurative, ulcerative, gangrenous, etc. I have long taught, however, that we should distinguish two great results of the exudation — viz., that it may live or die. If the exudation lives, it constitutes a molecular blastema, in which new growths, temporary or permanent, spring up according to the molecular law of development, such as pus and adhesive lymph. When, on the other hand, the exudation dies, three things may result — 1st, Rapid death, with chemical decom- position, producing mortification or moist gangrene; 2d, Slow death, with disintegration of tissues, causing ulceration; 8d, What may be called a natural death of the transformed exudation, whereby it is broken down, liquefied, and at length absorbed. This is resolution. IV. 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 pathologists in certain conditions, denominated respectively diathesis, dyscrasia, or cachexia. I propose at present to direct your attention to some of the changes which take place in the exudation as it occurs in the body during health. These vary — 1st, As it occurs on serous membranes, where it exhibits a finely fibrous structure, and has a strong tendency to be developed into INFLAMMATION. 165 molecular fibres ; 2d, As it occurs on mucous membranes, or in areolar tissue, where it is generally converted into pus corpuscles ; 3d, When it occurs in dense parenchymatous organs, such as the brain, where it assumes a granular form, and is associated with numerous granular • orpuscles ; 4th, As it is poured out after wounds or injuries, and occurs Oil granuhicing sores. In this last case the superficial portion is trans- formed 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. O.i examining the minute structure of the exudation on a serous surface when recently formed, and when it presents a gelatinous semi- transparent appearance, it will be found to be made up of minute filaments mingled with corpuscles (Fig. 138). 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 buffy coat of the blood. As the exudation becomes firm, the filaments appear more distinct and consolidated, varying from yj To 0 0 0 ^^^ of an inch in diameter. Bundles, or different layers of them, often cross each beco nes older they assume more and more the character of those in dense fibrous tissue. The corpuscles, when newly formed, are delicate and transparent, 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 toVo^^j enclosed granules from yy^ool-h loooo^^ diameter. On the ad- dition of water and acetic acid, the corpuscles undergo no change, al- though sometimes the latter re-agent causes the cell wall to contract and thicken ; and at others, to be somewhat more transparent. In 1842, I ‘r.V.'.a Fig. 138. other ; and as the lymph Fig. 130. Fig 140. Fig. 141, Fig. 142. Fig. 143. separated tliese bod.es from pus cells, and called them plastic corpuscles, from the frequency of their occurrence in plastic lymph. Lebert in Fig. 138. Molecular fibres and plastic corpuscles, in simple exudation on a serous surface, a, The latter after the addition of acetic acid. 250 diam. Fig. 139. A portion of recent lymph from the pleura. Fig. 140. Another portion of the same, further developed. Fig. 141. Portion of firm pleural adhesion. Fig. 142. Another portion of the same, further developed. Fig. 143. The last acted on by acetic acid. — {Drummond.) 180 diam. 166 PRINCIPLES OF MEDICINE. 1845, confirmed my description, and called them fyoid^ from their re- semblance to pus. These corpuscles after a time melt away among the fibres, but several of them remain, constituting, as shown by Dr. Drummond, permanent nuclei. After a time, blood-vessels grow in the exuded lymph (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 ulti- mately form the dense chronic adhesions so common between serous membranes. (See pp. 174-75.) 2. Exudation poured out on a mucous membrane sometimes presents a fibrous mass, as in cases of croup and diphtheritis, but more generally it passes into an opaque, unctuous, straw-colored fluid, long known under the name of pus. When poured into the meshes of areolar tissue, and occasionally into the substance of the brain, the same transformation occurs, and then forms an abscess. On examining the minute structure of pus, it is seen to be composed of numerous corpuscles floating in a clear fluid. These corpuscles are globular in form, and vary in size from the of an inch in diameter. Their surface is finely punctated. 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 increased in size and more transparent, their Fi^. 144 finely punctated surface disappearing. Weak acetic acid partially, and the strong acid com- Fig. 145 . plelcly, dissolves the cell-wall, and brings into view ail included body, generally composed of two or three granules close together, and rarely four or five, each with a central shadowed spot. These are usually about the g of an inch in diameter. (Figs. 144, 145 ; also Figs. 66, 67.) In some cases the pus corpuscles now described are surrounded by an albuminous layer closely resembling a delicate cell-wall (Fig. 68), which I first described in 1847. It is about the or of an inch in diameter, and is highly elastic, assuming different shapes, ac- cording to the degree and direction of the pressure to which it is sub- jected. Water and acetic acid cause it at once to dissolve, whilst the included pus corpuscles exhibit the usual body . ^ .... . composed of two or three granules. In what is called scrofulous pus, the cor- puscles, instead of being round and rolling freely on each other, are misshapen and irre- gular (Fig. 69), and, on the addition of acetic Fig. 146. acid, the granular nuclei are found to be ill formed or absent (Figs. 146, 147). 3. In parenchymatous organs, the exudation insinuates itself among O. •iS-O ■'w' a:) Fig HJ. Fig. 144. Pus cells. Four cells have been acted on by acetic acid. Fig. 145. Pus cells containing fatty molecules, after adding acetic acid. Fig. 146. Sciofulous pus cells after the addition of acetic acid. Fig. 147. The same. In both specimens the nuclei are irregular or absent. 250 d.l IXFLxiMMATIOX. 167 Fig. 148. tliG elementary tissues of wliicli 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 well 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 form of minute molecules and granules, which are frecpently seen coating the ves.^^els externally, and filling up the intervascular spaces (Fig. 148). The granules vary in size from the 73^0 the 6 in diameter. They always contain among them round transpa- rent globules, varying in size from the ;g^i(j-„th to of ioch in diameter. These are the nuclei of round or oval cells which may frequently be observed in various stages of development. When fully formed, the cells vary greatly in size, for the most part measuring from the joVo^^ ^0 -^igthof 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 appear- ance. 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 aether, and break down into a molecular mass on the addition of potash and ammonia. These are granule cells (149). Masses of these granules may be occasionally seen floating about, of irreg- ular shape, without any cell-wall. They are pro- duced either by the solution of the cell-wall in which they are contained, or from the separation, rig 149. or peeling off, of such masses from the external wall of the vessels; and form granular masses (Fig. 149 a). Pressure causes 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 colostrum secreted by the mammary glands ; in the exudative softening of parenchymatous organs; on the surface of granulations and pyrogenic 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 tumors. In fact, there is no form of cell-growth, whether healthy or morbid, that may not, under certain conditions, accumulate oil or fatt^ 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 mere fatty degeneration of the vessels, as some have supposed. In some Fig. 148. Granular exudation and granular masses, from cerebral softening. Fig. 149. Granular cells and masses from cerebral softening. 50 di. 1G8 PKINCIPLES OF MEDICINE. instances I have seen them in all stages of development coating the blood* vessels, as in Fig. 150. That softening from the formation of granules and granular cells may occasionally disappear, and the new structures bo absorbed is rendered probable by the history of several well-recorded cases; but the changes there- by produced, especially in nervous textures, have not hitherto been made the subject of special in- vestigation. 4. If a recently-formed granulation on the surface of a healing sore be examined, numerous cells will be observed, of various shapes, and in different stages of development. Some are round, others caudate, spindle-shaped, elcvngated or split- ting into fibres, as originally described by Schwann (Fig. 151). In many cases there may be seen a number of free nuclei, imbedded in a slightly fibrous blastema, elongated at both ends, becoming fusiform, and splitting up the surrounding exuda- tion, as described by Henle. Not unfrequently the liuclei 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 cicatriza- tion in its various stages and in different tissues, offers the best means of studying the manner in which nucleus and cell fibres are respectively { 'U'lned. As these , . G 1 bres are developed in the deeper layers of the exudation, a, villous vascular ! lasis is formed, and t'le superficial pus- crorpuscles, after 1 aving served to jirotect the more permanent growths are thrown off in the form of dis- charge. When the fibrous structure becomes more con- Fig. 151. sistent and dense, the amount of pus diminishes, and a greater tendency is manifested by the exudation to pass into permanent t.ssue. At length pus ceases to be developed ; the whole remaining exudation is transformed ri" ] 50. Two vessels coated with exudation from softening of the ' Granular cells may be seen forming in it. "50 aiam. Fig. 161. Vertical section of a granulating sore Externally, pns 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. INFLAMMATIOX. 169 into fibres; a new surface is produced, which after a time contracts and forms the permanent cicatrix. V. — Death of the Exudation. — The exudation may die in three ways — 1st, Instead of passing through the vital transformations we have previously described, it may die rapidly — constituting what has been called MorHfication or Moist Gangrene ; 2d, It may die slowly — causing gradual disintegration and loss of texture, and thereby forming what has been denominated ulceration ; 3d, There is a natural death of the exudation, which is resolution. 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 cor- puscles more or less mixed up with the liquor sanguinis 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 morti- fied, or to be affected with moist gangrene. This change commences first in the blood extravasated, which becomes of a purple color more or less deep ; the corpuscles break down and become disintegrated; their hseniatozine dissolves and colors the serum ; and, should the exudation have coagulated, it forms brown, rust-colored, purple, or blackish masses. An acid matter is now formed, which, acting on the neighboring tissues, produces foetid gases, that are abundantly given off from the afiected part. [Sulphuretted hydrogen is evolved, which causes the blackish sloughs usually observed in such cases, aud discolors silver probes and the pre- parations of lead. After a time, the elementary tissues surrounding or involved in the exudation, become more or less affected. The tranverse striae in the fasciculi of voluntary muscles first become pale, aud are then obliterated. Cellular tissue, fat, and other soft substances lose their con- nection, -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, but at length, commencing externally, they become rough, 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-down 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 affected ; and an opening is formed, which rapidly enlarges, and gives vent to the discharge. In a similar manner, gangrene of internal organs, by destroying the inter- mediate parts, at length enables the fluid to reach the surface, or to find its way into the excretory passages, such as the bronchi, the intestinal canal, the meatus auditorius, etc. In this manner, life may be endangered, by 170 PEINCIPLES OF MEDICINE. the destruction of organs necessary for its continuance ; by the exhaustion resulting from the discharge ; and sometimes by the absorption of the ichor- ous matter, which, entering the circulation, acts as a poison to the economy. On the other hand, a favorable termination may take place, either by the dead substance breaking down, and bein gevacuated externally, or by Fig. 152. its being separated en masse in the form of slough. In such case a process of regeneration and healing may be set up in the exposed living texture, which may produce a cicatrix, 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 favors the decomposition of the exudation poured out ? In order to answer these questions, we must distinguish between ordinary mortifica- tion arising from a variety of circumstances, and moist gangrene properly so called, which is undoubtedly the rarest of all the terminations of ex- udation. 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 affected 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 inflammation. But when stasis of the capillaries is produced to a con- siderable 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 see 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 neighboring parts correspondingly great ; so that these, as well as the exudation itself, is destroyed. In this sense, therefore, it may be said to depend on the rapidity and amount of the exudation ; but not in the sense of those who consider adhesion, suppuration, and gangrene, as different stages of one process. Suppuration, as we 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 primar}" altera- tion 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. Fig. 162. Moist gangrene, following compound fracture — all the injured parts in- filtrated with exudation, which has died and mortified. — Liston. INFLAMMATIOISr. m 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. Fig. 153. If there is not sufficient oxygen, for instance, an excess of carbon is pro- duced in the debris. There is also often developed a species of destruc- tion by contact, which causes parts undergoing decomposition to excite it in neighboring ones [eremacamis of Liebig) ; which does not take place in dry gangrene. A gangrenous stomatitis {Cayicrum oj'is) will thus destroy, in a short time, a large portion of the soft parts of the lips and face, and Noma 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 ma}^ occur before a dry gangrenous foot is completely separated by decomposition. There are sometimes external causes also which seem to produce mor^ tification, 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 sloughing gangrene, prevalent, not only in the Infirmary of Edinburgh, but throughout the city generally. All kinds of sores and wounds were affected by it, even those of a specific 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 ill- ness, 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 simultaneously in different parts of the city, in individuals who had no communication 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, there- fore, 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 dysentery, Fig. 153. Dry gangrene from debility — being death of the pre-existing tissues, unconnected with exudation.— Xwtort. 172 PEINCIPLES OF MEDICIXE. as well as their more frequent occurrence in summer and autumn — that is, at a period of the year when increased temperature favors the de- composition of animal matter. The good effects which result from change of air, when every kind of treatment fails, still further point out its con- nection with some atmospheric changes. These may probably depend upon some peculiar electrical state, not yet explained, powerfully influenc- ing the chemical combinations of the diseased part, and ]n-eventing cell- growth. At least such is what we may reasonably suppose, 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 undergoing 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 pressure, the circulation is obstructed, and death of the portion affected results. This dead portion is sometimes imprisoned in fresh exudation, as the ulceration extends, and the whole part affected at length becomes disin- tegrated, All this time the exudation exhibits little of that tendency, so conspicuous in healthy peisons, 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 semi-fluid mass, which has a tendency to point where it can most readily be dis- charged, that is, towards the surface of the skin or mucous membranes. Here, 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 in- definitely. 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 upon by lying, or by the growth of tumors, the vitality of the part is slowly destroyed. INFLAMMATION. 173 At the same time an exudation is poured out from the neighboring 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 off 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 purulent matter, the corpuscles m it presenting their normal character. In chronic, scrofulous, and syphilitic sores, the corpuscles are generally of an irregular form, constituting what has been denominated unhealthy purulent matter. Not unfrequently 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 re- garded as the result of a peculiar operation, which he denominated ulcerative absorption. No doubt the process, such as we have described it, is peculiarly favorable to the production of a fluid containing mole- cules so minute that they may readily permeate the neighboring vessels by endosinosis. But it must not be overlooked that much of the sub- stance lost in ulceration, especially of the more consistent and tough structures, after having been more or less broken up, is thrown off from the surface in the form of discharge. This is proved by direct observa- tion. In either case all such parts first 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 off from the surface. In bones the processes corresponding to mortification and ulceration in soft parts, are generally denominated Necrosis and Caries, Resolution. When pus is not evacuated externally, the cells ultimately dissolve, their walls disappear, the 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. Mean- while the original abscess, or collection of matter, is said to be resolved. Numerous observations have satisfied me that this is tlie process which a pneumonia undergoes on its removal. In this disease the exuda- tion is infiltrated into the air vesicles and minute bronchi, and between the fibres, blood-vessels, and nerves of the parenchyma, imprisoning the whole in a soft mass, which coagulates and renders the spongy texture of the lung more dense and heavy, or what is called hepatized. This accomplished, no air can enter, the nerves are compressed, the circulation is in great part arrested; and the object of nature is now to convert the solid exudation once again into a fluid, whereby it can be partly evacuated from the bronchi, but principally reabsorbed into the blood, and excreted 174 PRINCIPLES OF MEDICINE. from the economy. This is accomplished by cell-growth. In the amorphous coagulated exudation, granules are formed ; around groups of these cell-walls are produced, and gradually the solid amorphous mass is converted into a fluid crowded with cells. This is pus. The cells, after exudation is again reduced to a condition susceptible of absorption through the vascular walls, and once more mingles with the blood, but in an altered chemical condition. In the blood the changed exudation (now called fibrin) undergoes further chemical metamorphoses, whereby, according to Liebig, it is converted by means of oxygen into urate of ammonia, choleic acid, sulphur, phosphorus, and phosphate of lime. The urate of ammonia, by the further action of oxygen, is converted into urea and carbonic acid; the choleic acid into carbonic acid and carbonate of ammonia ; the sulphur and phosphorus into sulphuric and phosphoric acids, which, combining with an alkali or earth form sulphates and phosphates. If it should happen that the quantity of oxygen taken is not sufficient completely to accomplish this cycle of changes, then, instead of urea, either urate of Ammonia appears in the urine, or if the ammonia have entered into any other combinations, pure crystals of uric acid. In consequence of these or similar changes, the exudation is finally removed from the economy. The same process takes place in abscesses, and is frequently seen in buboes, which instead of being opened become harder and harder, smaller and smaller, until at length they disappear. In a pleurisy or pericarditis, the transformations occurring in the exudation are different. We have previously described the changes which follow pleurisy (pp. 1G5-66). Let us now follow them in the case of peri- carditis. When a severe inflammation of the pericardium occurs, the liquor sanguinis is exuded in considerable quantity, separating the serous layers to a greater or less extent. After a time the fibrin coagulates and forms a layer which attaches itself to the membrane, whilst the serum of the blood accumulates in the centre. The coagulated fibrin at first assumes the form of molecular fibres, plastic or pyoid cells are formed in it (Fig. 138), others throw out prolongations, so as by their union to form a })lexus, which, communicating with the vessels below the serous mem- Fig. 154. Three air vesieles of a pneumonic lung, filled with exudation in different stages of development, a, Molecular exudation recently poured out ; 6, Cells form- ing in the exudation; e. Cells (pus-cells) fully formed. See case of Alexander Walker among Diseases of the Nervous System. 250 diam. INFLAMMATION. 175 brane, renders the exudation vascular (Fig 254). Gradually the surface assumes the appear- ance of a villous membrane (Fig. 155), which possesses also the absorbent functions of one. The enlarged villi frequently contain vacuoles or spaces, reminding me strong- ly of the general structure of the pla- cental tufts, than which nothing can be imagined more perfectly adapted for the purposes of ab- sorption (Fig. 156). In consequence, the serum now disap- pears, the two false Fig. 155 . membranes are brought into contact, and thus the absorption, as soon as Fig. 156. Fig. 165. Layers of lymph in pericarditis, presenting the form of large villi. — ( CruveUhier.) — Half the real size. Fig. 156. Structure of the villi in pericarditis. On the left of the figure are some villi treated with acetic acid, and thereby rendered very transparent, showing the elongated nuclei of the fibre cells of which tliey are principally composed, a. The vacuoles or spaces common in these villi ; ft. Group of epithelial cells which in many places covered the villi ; c. Cells of various shapes, easily squeezed from the soft vil- lous structure, undergoing the fibrous and vascular transformations. — (See Fig. 254.) 200 diam. 176 PRINCIPLES OF MEDICINE. it is no longer required, is put an end to, and adhesion occurs. The matters absorbed into the blood pass through the same series of changes as those in pneumonia do, and are eliminated from the economy in a similar manner. Such is the natural progress of pericarditis. The two kinds of processes now described exhibit the same wise de- sign in pathological as we everywhere find in physiological actions. In the vascular tissue of the lung, new blood-vessels are unnecessary. But in the nou-vascular serous membrane, they must be formed to bring about removal of the morbid products. In the one case the entire exudation is transformed into cells to produce rapid disintegration and absorption, which latter is easily accomplished by the already formed numerous vessels of the lung. In the other case the exuded liquor sanguinis is separated into solid and fluid parts, and as there are no vessels in the serous membrane, they are formed in one portion of the exudation to cause absorption of the other. VI. General Treatment of Inflammation. — ^The foregoing facts and considerations must lead us to the conclusion, that practically the medical man may be called upon — 1st, To check or diminish the inflam- matory congestion ; 2d, When exudation 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 exudation follows certain preliminary alterations in the capillary vessels, and is imn.ediately 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, by 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 inflamma- tion. 1. To check or diminish the inflammatory congestion, we must adopt measures to restore the capillaries to their normal condition, prevent their distension with blood, and lessen the attractive power (whatever that is) which draws the blood into the irritated textures. This is ac- complished — 1st, By local applications of cold and astringents, which stimulate the capillaries to contraction ; 2d, By soothing topical applica- tions, such as warm fomentations, opiates, etc., which relieve the irrita- tion 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 of late years been confined to some active congestion of the external tissues, while that of the latter has been abandoned. 2. Wh'Mi 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 ultimately INFLAMMATION. 177 break down, and so render it capable of being absorbed (resolution), or they are converted into a tissue that becomes pennaneiit. In the other case, it disintegrates slowly, constituting ulceration — or putrefies, forming moist gangrene, when it is separated from the economy in discharge or as a slough. It is by regulating the formative power of the exudation that we check or favor resolution ; and we can only do this by employ- ing those means which lessen or advance cell-growth in all living organ- isms. Thus locally, cold, dryness, and pressure check — while heat, moisture, and room for expansion favor — growth. And as regards 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, tartar emetic has been recommended, and to assist the absorption of the exuded matter, calomel has been a favorite remedy ; but the manner in which these act has been disputed, and whether it be as a solvent of the effete matters in the blood, or by operating on the excretions, is yet un- determined. The former probably acts in both these ways — the use of the latter, as an antiphlogistic, has of late years been almost abandoned. The action of counter-irritants, although undoubtedly useful in removing pain and in causing absorption of chronic exudations, is little understood, and belongs to the most mysterious department of therapeutics. 3. In order to favor the excretion of the effete matters in the blood, purgatives, diaphoretics, and diuretics, alone or combined, will occa- sionally 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 equalities, they favor indirectly the rapid absorption of the exudation. Formerly it was supposed that the essential phenomenon of inflam- mation consisted of the alteration in the blood and blood-vessels^ The views previously detailed seek to establish that this process really con- sists in irritation of the extra-vascular elements of the textures, pro- ducing exudation of the liquor sanguinis. The former doctrine naturally ted its upholders to maintain an antiphlogistic treatment; the latter one as naturally led to an opposite practice. There is no inflammation so well capable of testing the value of any particular treatment as a pneu- monia : first, because there is none that can be more accurately deter- mined by functional symptoms and physical signs; secondly, because the perturbation of the system and importance of the organs involved have ever, and must always, attract strongly the attention of medical men ; thirdly, because it, perhaps more than any other, has been sup- posed to be amenable to blood-letting and antiphlogistics. It is now eighteen years since a careful investigation into the pathology of inflam- mation induced me to doubt the value of the then universal practice in these cases, and this for the following reasons : — In the first place, the cause of the inflammation is an irritation of the textures — of the ultimate molecules of the part — in consequence of which their vital power of selection is destroyed, and that of their attrac- tion is increased. The removal of blood by venesection cannot alter this state of matters — neither can other lowering remedies. If the inflamma- tion be superficial and limited, local bleedieg may relieve the congestion, 12 178 PKINCIPLES OF MEDICIXE. as in conjunctivitis, but if exudation has occurred it cannot remove that. In the second place, an exudation or true inflammation having oc- curred, it can only be absorbed by undergoing cell-transformation. Now, tliis demands vital force or strength, and is arrested by weakness. Hence inflammations in healthy men rapidly go through their natural course : in weak persons this is delayed ; hence their fatality. In the third place, the strong pulse, fever, and increased flow of blood in the neighborhood of inflamed parts, have been wrongly inter- preted by practitioners. They are the results, and not the causes, of inflammation, and show that the economy is actively at work repairing the injury. So far, therefore, from being interfered with and interrupted, they should be encouraged — locally by warmth, which also relieves pain, and internally by nutrients. It follows, fourthly, that if these views be correct, our object in the treatment of internal inflammation should be directed towards bringing the disease to a favorable conclusion, by supporting rather than diminish- ing the vital strength of the economy, and this not by over-stimulating, as was done by Dr. Todd, but simply by attending to all those circum- stances which restore the nutritive processes to a healthy condition. Having been guided by thes'e views in my practice for the last six- teen years, and having seen that gradually they have been adopted by the profession, it is, I think, in my power to offer you the most convinc- ing proof of their correctness, by contrasting the results of an antiphlo- gistic treatment, as formerly practised in pneumonia, with those furnished by the cases that have been carefully recorded by my various clinical clerks in the Royal Infirmary. For the details. I must, in order to prevent repetition, refer you to section III., in which, under the head of “ the diminished employment of blood-letting, etc.,” the facts and arguments on this subject are fully detailed. The cases also are given under the head of Pneumonia. All that need be said here is, that the mortality of this disease, which used to exist ill large hospitals, varying fi om 1 in 3 to 1 in 7 cases, is in my wards of the Royal Infirmary almost nil. Cases of simple pneumonia, single or double, always recover ; while the few cases that die owe their fatality to severe complications. From these facts I conclude — 1st, That simple pneumonia, if treated so as to support instead of lower the nutritive processes, so far from being a fatal disease, almost invariably recovers. ‘2d, That the cause of mortality in these cases is exhaustion, cither before they come under medical supervision, or, as formerly practised, from an antiphlogistic or a lowering treatment. All bleedings that do not exhaust must be regarded as palliative, rather than as curative. 3d, That the same rule applies to all inflammations, the amount of danger bring in direct ratio to the weakness of the system and the exist- ence of complications in the disease, especially blood-poisoning. I need not dwell at length on what it appears to me are these im- portant results. I shall only remark, in conclusion, that, in my opinion, Ihev arc not the elfect of chance ; of empirical experiment ; of a change in the nature of inflammation, or of the force of the pulse in man and TUBERCULOSIS. 179 animals ; of an alteration in diet or of drink, or of nervous susceptibility; nor of a change in the type of disease; all of which have been supposed by some to be explanatory of facts which can no longer be denied. The more I consider this subject, the more am I convinced that it is to the advance of medical science only that it can be rightly attributed, and that it is our highest privilege and honor so to consider it. Indeed, no stronger proof can be offered of the improvement in practice that has resulted from a more correct pathology, than the diminished mortality and great success wliich, it has been shown, now attend our treatment of acute inflammations. TUBERCULOSIS. I propose in this place to speak of that very common and important morbid condition denominated Struma, Scrofula, and, in recent times, Tuberculosis — that is to say, the formation of Tubercle. The term “ tubercle” literally implies a little swelling, and in that sense still serves to distinguish a class of skin disease, under the name of “ tuberculae.” Its unfortunate application to the rounded and other masses so frequentl3r f^mid in the lungs, bones, and other textures, renders it imperative upon us to define what we now understand by it. At present, therefore, tubercle may be regarded as an exudation possessing deficient vitality, sometimes grey, but more frequently of a yellowish color, varying in size, form, and consistence, essmtially composed of molecules and irregularly-formed nuclei. Forms of iiibercle , — These may be distinguished as — 1st, Miliary titbercle, existing in small grains like millet-seeds, and which may be yellow or grey, hard or soft ; 2d, Infiltrated tubercle, existing in masses or patches more or less extensive ; 3d, Encysted tubercle — that is, masses of tubercle surrounded by a fibrous cyst ; 4th, Cretaceous and calcareous tubercle — that is, tubercle loaded with mineral matter, sometimes break- ing down under the finger, and at others of stony hardness. In this way tubercle not only varies in form, but in extent, color, and consistence. It may be diffluent, soft, cheesy, wax^q indurated, chalkjq and calcareous. Minute structure of tubercle . — A small portion squeezed between & 0>p'0 o» Fig. 157. Fig. 158. Fig. 159. glasses, and examined under the microscope, presents a number of irregu- larly-shaped bodies, approaching a round, oval, or triangular form, and Fig. 157. Corpuscles from firm tubercular exudation into the lung, a, After the addition of acetic acid. Fig 158. Corpuscles, granules, and debris, from soft tubercular exudation into the cerebellum. Fig. 159. The same, from tubercular infiltration of a mesenteric gland. 250 dlam. 180 PRINCIPLES OF MEDICINE. varying in their longest diameters from the 2/00 to inch. These bodies contain from one to seven granules, are unaffected by water, but rendered transparent by acetic acid. They are what have been called tubercle corpuscles. They are always mingled with a multitude of mole- cules and granules, which are more numerous the softer the tubercle. Occasionally, when softened tubercle resembles pus, constituting scrofu- lous purulent matter, we find the corpuscles more rounded, and approach- ing the character of pus cells. They do not always, however, on the addition of acetic acid, exhibit the peculiar granular nuclei of pus cells. Fig, leo. Fig. 161. The grey granulations described by Bayle may seem, on careful management of the light, and after the addition of acetic acid, to contain similar bodies to those described as tubercle corpuscles, being closely 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 mi- neral molecules and crystals of cholesterine. Tubercle corpuscles may be associated with pus and granule cells, as well as with cells peculiar to glandular organs or mucous surfaces in various stages of fatty trans- Fig. 162 . formation and disintegration. With all these they have frequently been confounded. Everything that I have seen of tubercle tends to convince me that it ^00 ‘So Fig. 160. Section of a firm miliary tubercle of the lung. Fig. 161. Section of a grey granulation in the lung, showing the pulmonary vesicles filled with tubercle corpuscles. Fig. 162. Molecular structure of a calcareous pulmonary tubercle. — {liadchjffe Hall.) 260 diam. TUBERCULOSIS. 181 consists of an exudation wLicli has little tendency to pass into cell-forms. The original albuiniiious molecular matter melts into nuclei, which con- stitute the tubercle corpuscles, and are developed no further. It has been regarded by some pathologists as a breaking-down of pre-existing textures, and by Virchow as forming in the interior of connective tissue corpuscles. The former view is based upon the circumstance that cells in the act of breaking down may be observed in a certain stage to present irregularly-shaped nuclei with numerous molecules, which closely resemble those found in tubercle, as in chronic pneumonia and in the reticulum of cancer. I feel persuaded, however, that tubercle is a histogenetic, and not a histolytic process, and that as such it may easily be demonstrated in every organ v/hich it attacks. That it is caused by a pre-existing growth in the so-called connective tissue corpuscles, is open to the same objections that I made to the supposed origin of pus in the same bodies. In no case can it be demonstrated. Clmnical com/position of tubercle . — Tubercle has been analysed by numerous chemists. The general results are as follows: — 1st, That tubercle consists of an animal matter, mixed with certain earthy salts. 2d, That the relative proportion of these varies in different specimens of tubercle. That animal matter is most abundant in recent and earthy salts in chronic tubercle. 3d, That the animal matter consists almost wholly of albumen, mixed with a minute quantity of fibrin and fat. 4th, That the earthy salts are principally composed of the insoluble phosphate and carbonate of lime, with a small portion of the soluble salts of soda. 5th, That very little difference in ultimate composition has been detected between recent tubercle and other albuminous compounds. Pathology cf tubercle . — In endeavoring to determine the nature of tubercle, we must remember that it occurs in young persons in whom the nutritive functions are deficient in energy, whether from poverty and incapacity of obtaining food, from deficient stamina, or from causes of whatever kind which induce exhaustion. Hence its frequency among the ill-fed poor, in orphan and foundling institutions, among badly- nursed children or weak and dyspeptic young persons, and after acute inflammations, whooping-cough, eruptive fevers, and other disorders that weaken the body. When, under such circumstances, exudation occurs in one or more textures, it does not undergo those changes we observe following inflammation in healthy persons. The vital changes are slow, and easily arrested. Instead of cells and perfect textures being produced, the efforts at vital transformations are abortive. The whole remains molecular and granular, or at most ill-formed nuclei are produced, which have received the name of tubercle corpuscles. It is rare, however, that this weakness of the constitution acts uniformly at all times and in all textures. Hence it may frequently be observed that tubercle is more or less associated with pus and granule ceils, or fibrous and other growths ; with the exception of cancer, with which it is rarely combined. I regard tubercle, therefore, as an exudation, which may be poured out into all vascular textures in the same manner and by the same mechanism as occurs in inflammation, only from deficiency of vital power it is incapable of undergoing the same transformations, and 182 PRINCIPLES OF MEDICINE. exhibits low and abortive attempts at organisation, and more frequently, as a result, disintegration and ulceration. For the same reason we observe that whenever an undoubted inflammation becomes chronic with weakness, the symptoms and general phenomena become identical with those of tuberculosis. Hence there is little difterence between a chronic pneumonia of the apex of a lung and a phthisis ; the one, indeed, pass- ing into the other. When ve endeavor to discover the origin of the weakness produc- ing this effect on the exudation, we must ascribe it to imperfect nutrition ; indeed, it is impossible for any observant practitioner to avoid noticing throughout the whole course of the disease the derangement that occurs in the digestive system. All writers refer to the deficiency and irregu- larity of the appetite, and the functions of the whole alimentary canal will be found from first to last in an abnormal condition : the tongue is either furred and furrowed, or glazed and unusually red ; the teeth are carious; the stomach capricious — sometimes rejecting food, at others retaining it an unusual time, with accumulation of flatus. There is a general indisposition to eat fat or fatty substances ; and the appetite is feeble, absent, or, in rare cases, voracious. In the former case there is thirst and eructation of acid matters into the mouth ; flatulence and tympanitis of the bowels are frequently complained of; the alvine discharges and egesta are as irregular as the food and ingesta. Some- times there is constipation, at others diarrhoea. The stools are only slightly tinged with bile, and in children often consist of white glairy matter, like white of egg. It may also be invariably observed, that wdien, by proper regulation of the diet, of exercise, or other circumstances which regulate the nutritive functions, the alimentary canal performs its duty, the health improves, and the tubercular formations diminish. These, indeed, according to their excess or progress in particular organs, communicate to the disease more or less of a local character. In systematic w'orks they have been described at length as separate diseases, although, in truth, they are only manifestations of one disease. After a time the continuance or violence of the local disease reacts upon the constitution, and a state called hectic fever is established, the which, inducing exhausting diaphoresis and emaciation, ultimately de- stroys the patient. Natural progress of tuberculosis . — In tracing, therefore, the natural progress of tuberculosis, we observe it to commence in debility caused by impairment of nutrition. This leads to local congestions and exudations. The latter remain abortive, and consist of molecules, granules, and imperfect nuclei, which soften and cause ulceration, with more or less disorganisation. The great contribution of M. Louis to the pathology of this subject was the establishment of a law, that whenever tubercle occurred in ihe body it also existed in the lungs, and whenever it occurred in the lungs it appeared first at the apex. This law, though now known to be subject to several exceptions, is still so generally correct as to be of the utmost service in diagnosis. Now, in the lungs, it was long supposed, and the opinion is still very general, that tubercle almost always proceeded onwards to a fatal termination; }^et so far is this from being the tact that it can easily be shown that tubercle is TUBERCULOSIS. 183 arrested spontaneously in one-third of all the persons in whom it occurs. Nothing is more common in examining dead bodies than to meet with crectaceous and calcareous concretions at the apices of the lungs more or less associated with cicatrices. Of seventy-three bodies which I ex- amined consecutively some years ago in the Royal Infirmary, I found these lesions in twenty-eight. Of these, puckerings existed with indura- tion alone in twelve, with cretaceous or calcareous concretions in sixteen. Since then I have examined many hundred lungs at the inspections in the Infirmary, and am satisfied that these proportions exist pretty constantly. At the Salpjtriere Hospital in Paris, Roger found them in fifty-one bodies out of a hundred ; at the Bicetre Hospital, in the same city, Boudet found them in 116 out of 135 bodies. Both these institu- tions are establishments for persons above seventy years of age. These lesions are so frequent, therefore, that it is important to determine whether they are really proofs of arrested tubercle. This seems to be established by the following facts : — 1. A form of indurated tubercle is frequently met with, gritty to the feel, which, on being dried, closely resembles cretaceous concretions. 2. These concretions are found exactly in the same situation as tuber- cular deposits are. Thus they are most common in the lungs, and at their apices. 3. When the lung is the seat of tubercular infiltration throughout, whilst recent tubercle occupies the inferior portion, and older tubercle and perhaps caverns the superior, the cretaceous and calcareous concretions will be found at the apex. 4. A comparison of the opposite lungs will frequently show, that whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect, and has occasionally even passed into a substance of stony hardness. 5. The puckerings found without these concretions exactly resemble those in which they exist. Moreover, whilst puckering with grey induration may be found at the apex of one lung, a puckering surrounding a concretion may be found in the apex of the other. 6. The seat of cicatrices admit of the same exceptions as the seat of tubercles, and in about the same proportion. There can be no question, therefore, that these cicatrices and concretions for the most part indicate the arrestment, disintegration, and transformation of pre- existing tubercular exudations into the lungs. The arrestment of tubercle in the lung is not confined, however, to its early stage. It may be stopped at any period, and numerous cases are now known where even vast tubercular caverns have healed and cicatrised. I here show you a series of preparations, which must con- vince the most sceptical of the truth of this statement."^ Treatmsnt . — It follows, therefore, that if we can succeed in support- ing the nutritive functions, there is no reason why tubercle once formed should not be gradually absorbed, and a tendency to subsequent deposits completely checked. Formerly this was rarely accomplished, in conse- quence of the idea that phthisis pulraonalis ought to be treated by paying attention especially to the lungs and respiration. Hence cough mixtures, sedatives, a warm atmosphere, tar vapor, and other substances to influ- * See the author’s work, “ The Pathology and Treatment of Pulmonary Con- sumption,” 2d edition. Figs. 21 to 26. 1S4 PEINCIPLES OF MEDICINE. ence the local lesion. Other symptoms had their special treatment, such as sulphuric acid to relieve sweating, acetate of lead and opium to check haemoptysis, tonics to give strength, astringents to check diarrhoea, and so oil ; while so far from any vigorous effort being made to improve nutrition, the diet was kept low» consisting of farinaceous substances, or, at most, milk; and to avoid irritation, the patients were confined to bed or their rooms, which were kept at an equable tempei'ature. Our present knowledge has led to a complete revolution in our prac- tice. Thus, moderate exercise to stimulate respiration, cold sponging, nutritious diet, and a bracing system, have been found more beneficial; at the same time avoiding anodynes and cough mixtures, which, by diminishing the appetite and inducing weakness, interfere with nutrition. Indeed, it has been proved that the best method of lessening cough, ex- pectoration, and sweating, are the means which produce increase of gene- ral strength ; so that, if we can carry out the general indication, the local symptoms may be safely left to themselves. In doing this, we have now the advantage of possessing a remedy which, in cases of tuberculosis, is of the highest nutritive importance, as it gives to the system that fatty element in which it is so defective, and in a form that is more easily assimilated, and more capable of adding to the molecular element of the body, than any other. I allude to cod- liver OIL. And now, you cannot fail to perceive how the molecular doctrine of organization and of growth not only explains the known facts in physi- ology and pathology, but constitutes the basis for a true therapeutics. Fatty particles, as we have seen, form the molecular fluid of chyle; while out of chyle, blood, and through it all the tissues, are formed. Impair- ment of digestion in scrofula and tuberculosis renders chylifieation im- perfect ; the fatty constituents of the food are not separated from it and assimilated ; the blood consequently abounds in the albuminous elements, and when exuded forms, as we have seen, tubercle. To induce health, it is necessary to restore the nutritive elements which are diminished, and this is done directly by adding a pure animal oil to the food. While an inflammatory exudation in previously healthy persons should be treated by supporting the vital powers generally, so as to permit its molecules going through the transformations necessary for their growth and elimin- ation ; in tuberculosis we add the constituent of food necessary for the formation of the molecules themselves. By so doing, we form good chyle and blood , we restore the balance of nutrition which has been disturbed ; respiration is again active in the excretion of carbonic acid gas; the tissues once more attract from the blood the elements so necessary for their sustenance. The entire economy is renovated ; so that, while the histogenetic processes are revived, the histolytic changes in the tubercle itself also are stimulated, and the whole disappears. When, in 184i, I first announced the virtues of cod-liver oil as an analeptic or nutrient in this class of cases,* so little was the substance known, that linseed oil was furnished to the Eoyal Infirmary of this city instead of it, when I induced I)r. Spittal to try it in his wards. At present, I need scarcely * On the Oleum Jecoris Aselli: Edinburgh, 1841. See also the same work, with Appendix by the Author, 1848. MORBID GROWTHS. 185 say, whole fleets are engaged in transporting the oil from the extensive flsheries, where it is manufactured for medicinal purposes ; and its bene- ficial results are universally recognised. In 1852, Dr. Wood of Philadelphia remarks of it, in his Practice of Physic (see vol. ii., p. 95, note), that in Philadelphia, during the ten years from 1840 to 1849 inclusive, the average proportion of mortality from phthisis was 1 in about 6'76 from all causes, or 14‘8 per cent, and the same average existed in previous years. Cod-liver oil was then gene- rally used in its treatment, and the mortality sank in this disease during 1850-51 to 1 in 8-33, or about 12 per cent, and in 1851 it was only 11'86 per cent. In 1862, Dr. C. J. B. Williams, in one of the Lumleian Lectures delivered to the London College of Physicians, observes, that the experi- ence of Louis and Laennec gave an average duration of two years’ life in phthisis, after it was decidedly developed, but that since cod-liver oil was introduced, he infers, from 7000 cases, that the average duration of life has been four years — that is, doubled. My own conviction is, that innumerable cases which formerly would have died rapidly, now rally, live for years, and many of them ultimately recover. The hopelessness which used to seize upon many consumptive persons, and on their friends, is also now removed, and the resolution to combat the disease by appropriate diet, exercise, and other hygienic means, has added further success to our treatment. I venture then to say, that in the same manner that in recent times we have diminished the mortality in cases of acute inflammation, so we have diminished the mortality and increased the duration of life in cases of tuberculosis, and more especially in that most fatal form of it— phthisis pulmonalis. In the one disease, as in the other, the improvement can only justly be ascribed to the advance of physiology and pathology ; to our superior knowledge of the nature of the disease, and, as a conse- quence, to our treatment of it on more scientific and successful principles. MOEBID GEOWTHS OF TEXTUEE— THEIE GENEEAL PATHOLOGY AND TEEATxMENT. The exclusive study of morbid growths, according as they affect in- ternal or external parts, has led to limited views of the subject. The surgical tendency to speak of them as tumors, and to regard them in reference to the great practical question of excision, has interfered with the true pathological doctrine — namely, that, however or wherever pro- duced, they are essentially the same. No doubt they are very common in external 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 consideration. 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 determined, when certain tissues or organs have increased in size dispro- portioned to the rest of the body. Exercise, within certain limits, may 186 PRINCIPLES OF MEDICINE. 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 condition. 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 ventricle 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 neighboring 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 hj'pftrtrophj. Membranes may become preternaturally thickened, causing more or less induration^ whereby the movements of parts nmy be affected, or the calibre of t,ubes 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 tumor. Lastly, we must not overlook the fact that certain transforma- tions in the exudation, formerly noticed, lead to increase of texture, and produce morbid growths altogether foreign to the healthy frame. A cultivation of histology excited the hope that, by studying the ultimate structure and mode of development of morbid growths, 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 1849,^ I pointed out what were the ultimate elements of all morbid growths, and that not 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 characterise morbid growths, such as fibro-molecular, fibro-nucleated, fibro-cellular, fibro-vascular, etc., for the simple reason that tumors very unlike in their external characters and natures may be composed of the same elements. For instance, cystic, glandular, cartilaginous, and can- cerous 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 arrangement, that the microscope is destined to be of * On Cancerous and Cancroid Growths. Edinburgh, 1849. CLASSIFICATIOX OF MOEBID GKOWTHS. 187 infinite importance in pathology and diagnosis. Neither will chemical composition furnish us with trustworthy means of distinguishing morbid growths, 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 growths I. Fibrous growths II. Fatty growths III. Cystic growths lY. Glandular growths . V. Epithelial growths . VI. Vascular growths VII. Cartilaginous growths VIII. Osseous growths IX. Cancerous growths . All these primary divisions aia according to the presence of particul blances which have received names. Fibroma^ or Inoma. Lipoma. Cystoma. Andenoma. Epithelioma. Angionoma. Enchondroma. Osteoma. Carcinoma, susceptible of being subdivided r substances, or to fancied resem- 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 1. Like water Hygroma. 2. u black pigment . Melanoma. 3. a green pigment . Chloroma. 4. u blood Haem atom a. 5. u glue Colloma. 6. u lard S tea tom a. 7. u gruel Atheroma. 8. a honey IMeliceroma. 9. u cholesterine Cholesteatoma. 10. u flesh Sarcoma. 11. ({ nerve Neuroma. 12. ti brain Encephaloma. 13. u marrow Myeloma. 14. marble Schirrhoma, 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 tumor, for instance Syphonoyna, or tubular growth, described by Henle;f Cylin- droma^ by Billroth Keter adenoma^ by Bobin,<^ etc. etc. * 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 em- ployed in medicine. Those, however, who may object to it on this ground, can employ the more correct novel term of Inoma, from is-ivos, a fibre, f Zeit fiir. Ration. Med. 3 Bd. 1 Heft. X Ueber die Entwicklung der Blutgefasse, Berlin, 1856. § Traite d’Anat. Pathologique, par Lebert, p. 339, ct seq. 188 PEINCIPLES OF MEDICINE. Further varieties have been made to express one or more combina- tions of these elements, and hence the terms Fihro-cijstic, Filro cartilagi- nous^ Fihro- Sarcoma^ Osteo- Sarcoma^ and so on. Indeed, this kind of nomenclature admits of further extension, and such terms as Fihro- cpithelial, Angio-cysticy Cystic- adenoma^ Osteo-fihrous^ and so on, might be employed with advantage. When, also, growths have a certain re- semblance to, or largely partake of the character of the structures and substances referred to, while their real nature is not absolutely or alto- gether the same, the words Fibroid^ Cgstoidy Adenoid, Chondroid, Osteoid, Colloid, Ilmnatoid, Fungoid, FncepTialoid, 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 terms 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 afterwards see that almost every kind of growth may be innocent in some cases, and malignant in others. The distinctions, therefore, sought to be established from such theoretical considerations are not oi ly erroneous, but have proved — as we shall subseque ntly show — most ii jurious in practice. I have known innocent growths never operated on by the surgeon, 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. Fibrous Growths. — Fibroma or Inoina, The pathological formation of fibrous growths is the most common ^ and universal which occurs in the body. It is essentially of two kinds — 1st, a simple increase by division or enlargement of pre-existing fibrous tissue ; 2d, a new formaiiou of fibres in an exudation. I. As examples of the first kind of increased fibrous growth, we may refer to what takes place in voluntary and involuntary muscle, in simple hyper- trophy. In voluntary muscle, the fas- ciculi and fibrillae increase in breadth, and there is a tendency to fissiparous Fig. IGo. Structures in hypertrophied heart, a, A muscular fasciculus dividing dichotoinously ; b, a slender fasciculus dividing ; c, anastomosing fasciculi ; d, con- centric ; e, smooth colloid (amyloid ?) bodies.— ( Wedl.) 250 diam. FIBROUS GROWTHS. 189 division whereby they become more numerous. There may be also observed fasciculi varying greatly in size, but without cells such as are visible in embryonic muscular formation. The same thing occurs m hypertrophy of non-voluntary muscle, where, in addition to great increase of bulk in individual cells, other smaller ones in various stages of devel- opment may also be detected. In the uterus during pregnancy this is easily observable, but in the thickening of organic muscular fibre ot the stomach and other hollow viscera, the large elongated fusiform cells are not discoverable. Fig. 164. Fig. 165. II. With regard to the second kind of increased fibrous growth, it may be said to present various forms. We have previously seen that the coagulation of liquor sanguinis often occurs in the form of filaments (Fig. 138), which become more and more dense. These are molecular fibres. Occasionally when the exudation coagulates, it presents a tendency to fibrillate or split up, Fig; 166, Fig. 167. Fig. 168. Fie. 16P, owing apparently to the formation of nuclei, which become more or less elongated. These are nuclear fibres. At other times cells are formed, which elongate, become fusiform, split up, and so produce fibres in the manner described by Schwann in healthy tissues. These are cell fibres. In these three ways, there may be produced all kinds and forms of fibrous Fig. 1 64. Fibrous structure of the uterus. Fig. 165. The same, hypertrophied from great increase in size of its fusiform cells. Fig, 166. Cell fibres and fibre-cells from a fibro-cellular growth in the coats of tlie stomach. Fig. 16Y. Fusiform cells from a sarcomatous growth in the kidney. (See also Fig. 213.) Fig. 168. Fibro-nucleated structure, from a so-callcd medullary sarcoma of the humerus. Fig. 169. Fibrous stroma of a tumor acted on by acetic acid. 250 diam. 190 PRINCIPLES OF MEDICINE. element, from tlie finest and most delicate areolar tissue, to one resembling in consistence ligament or fibro-cartilage. Hence, as far as structure is concerned, we may have fibro-ynolecular^ fibro-nucleated^ and Jihro- cellidar fibrous growths. 1. One of the most common forms of pathological fibrous tissues is that of cicatrix^ which is generally produced in the same manner in every tissue and organ. The exudation in such cases is partly transformed into filaments, and partly into pus. The former are in connection with the deep-seated tissues and capillaries, and are covered and protected by the latter. On examining a fungous granulation on the surface of a wound, it may be seen to contain round, oval, caudate, and fusiform cells, in all stages of their development towards fibres. As these increase in amount and become approximated,' the formation of pus gradually ceases. At length the new growth reaches the surface of the healthy tissue, con- tracts, causing more or less puckering of the surrounding structures, and becomes dense like ligament. (See Fig. 151.) 2. Another form of pathological fibrous growth occurs after the sub- cutaneous section of 1 liA ill[ lii ■■ ‘^1 '']f ! 1^1 viscera. Fig. 170. Fig. 171. Fig. 172. tendons, and in the coats of some hollow In this case the exudation thrown out fibril- lates, oval or fusi- form nuclei are formed, which are scattered irregularly through the mass, and the whole often have seen the coats of assumes a remarkable degree of toughness. We the stomach above an inch thick from this cause, entirely independent of cancerous formation. (Fig. 170.) 3. A third form of pathological fibrous growth is the result of chronic exudation on serous membranes. The white patches so frequently seen, more especially on the pericardium, pleura, and peritoneum, are owing to this cause (Fig. 171). Occasionally such membranes are connected by bands of firm fibrous tissue, or closely united and hypertrophied into a dense, white ligamentous substance, upwards of half an inch thick, as may frequently be seen in the pleurae over chronic tubercular lungs. 4. A fourth form of pathological fibrous growth is seen in an increase of the areolar tissue of the skin, or other organs, and also results from exudation. Thus we observe peculiar thickening and indurations of the skin, owing to this cause, in the adult, and in the hide-bound skin of certain foetuses. Atrophy of parts may arise as a consequence, through pressure thereby produced ; for instance muscle may be converted into a ligamentous substance. So called cirrhosis of the liver, lung, and kidney, are owing to a similar cause. Fig. I'ZO. Fibres, from induration of the stomach, with embedded nuclei. Fig.' 171. Fibrous tissue, with free nuclei and fusiform cells, from a white patch on the peritoneum. Fig. 172. The same, after the addition of acetic acid. 250 atam. FIBROUS GROWTHS. 191 5. A fifth form of pathological fibrous growth is that of tumor. Under this head must be classed a number of growths, hitherto denomi- nated sarcoma and neuroma, as well as those usually called fibrous. They all consist of a fibrous structure, in difierent stages of development, the softer and more vascular forms being such, even when their substance has not yet completely passed into perfect fibres. For tins reason they have been made to constitute a distinct group by Lebert, under the name of fibro plastic tumors, ■ and may bj fibro-nuclear or fibro-cellular in str’icture. Such growths, however, may always be seen passing into true fibrous tissue. In some, whilst one part of a tumor is sarcomatous, or fleshy, another is truly fibrous; but the difference is only one of develop- ment, and cannot therefore constitute a good ground of distinction. Other kinds of fibrous tumors resemble tough ligament and fibro- cartilage, and present a variety of intermediate conditions of form be- tween the areolar and elastic tissues. Fibrous tumors, tiiei'efore, may be divided into — 1st, Sarcomatous; 2d, Dermoid; and 3d, Neuromatous Fibrous Tumors. Sarcomatous or soft fibrous Tumors . — These tumors are either spherical or more or less lobulated (panci-eated sarcoma of Abernethy). The first are of the consistence of muscular tissue, or very soft cartilage, and are generally surrounded by a distinct cyst. On section, they pre- sent a smooth or finely granular surface. Their color varies from a yellowish-white to a rose pink or deep red, and is dependent on their degree of vascularity. Occasionally a section presents different colors, the external portion being more vascular than the internal; or it is more or less mottled, the red tint alternating with the yellow. At other times the section presents several ecchymotic spots, varying in size, caused by extravasation of blood from the capillaries. Ov/ing to the vascularity of these tumors, there is a disposition in them to exudation, and to a breaking down of their substance, with formation of purulent fluid. For the most part, they increase in size slowly, and only cause in- convenience from their bulk, or by pressure on neighboring nerves and tissues. Owing to this pressure, they may induce absorption or ulcera- tion of the parts around them. Not unfrequently these tumors are more soft and lobulated, and have in consequence been frequently mistaken for encephaloma. The lobules vary greatly in size, and present externally a papillary, or cauli- flower form, sometimes resembling the pancreas, and hence the name given to them by Abernethy. Occas’onally the lobules are surrounded by a more or less dense layer of areolar tissue. They are, for tlie most part, of a greyish, yellowish, or rosy color, their tint varying with their amount of vascularity. These tumors are found in many places, as below the skin, richly supplied with cellular and fibrous tissue. They are not unfrequently observed in the mamma, where their separation from schirrus constitutes one of the nicest points of surgical diagnosis. They may occur in bone, and have received the name of osteosarcoma.^ although many tumors that have received this name have been shewn to be cancerous. They constitute small mushroom-like growths on the conjunctiva (Lebert)., and may destroy the eye from the pressure cau.-.ed by their enlargement. 192 PRINCIPLES OF MEDICINE. The minute structure of these sarcomatous tumors is essentially fibrous, but many of the fibres are seen to be made up of congeries of fusiform cells closely applied together (Figs. 175, 213) These cells are of a spindle shape, varying in length and breadth, and are for the most part distinctly nucleated. Many of them may be seen branched at their extremities, and passing into fibres, according to the mode of develop- Fig. 177. ■mwmm ; S'*'.? r\\o‘ r j ■ b ■ (!) fe'T ' Fig 178. Fig. 179. ment of fibrous tissue described by Schwann. In some, the nucleus has disappeared. Other of the cells are round or oval, or only slightly elongated. All these stages of a fibro-cellular growth may be observed in the same tumor. In the softer parts, isolated cells and nuclei abound (Fig. 173), whereas, in the harder and denser parts, the develop- ment into fibrous tissue is perfect (Figs. 175, 176). At other times associated with the fibres we find a multitude of oval nuclei, without cells of any kind. These I described in 1849 Fig. 173. Cells in the soft part of a fibrous tumor removed from the neck by Mr. Syme. Fig. 174. The same, after the addition of acetic acid. Fig. 176. Fibres in various stages of development from a harder nodule of the same tumor. Fig. 176. Perfect fibrous tissue from another nodule of considerable density. Fig. 177. Corpuscles scraped from the surface of a fibro-nucleated growth of the thigh, excised by Mr. Miller. Fig. 178. The same, after the addition of acetic acid. Fig. 17‘J. Appearance of a thin section of the tumor. Fig. 180. Another section treated with acetic acid. FIBROUS GROWTHS. 193 as fibro-nucleated growths. They may be hard or soft, and present the structure represented Figs. 177 to 180, and 168. Some tumors of this kind are so soft, as to be pu’py in their consistence, and contain between the meshes of their fibro- cellular structure a certain amount of serous liquid. These are soft polypi. For the most part, they constitute pro- minences on the mucous membrane, to which they are attached by a neck, which may be broad or narrow (Fig. 181). Ex- ternally, they are covered with mucous membrane, more or less hypertrophied and thickened (Fig. 184). Fig. 182. Fig, 183. Fig. 184. Fig. 185. Dermoid or hard fibrous tumors . — These tumors are generally of a white color, more or less tough and elastic, resembling the well-known structure of the dermis. This, indeed, is not so apparent in examining the compara- tively thin human dermis; but on looking at that of some of the larger animals, and more especially of the whale, the analogy in structure at once becomes evident. These tumors are of a rounded or oval form, frequently embedded in a cyst, composed of the indurated structures in which they He. They are of considerable density, vary- ing from that of tendon to that of ligament or fibro-cartilage, and on section present numerous w'liite glistening fibres, intimately interwoven together, or arranged in bundles constituting circles, or loops intercrossing with Fig. 181. Soft polypi growing from the Schneiderian mucous membrane — {Liston). — Half natural size. Fig. 182. Fibre cells and fibres from the pulpy interior of a polypus removed by Mr. Syme. Fig. 183. The same, after the addition of acetic acid. Fig. 184. Ciliated epithelial and pus cells from the exterior of the tumor. Fig 185. The same, after the addition of acetic acid. ‘loO diam. Fig. 186. Section of a dermoid fibrous tumor, embedded in the uterine walls. One-fourth of the entire growth is represented. Natural size. 13 194 PRINCIPLES OF MEDICINE. eacli other. Occasionally they have a calcareous centre or nucleus. Their color is generally white, but sometimes they have a yellowish tinge. They are for the most part not very vascular, although there is great difference in this respect, some approaching the pinkish color of sarcomatous growths, and others being of dead white and of extreme density, containing scarcely any vessels. They vary greatly in size, from that of a pin’s head to a volume measuring several feet in circumference. These tumors may be situated in various tissues and organs, as in the subcutaneous and submucous cellular tissue, in the mamma, and uterus, in which last-named organ they are most common. When developed in the uterus, they often push the mucous membrane before them. In this way they grow out- wards, forming what are called hard polypi. At other times they grow to- wards the serous or internal cavity, pushing the membrane before them in a similar manner, so that it ultimate- ly constitutes a neck or pedicle, by which they are attached to the uterus. Such pedunculated fibrous tumors are sometimes found in the peritoneum Fig. 1&7. growing from the uterus. Occasion- ally the pedicle breaks across, and the tumor becomes free in the serous cavity. To the same cause are owing the small fibrous, oval or round bodies, called loose cartilages, found in the joints, more especially that of the knee, some of which are truly osteo-cartilaginous. Others are found in the veins, and denominated phleholites. The minute structure of these dermoid tumors is found to consist of fusiform cells more or less aggregated together. In tie softer portions of the growth they can easily be separated by needles, but in the indurated portions they are so dense that this is impossible. Sometimes the filaments are more or less waved, as in ordinary fibrous tissue ; at others, they are curled and brittle, as in elastic tissue. On making a thin sec- tion, they may often be seen to form a concentric fibrous structure, and on the addition of acetic acid, tlie nuclei, scattered throughout the tissue, are made very apparent (Fig. 187). Not unfrequently these latter are collected together in masses Fig. 187. Section of a dermoid fibrous tissue from the uterus, after the addition of acetic acid, sl'.owing the concentiic direction of the fibres. 250 diam. ^ Fig. 188. Section of hard uterine-polypus, which had been boiled in dilute acetic acid and dried ; a, groups of nuclei, surrounded by bundles of fusiform fibres — {Wedl.) 250 diam. FIBROUS GROWTHS. 195 (Fig. 188), and sometimes they are isolated, as in the sarcomatous tumors ; but then the proportion of them to the fibrous element is generally small. The bony nuclei of such tumors are composed of amorphous mineral matter, not of true bone (see Fig. 368), although Le- bert says, that on two occasions he has seen true bone produced. Wedl also has figured true bone in the interior of these growths (see Fig. 282). The two forms of fibrous growth now spoken of may frequently be found associated together in one tumor. Some are composed of several rounded or oval masses varying in size, enclosed and separated from each other by a cyst, or layer of areolar tissue. The external surface, under such circumstances, is more or less nodulated. It may frequently be observed that some of these nodules are soft and pulpy — semi-gelatinous, with a very sparing layer of fibrous tissue ; whilst others may be seen more or less tough, gradually passing into a fibro-cartilaginous density, grating under the knife. Nay, even in the same nodule I have frequently observed some parts of it soft and others hard, and have shown that the softer parts are mostly cellular, and the harder fibrous, and that between the two there are many degrees of variation. Neuromatous Fibrous Tumors . — This form of fibrous tumor is developed in the nerves, sometimes spontaneously, at others as the result of injuries, and especially of amputa- tion. In the museum of the Rich- mond Hospital, Dublin, I examined a most remarkable series of preparations taken from two individuals, in whom almost every nerve of the body pre- sented knotty swellings. In some places these were developed into tu- mors, which varied in size from a pea to that of the human head.* A subcutaneous tumor, described by the late Mr. W. VV ood, of Edinburgh, must be referred to this class of tumors, f All these neuromata, on being minutely examined, are found to con- sist of fibrous texture, more or less dense, the filaments often arranged in wavy bundles running parallel to each other, but occasionally assum- ing a looped form, or intercrossing with each other, as in Fig. 186. I have also found them to contain groups of cells, so that, on the addition of acetic acid, they closely resemble the structure represented Fig. 188. Not unfrequently they are fibro-cartilaginous, sometimes with the cells closely aggregated together, at others widely scattered (Fig. 190). In some of the neuromatous swellings described by Dr. Smith, of Dublin,* *See Smith’s Treatise on Neuroma ; Dublin, 1849. f Edin. Med. and Surg. Journal, 1812. Fig. 189. Section of neuroma connected with three nervous trunks . — Natural iize. — t^Smith.') 196 PRINCIPLES OF MEDICINE. I found the fibrous tissue to present wavy bundles, among which a few Fig. 190. Fig. 191. granule and cartilage cells were scattered and shrivelled, apparently from the action of spirit (Fig. 191). Fatiy Growths. — Lipoma. The morbid increase of fat is frequently so imperceptible, that it is impossible to separate the pathological from the physiological state. Obesity may gradually increase, either locally or generally, internally or externally, so as to cause, not only inconvenience, but actual disease. Some individuals have become celebrated from their excessive fatness. (See Polysarcia.) Fat sometimes occurs in masses, being only an exaggeration of the normal texture of the part, as when it collects about the heart, in the omentum, or on the serous membranes, in which case it takes the exact form of the included viscera. Fat may also be aggregated in masses in unusual situations, and then form the so-called fatty tumor. Fatty tumors vary in size ; they may reach a growth weighing up- wards of 30 lbs. Sometimes their surface is lobulated, at others smooth. They are of a yellow color, resembling adipose tissue, and are occasion- ally divided into bands by white fibrous tissue. The relative amount of these two elements varies greatly in different specimens, some being soft, oily, containing few fibres, others being hard and dense, the areolar tissue preponderating. For the most part they are very sparingly sapplied 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 considered as fibrous or sarcomatous tumors, combined with an unusual quantity of fat. Occasionally they are con- nected with the ordinary adipose tissue of the body. "We see this in fatty tumors so common in the subcutaneous tissue. They are often Fig. 190. Thin section of a subcutaneous tubercle, composed of fibro-cartilage. Fig. 191. Fibrous structure of a neuromatous swelling, given to me by Dr. Smith, from one of the cases he has described. 250 diam. I FATTY GROWTHS. 197 surrounded by a delicate cyst or envelope; but in others this is not per- Fig. 192. ceptible. It is when the collection of fat resembles the ordinary adipose tissue, that the tumor has received the name of Lipoma. When it is more lardaceous, some have applied to it the term Steatoma, in the same manner as when the substance is encysted. When firm, and largely mingled with fibres, it may be called Fibro-Lipomatous, as in the lobu- lated tumors that constitute so frightful a de- formity of the nose (Fig. 192). The minute structure of these tumors varies according to the amount of adipose or fibrous tissue in their composition. The adi- pose matter is composed of vesicles of a round or oval form, more or less liable to undergo alterations in shape from pressure (Fig. 191). They vary from the yoV 3 of an inch in diameter; are composed of a diaphanous cell-wall, which frequently includes a nucleus. Fig. ] 92. Lobulated Lipoma of the nose. — {Bickersteth.) ^ Fig. 193. Smooth Lipoma, removed from under the tongue, one-half the natural Tize. — ( Liston.) 198 PRINCIPLES OF MEDICINE. The nucleus is generally round or oval, about the 2 /o otli or of an inch in diameter. Occasionally it is stellate or penniform, of a crys talline appearance, from the formation of crystals of margarine or mar- garic acid around it (Figs. 195, 196 a). On rupture of the cell-wall the oil may be made to flow out, and the cell-wall puckers or shrinks up. Such col- lapsed cells may frequently be seen among the more perfect formations, mixed with globules of oil and fat granules. The fi- brous tissue presents the usual appearance of areolar texture running between groups of the adipose cells, being denser, and occupy- ing greater space, according to the propor- tion in which it enters the tumor. Steato- matous and melicerous fatty matter may consist of the cells just described, mingled in various proportions with granular miatter. In some melicerous encysted growths, we have found the whole to be com- posed of granular matter, in which faint traces of delicate cell-walls were seen more or less compressed together. In all such productions the re- lative 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 generally springs up in the cellular substance surrounding the muscular fasciculi, and by its increase and pressure upon them, causes Fig. 1 94. Two layers of voluminous fat cells, varying in size, from a L\j>om a. 2C0 (h. Fig. 195. Fat cells from the same Lipoma^ dried, showing crystalline bundles of Margaric acid. 250 diam. Fig. 196. Structure of a Fibro-Lipomaious tumor; a, isolated cells, showing Stellate crystals of Margaric acid. 250 diam. CYSTIC GROWTHS. 199 the transverse striae to disappear, and the whole to assume a granular appearance — (See Fatty Degeneration, Fig. 328.) Cystic Growths. — Cystoma. The different crypts and follicles of the skin and mucous membrane, as well as several of the excretory ducts of internal organs, may become obstructed, and as a consequence enlarged and hypertrophied. It is true such growths usually consist of one or more elementary tissues, and do not therefore properly constitute a class of themselves. Their importance in a practical point of view, however, as well perhaps as the difficulty of knowing under what head to describe such compound growths, warrants our speaking of them separately. 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 they have been divided into simple and compound., according as the tumor 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^ melicerous, and steatomatous growths. The latter mode of division is very faulty, as many of these varieties are only altered forms of one substance — fat ; whilst some compound encysted tumors 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 compound, and then describe their different kinds of contents. Simple cystic growths. — These growths are formed of a cyst generally composed of fibrous tissue, lined by a smooth membrane. Sometimes the membrane is structureless, or only composed of areolar tissue. At other times it is covered with a distinct layer of epithelial cells, the nuclei of which are very apparent on the addition of acetic acid. The former kind constitute the vesicles so frequently found in the plexus choroides, in the kidneys, ovaries, etc., and'vary in size from a pin’s head to that of a hazel nut, or even a walnut, and usually have aqueous con- tents. The latter kind consti- tute the cystic growths which arise in the follicles of the Tig. 197. skin, in the mamma, ovaries, testicles, etc. ; these frequently reach the size of an orange, and are sometimes much larger, and vary greatly as to the nature of their contents. For the most part they are only spar- ingly supplied with blood-vessels, and seldom cause inconvenience except from the deformity they occasion when situated externally. Fig. 197. Simple cyst of the broad ligament of the uterus, with very vascular walls, a, New vessels ; 6, broad ligament. — ( Wedl.) 30 diam. 200 PRINCIPLES OF MEDICINE. Compound cystic growths are of two kinds. 1st, The external sr.c ^ contain on its internal surface secondary or even tertiary cysts, which may be sessile or pedunculated — or the growth may be di- ' vided into numerous compartments by divi- ■"yw VL' sions of the fibrous sac. These are the true multilocuiar encysted tumors. The external Fig, 199. cyst in every case is formed of fibrous tissue. The internal surface is smooth, sometimes with, at others without, an epithelial layer. The primary as well as the 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 devel- opment. They may also ulcerate. In the ovary these growths frequently attain an enormous size, measuring several feet in cir- cumference ; tli3 cystic internal membranes often secreting more or less rapidly even gal- lons of fluid. 2d, Numerous cysts may be pedunculated from one stock, and more or less crowded together, with a tendency to grow outwards instead of inwards ; as happens in the case of so-called uterine hydatids, which is a cystic disease of the chorion, as described by Mitteuheimer,* 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 colorless fluid, resembling water, 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, which coagulates on boiling. Such are frequently the contents of so-called serous cysts, or false hydatids of the plexus choroides, kidneys, ovaries, etc. A Hyd/rocele^ and other dropsies of shut serous sacs, may be looked on pathologically as consti- tuting a form of hygromatous encysted growth. 2. The contained fluid may have an amber or golden yellow color, 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 gelatin, at others they are firm, and capable of being cut with a knife, like tolerably strong glue or firm calves-foot jelly. The color of the gelatinous matter may vary from a slight yellowish tinge, to a * Muller’s Archiv. fur Anatomic, etc., 1850, p. 417. Fig. 198. Diagram of compound cystic growth, containing secondary and tertiary cysts, developing themselves endogenously. Fig. 199. Diagram of compound cy.stic growth, in which the included cysts are formed by irregular divisions of the fibrous sac. Fig. 200 Compound cystic sarcoma of the mamma. The cysts are more numerous at a than at b. — [Sliller.) One-fourth the natural size. Fig. 200. Fig. 198. CYSTIC GROWTHS. 201 deep amber, or brownish-yellow color. Sometimes this matter is struc- tureless, at others it may be seen to contain very delicate filaments, com- bined with pale oval bodies, the outlines of which become stronger on the addition of acetic acid (Fig. 202). This re agent frequently causes the gelatinous mass to coagulate into a firm white fibrous struc- ture, capable of being separated by needles, and presenting the appearance of filamentous tis- sue. This kind of contents is common in the cysts of the thyroid gland and ovary, and I 201 . have seen it in the kidney and other organs. On one occrslon the gelati- nous matter in the kidney contained ^ numerous granules ; and inoi-e than ^ have found in the centre of the clear amber masses a creamy white substance, either wholly gran- ^ iilar (Fig. 322), or in the process © % of formation into pus corpuscles. 4. The cyst may be distended with epithelial cells which have evidently been thrown off from its Fig. 202 . Fig. 203, internal surface, and been com- pressed together, and partially broken down. Hence, on examination, clusters of such scales may be found mixed with numerous debris, and fat granules and globules, some- times with crystals of choleste- rine. (Fig. 208.) The contents of the cysts are usually of a white or slightly yellow color, sometimes fluid, at others semi-solid. The molluseum contagiosvm of derma- tologists is thus constituted. A small pedunculated simple cyst, dependent from the peritoneal rmrface of the ovary, was found by Wedl to contain the structures represented Fig. 207. 5. The contents may consist principally of fat, either amorphous. Fig. 201. Colloid cystic growths ill three lobules of the thyroid gland. — {Wedl.) 15 diatn. Fig. 202. Delicate oval corpuscles in amber-colored, transparent colloid matter of the ovary. Fig. 20H. Round and oval corpuscles with filaments in light yellow, semi-trans- parent gelatinous colloid matter in the ovary. Fig. 204. Oval epithelial cells from the lining membrane of an ovarian cyst. Fig. 205. Polygonal epithelial cells from the same lining membrane. Fig. 206. Section of tlie wall of the same cyst, with epithelial cells m situ. 250 di. 202 PRINCIPLES OF MEDICINE. crystallized, or orgaDized, that is cellular. If amorphous, they resemble honey, coustituting the melicerous growths of morbid anatomists. In many cases, however, where the yellow color is uniform and the contents closely resembling honey to the naked eye, break down under the fin- ger, faint cell-walls, more or less com- pressed together, may be observed by the microscope in them. At other times the fatty con- tents are of a whitish color, forming masses of a pearly aspect and smooth surface, and are mingled with a roughened yellowish, and more granular Fig. 207. fatty matter. This is the cJioJesteaioma of Muller. This white matter consists of numerous crystals of cholesterine placed in a close juxtaposi- Fig. 20V. Cells from the interior of a simple cyst, a, 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 ; /, ff, cylindrical epithelium, seen sideways and from above : A, polygonal epithelium cells : i, fibre cells. — ( Wedl.) 250 diam. Fig. 208. Structure of cholesteatoma, consisting of disintegrated fat vesicles and epithelial seales with numerous crystals of cholesterine. — {Beale.) diam. Fig. 209. Encysted tumor, with fatty steatomatous contents. Natural size . — (Liston.) CYSTIC GROWTHS. 203 tion, — the granular fatty matter of oil globules and granules mixed with broken-up crystals, epithelial scales, and sometimes the products of fibri- nous exudation (Figs. 208, 210). Such is the general structure of the atheromatous encysted growths of various authors. Fig. 210. Fig. 211. 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 nucleated. Mixed with these may be a granular matter, combined with epithelial cells or their debris (Fig. 211.) 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 en- cysted growth (Fig. 209). 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 cav- ity, with ivory, enamel, and bone. Sometimes they are found em- bedded in a follicle of the lining membrane, at others like the hairs, they are quite unattached. 7. Occasionally the cysts con- tain lymph, or softened fibrin, pre- senting the structure of molecules Fig. 212. (Fig. 212), or of pus and granule cells — this is the result of exudation into their cavities. Occasionally there is a serous fluid more or less Fig. 210. 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. — {MiircJmori.) 200 diam. Fig. 211. Adipose cells, embedded in fatty granular matter from a steatomatous encysted tumor of the ovary. 250 diam. Fig. 212. Cysts in cystic-sarcoma of the mamma, filled with molecular matter. 204 PRIXCIPLES OF MEDICINE. mixed up with extravasated blood, giving to the contained liquid various colors and appearances, according to the age of the extravasation. Thus it may be red, dark brown (resembling cofi'ee), of a dark-greenish tinge, etc. etc. Sometimes it is of a dark bluish or blackish tint from excess of pigmentary deposit. 8. Sometimes the contents of the cystic growth are formed of a solid exudation, which has undergone the sarcomatous trans- formation as previously described, and wholly consists of fusiform cells (Fig. 213). The exudation poured into such cysts may pass into the cancerous forma- tion, and then the characters we have described will be associated with those which distinguish cancer. 9. Some cysts contain the peculiar secretion of the organ in which they are found. Thus cysts in the liver Fig. 213. may be full of bile, and those in the kidney 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 materials within, canals are distended, follicles or vesicles enlarged, and their walls thickened. Thus the simple cysts in the plexus choroides are owing to effusion of serum into the areolar spaces in the villi of the membrane and their subsequent distension. Those in the kidney may be owing to the dilatation of uri- niferous tubes above an acci- dental 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 obstruct- ed at their orifice ; and their contents gradually accumu- lating, distend the walls, ^ which become enlarged and thickened. Simple cysts in the ovary become dilated by enlargement of isolated Graafian vesicles, either Fig. 213. Fibrous tissue composed of fusiform corpuscles, from a sarcomatous encysted growth in the kidney. . , , , 7 • j'i‘^ 214. Cystic-osteoma of the femur. One-eighth the nainral size.-— ( jM Fig. 215. Cystic-osteoma of the tibia. One-eighth the natural size. ( J/wter, from the preparations referred to.) CYSTIC GROWTHS. 205 deep in the stroma of the organ, or on the surface, when they grow out- wards, and become pedunculated. This mode of cystic formation, from distension by material that can- not readily find an escape, is remarkably well observed in bones, in which cysts are sometimes produced in consequence of accumulated pus. In the Edinburgh University Museum is a remarkable preparation, in which a large osseous cyst has been developed in this manner, at the lower end of the femur (Fig. 214) ; and in the Edinburgh College of Surgeons’ Museum, is another, which has formed in a similar manner in the head of the tibia (Fig. 216). In the first specimen the osseous cystic walls are thin, in the second they are greatly thickened. In this respect they resemble the cranial bones, which in some cases are ex- panded and rendered thin, and under other circumstances become pre- ternaturally thick through disease. 2d, The origin of compound encysted tumors is not so well deter- mined. It is very probable, however, that in most cases they consist of clusters of simple cysts, which become compressed together, assume an increased power of growth, and are at length surrounded by a capsule. They are most common in the ovary ; and here we can readily under- stand how successive growths of Graafian vesicles may give rise either to the appearance of secondary or tertiary cysts, or to the multilocular form we have described. Once produced, the compound cyst enlarges, the in- dividual ones grow sometimes inwards and sometimes outwards, accord- ing 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 pedunculated, as in the so-called hydatid moles of the chorion. 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 Fig, 216. Cysts in cystic-sarcoma of the mamma, crowded with cells; a, the cells after the addition of acetic acid. Fig. 217. Fibrous stroma from another part of the same tumor, with commencing enlargement of the areolar spaces, after the addition of acetic acid. 250 diatn. 206 PRINCIPLES OF MEDICINE. gradual enlargement of the areolae in newly formed fibrous tissue. On examining thin sections of sarcomatous growths, we observe the fila- mentous tissue arranged in a circular form, enclosing spaces varying in size. These spaces are often lined by a distinct epithelial membrane, and sometimes contain serum, blood, or exudation, either in a granular or fibrous state. Such growths have long been known under the name of cystic sarcoma (Figs. 216, 217, and also Figs. 200, 212). 4th, The glandular or epithelial cells of an organ assume an in- creased power of development, and become scattered through its tissue in great numbers. In the kidney especially, a cystic disease is not un- frequently met with, in which the cysts vary from the size of a pea down to the ToVo^^ in diameter, as may be accurately traced with the aid of the microscope. The diagnosis and treatment of encysted growth belong to the special pathology of each organ affected by them. It need only be mentioned here that a knowledge of the structure of these tumors is not unimportant, as an examination of the fluid discharged from them frequently enables us to speak with certainty regarding their nature. Glandular Growths. — Adenoma. Glandular growths are essentially hypertrophies of gland texture, in the same manner that fibrous or fatty growths are an increase of fibrous Fig, 218. or fatty tissues. But the structure of a gland is compound, and embraces two kinds of growth. Strictly speaking, the growths are fibro-epithelial, but of a kind so peculiar as to warrant Lebert and Birkett in constitut- ing them into separate groups. Fig. 218, Structure of a cystic glandular tumor of the neck, in the neighborhood of the thyroid gland, a, Appearance of a portion slightly separated and viewed by a simple lens, presenting a grape-like bunch of lobules ; 6, c, ultimate lobules, com- posed of single or branched caecal tubes, distended with epithelial cells ; e, distended condition of these on the addition of water ; /, alteration of their shape on pressure ; p-, fusiform cells found in small numbers. — {Redfern.) 250 di-im. GLAXDULA.R GROWTHS. 207 Glandular growths may be regular or irregular, that is, they may in- volve the entire gland or only a portion of it, and in the latter case they may assume the form of tumor. They may also be perfect or imperfect, in the first case closely resembling the gland structure, in the second differing from it in various degrees, and passing into fibrous, cystic, fatty, and other forms of growth. It is not our intention to enter into minute descriptions of the various appearances and modifications of structure they present in the several glands. Under the names of chronic mam- mary tumor, bronchocele, enlarged prostate, and hypertrophied, in- durated, or swollen glands, their existence was recognized before 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 t.ssue 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 the human adult head, and weighed upwards of eight pounds. To the feel they vary in density, are lobular or smooth externally, and in the latter case are not unfrequently surrounded by a fibrous capsule. On section they are sometimes smooth and glistening, at others somewhat granular and dull. The cut surface varies in color, sometimes being almost white, at others of a pale yellow, pink, or fawn color, apparently from the greater or less amount of vascularity of the particular specimen. Their mode of growth is by no means uniform. Sometimes they remain Figs. 219, 220, and 221. Structure of a glandular tumor, surrounded by a fibrous cyst, removed from the female mamma. Fig. 219. Thin section transverse to the glandular lobules, after the addition of acetic acid, showing the condensed epithelial lining membrane and enclosed epithelium eells. Fig. 220. a. Mass of epithelium separated from the eut lobule; A, cellular contents.; c, the same, after the addition of acetic acid. Fig. 221, Longitudinal section of one of the duets leading from the lobules, after the addition of acetic acid. 250 diam. 208 PRINCIPLES OF MEDICINE. at one time and rapidly at another. Occasionally, after giving rise to much anxiety, they gradually disappear, but not unfrequently they pre- sent all the external cliaracters and symptoms of fibrous or sarcomatous tumors, and now and then those of true cancer. In structure, glandular tumors consist of gland elements — that is to 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, presenting blind sacs apparently without ducts, and are crowded with epithelial cells, more or less compressed together. If ducts do communi- cate with them, these are similarly distended, as seen in Fig. 221. The thyroid gland is especially liable to a new formation of tissue, first described by Rokitan- sky, in which embedded in a lax fibrous stroma are round- ed vesicles, sun ounded by a layer of delicate pavement epithelium, and containing colloid substance, which es- capes when one of these is ruptured. Fig. 222, «, Whether the remarkable structure denominated by M. Robin, “ Tumeur Heterade- nique,” f in any way resem- bles this, it is difficult for me to say, never having had an opportunity of examining a specimen. Lymphatic glands are very liable to enlarge through lo- cal irritation, arising from a neighboring ulcer or injury ; and the mesenteric glands are especially so, in conse- quence of the various ulcers which form in the intestines. In typhoid fever they are frequently found swollen as large as hens’ eggs, presenting a reddish or purple hue externally, soft and spongy to the feel, on section exhibiting a granular texture and greyish hue, and on pressure yielding a dirty white juice. This juice abounds in the cell elements of the gland, which exhibit an increased power of development. The cells enlarge, * Ziir Anatomie des Kropfes, Wien, 1849. f Lebert’s Anatomie Pathologique General et Speciale, Liv. 10, 11. Fig. 222. New formed tissue in a follicle of the thyroid gland. Areolar fibrous tissue surrounding the epithelial-like lining of the areolae. Many of these have been removed to sliow the glandular formations within. These vary in shape, some, i, being constricted, others round or oval — a, c. B, Colloid masses of various shape from the interior of a. Epithelium, with commencing fatty de- generation, seen also at t/, e, and /. 4, Blood-vessels containing colorless corpuscles of the glaml. — ( Wedl.) 250 diarn. Fig. 222. GLANDULAR GROWTHS. 209 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. 223, 224). The causes which excite glandular growths are not always apparent. They may be constitutional and local, and in the latter *. case the irritation exciting them may be direct, as from ^ a blow; indirect, as from a neighboring sore ; or reflex, as when uterine disease af- fects the mamma. Sometimes when the apparent cause is removed, the glandular growth disappears, but at Fig. 225. The laws Fig. 223. others it continues to grow independently of any such cause, which regulate the occasional persistence or disappearance of these growths have not yet been determined, but one essential and hitherto unrecognized condition, with regard to their independent 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 enlarge- ment with the formation of cells, often in such numbers that they can- not readily escape. This is especially the case in the female mamma of young women not pregnant, in whom, while this morbid action is pro- gressing, 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 tumors. Again, the enlargement of glands in the neighborhood of cancerous and scrofulous ulcers or growths, is not necessarily caused by the presence of cancer or tubercle in them. I have frequently examined enlarged 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 per- formed by the late Mr. II. Mackenzie, the inguinal glands on the affected side were greatly enlarged. After the death of the individual, I found no epithelioma in those glands, but again only simple hyper- trophy. But if this condition be allowed to remain for any length of Fig. 223. Cells in fluid, squeezed from a mesenteric gland, in a case of typhoid fever. Fig. 224. The same in another case. Fig. 225. The same cells, after the addition of acetic acid. 14 250 diam. 210 PRINCIPLES OP MEDICINE. 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 tumor. Einthelial Gro wths. — Epithelioma. The epidermic and epithelial cells are continally thrown off from the skin and mucous membranes, and new ones are as constantly formed. Numerous circumstances may arise, which induce their production in greater numbers, or their accumulation in particular parts. In this case they may soften and give a morbid character to fluids, as that of the urine, or they may become indurated, causing thickenings or swellings on the mucous surfaces, callosities, or tumors 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 tumors 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 compressed together, frequently united by filaments of fibrous tissue, and supplied by blood-vessels. The term epithelioma., first introduced by Hannover, may be appropriately applied to the entire group. The following are the principal forms assumed by this kind of growth : — 1. Corns and Callosities consist of a local hypertrophy of the epider- mis, and are composed of numerous epidermic scales condensed into an indurated mass. The corn is a distinct rounded or acuminated tumor, varying in size from a barley-corn to that of a pea, more commonly sur- rounded 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 epidermic 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 diffused 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 deli- cate nervous filaments below. At other times, from their bulk or hard-, ness, they cause increased pain whenever the pressure is modified or increased. Corns are common on the feet from undue pressure of the shoe ; callosities occur on the knees of housemaids, on the hands of handicraftsmen, sempstresses, etc., or in any other portion of the surface exposed to pressure. The cure consists in removing the cause. We have frequently observed, that during an attack of fever and the sub- sequent convalescence, the corns and callosities on the feet of patients ] ave disappeared, having “ grown out,” as it is called. Changing the shoe or bootmaker, or obtaining another last, has been known to remove them. EPITHELIAL GKOWTHS. 211 2. The scaly shin diseases must be classified among epidermic growths. Accuumlatioiis of epidermic scales, upon a reddened and indurated surface, constitute their characteristic features. In psoriasis t ley are gathered together in considerable masses. In pityriasis the ncales are sniiller are more easily separated from the surface, and frequently associated with minute cryptogamic vegetations. ^ The flattened and imbricated iorm of ichthyosis is also composed of similar accuiimlations of epidermic scales, but without the reddened surface. (Fig. 115). 3. Warts and Condylomata are also, for the most part, composed of epidermic cells condensed together. The wart consists of projections of a papillary form, varying in size, and occurs under circum- stances where pressure does not take place. These growths appear to be constitutional, or associated with peculiar states of the Fig. 226. Fig. 227. body. Thus condylomata and warts are frequently found round the mar- gins of the anus, vulva, and penis, in syph- ilitic individuals. Warts assuming the form of cauliflower excrescence, often ar- rive at a large size in such situations, weighing even several pounds. They fre- quently form on the hands of young per- sons, and are sometimes found on other parts of the body, earning and going with- out any obvious cause. Condylomata^ when closely examined, seem to be made up of a congeries of pa- pillae {papilloma)^ sometimes flattened at (ok the top so that they cannot be separated ; at others, presenting fissures or sulci which lead down to a common stalk. Sometimes the papillae are small and rounded ; at others, elongated and enlarged at their extremities. The tumors thus formed may be only the size of a pin’s head, or may be so large weigh Fig. 226. Warts on the penis. One-fourth the natural size. — {Acton.) Fig. 227. Summit of a papilla from a wart. Fig. 228. Perpendicular section of a papilla from an acuminate condyloma, after the addition of acetic acid, a, Vascular loop — internal to which is fibrous tissue forming the axis of the papilla — outside are nuclei. 6, 6, Basement membrane, c, c, Epidermic cells. — ( Wedl.) 250 diam. 212 PEINCIPLES OF MEDICINE, several pounds. In the latter case the central portions seem to consist of a fibrous structure, probably an hypertrophy of the dermis, which is supplied with blood-vessels (Fig. 229). Their surface sometimes is smooth, resembling thickened epidermis ; at others it is lobulated, composed of rounded groups of papillae, resembling externally a cauli- flower. These tumors, 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 surface is similarly composed, but internally we find more or less areolar tissue, supplied with blood-vessels. On snipping off a small isolated papilla from such a tumor, and examining it entire, it pre- sents a conical or round projection, covered with epidermic scales, as in Fig. 227. When a vertical section of it is made, we observe a vascular loop, surrounded by basenmnt membrane, external to which are layers of epithelial cells varying in thickness (Fig. 228). The Verruca Achro- cordon is a peculiar epidermic tumor, furnished with a cen- tral canal, through which blood-vessels ramify abun- dantly to all parts of the tu- mor. The central parts of such tumors are composed of fibrous structure (Fig. 229) ; exter- nally they consist of epidermic scales, arranged concentrical- ly round the central vascular part, which, if cut into, gives rise to great haemorrhage. — ( Vogd.) All these tumors may soften, and ulcerate on the surface, and, under such cir- cumstances, give rise to purulent and ichorous dis- charges. 4. Another form of epithe- lioma is one wdiich frequently commences as an ulcer, al- though sometimes it is pre- Fig- 2 S 0 . ceded by slight induration of, or a small wart on the part affected. It is common in the under lip, in the tongue, and in the cervix uteri. In the lip there may be often observed a furrow or groove in the indurated spot or wart, in which the ulceration commences. This slowly extends, with indurated, thickened, and raised margins, is circular and cup-shaped, its Fig. 229. Transverse section of the base of a condyloma. The dark shading in the centre and radiating lines, represent dense fibrous vascular tissue. — {Wedl.) Fig. 230. Ulcerated epithelioma of the lip. — {Liston.) EPITHELIAL GROWTHS. 213 surface sometimes covered with a white cheesy matter, at others with a- thick crust or scab (Fig. 230). It slowly extends, until it involves a greater or less portion of the lip and neighboring parts, pouring forth a foul ichorous discharge. In the tongue, the disease follows a similar course ; the base of ttie sore, however, is generally more fungoid or papillated on the surface, and exceedingly dense, owing to the close impaction and compression to- gether of laminae of epitheli- um, These on section present a mass having a white surface, with a tendency to split up and separate, are dense to the feel, and do not yield on pres- sure a milky juice (Fig. 211). On the cervix uteri similar ulcers are very common, with hard irregular edges, yielding a copious ichorous discharge, and causing more or less thickening of the neighboring textures. The so-called cauli- flower excrescence 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 ian jere. 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. lietzius.f Fig. 232. Fig, 233. In all these cases, the ulcers, when examined microscopically, present * Surgical Pathology, vol. ii. p. 41 Y. f Museum Anatomicum Holmiense. Sect. Path. Tab. Y, 1855. Fig. 231. Section of an ulcerated epithelioma of the tongue. Natural size. Fig. 232. Muscular tissue immediately below the white mass Fig. 231. Fig. 233. Concentric laminae of condensed epithelial scales, from the lower por- tion of the white matter seen Fig. 231, with epithelial cells, and fragments of muscular fasciculi. 250 diarn. Fig. 231. 214 PRINCIPLES OF MEDICINE. on the surface masses of epithelial cells in all stages of their development. Some spherical and nucleated are about the yo'oo^^ diameter, others are much larger ; both often resembling cancer-cells when isolated or viewed alone, but associated with flattened scales, vary- ing 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, 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 or less compressed and condensed together, and when the epithelioma is chronic, and the structure dense, these present concentric laminae sur- rounding a hollow space or loculus, evidently owing to the compression together of numerous epithelial scales. This peculiar appearance, some- Fig. 235. times called “cell nests,” is characteristic of this form of epithelioma (Fig. 233). On breaking them 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 (Fig. 237.) The lymphatic glands in the neighborhood of such ulcers have a great tendency to be secondarily affected, in which case they enlarge, soften, and easily break down under the finger. Not unfrequently they contain a yellow cheesy-looking substance, which, under such circum- stances, represents fatty degeneration, analogous to the reticulum c»f cancerous formations. On crushing a portion of the altered glandular substance between glasses, it presents the appearances represented Fig. 237. If the concentric masses are broken down, the individual epithelial cells are here also seen to be of various fantastic shapes, in which fragmentary portions of circles are detectable (Fig. 237). In the Fig. 234. Ei)idermic scales, in mass and isolated, trom the surface of an epitheli- oma of the scrotum, in a chimney sweep. Fig. 235. Group of deep-seated cells, in the same case. Fig. 236. The same, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 215 yellowish portions the nuclei are composed of fatty granules, and the. Fig. 237. Fig. 238. cells themselves are molecular, and mingled with numerous oily particles, (Fig. 238, also Fig. 122). A modification of this form of epithelioma occurs on mucous surfaces, especially in the urinary bladder, and has been variously called villous cancer, dendritic vegeta- tion (Zottenkrebs of Rokitans- ky). It forms a fungous projec- tion, having a fibrous basis which is elongated into branched stems, supporting villi, more or less ao-fjreo-ated together, and covered with a layer of epithe- lial cells. It is soft, and readi- 24o. ly breaks down under the finger, the pulpy matter exhibiting under the microscope numerous irregularly-shaped cells, partly fibrous and partly epithelial, in various stages of development (Fig. 239). 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 tumors, 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 tr.uncated, presenting at its extremity two or more fibres, produced by the longi- Fig. 23Y. Fragments produced by breaking up the concentric masses figured, Fig. 233, from a fymphatic gland. Fig. 238. Epithelial cells, in yellow cheesy matter, of the same gland. Fig. 239. Cells in pultaceous white matter, from a fungoid epithelioma of the Urinary bladder. Fig. 240. The same after the addition of acetic acid. 250 diam. 216 PEINCIPLES OP MEDICINE. In length they vary from one i][narter tudinal splitting up of the hair, of an inch to several inches. 6. Horny productions . — Under this head may be classed the promi- neiit growths in some forms of ichthyosis , tu- mors resembling warts, but so indurated 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, narrow at their insertions, like col- umns of many sides, accu- rately fitting to their neigh- bors. Horny iumors occa- sionally occur, varying in size from a bean, or extend- ing over a space the size of half-a-crown. M any cases are on record of true horn having grown from the sur- face, especially from the head, originating in some sebaceous follicle. They have grown several inches long, as seen in Fig. 241. On making a section of these productions, they are found to be identical with the structure of true horn in the lower animals, or with that of the nails on the hands and toes. They consist of condensed epidermic scales, which on the addition of acetic acid, assume all the characters of such structures. Vascular Growths. — Angionoma. Vascular growths are formed by an increase in the dimensions or number of the arterial, capillary, or venous vessels. Several growths already described, as well as such as arc of a cancerous nature, are very vascular; — indeed, so much so, that in some cases the slightest touch causes alarming haemorrhage, as in the case of so-called uterine polypi, and fungus haematodes. No doubt there is considerable increase of vas- Fig. 241. From an old preparation in the Edinburgh University Museum. The medal attached to it bears the following quaint inscription : — “ This horn was cut hy Arthur Semple, Chirurgeon, out of the head of Elizabeth Low, being three inches above the right ear, before these witnesses, Andrew Temple, Thomas Burne, George Smith, John Smytone, and James Tweedie, the 14th of May, 1671. — It was growing seven years ; her age 60 years. Natural size. VASCULAR GROWTHS. 217 cular growth in such tumors, but their basia is formed of other materia^ — they are not wholly vascular. This term is more properly applied to those diseases which have hitherto been denomi- nated aneurism^ erectile tumors^ and varix. 1. Aneurisfn 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 tumors, Inr'ior than the human head. Fi2. 242. In such cases we find the growth to consist externally of the dilated and hypertrophied structures of the vessel itself, or of the tissues in its immediate neighborhood, and of layers of blood, more or less coagulated within it. The varieties of aneurism are numerous, but, the principal are—- 1. Aneurism hy dilatition^ in which the whole circumference of the vessel fiet 243 . is dilated. 2. Saccular^ also called true Aneurism^ in which one portion or side of the vessel is dilated into a sac. 3. False Aneurism^ in which the coats of a vessel have been ruptured. It has been called primitive when all the coats are divided, as by a wound, and consecutive^ when it is consequent on ulceration or rupture of the internal and middle coats. 4. Mixed Aneurism^ in which, after dilatation, general or partial, of all the coats of a vessel, the internal and middle ones burst, and a false aneurism is superadded. 5. Dissecting Aneurism^ in which there is laceration of the internal and middle coots, so that the blood becomes infiltrated between the coats of the vessel, separates them for a greater or less distance, and bursts externally at some distance from the internal lesion. 6. Hernial Aneurism^ in which the external and middle coats are lacerated, and the internal protrudes through them, forming a her- nial aneurismal sac. 7. Aneurism hy anastomosis, in which an artery, by an unnatural communication with the vein, causes a pulsating tumor in the latter. The tendency of these growths is to burst externally or internally Fig. 242. True saccular aneurism of the aorta, nearly filled with coagulated clot. — One-third the real size. — {After Hodgson, slightly modified.) Fig. 243. 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.) 218 PRINCIPLES OF MEDICINE. into spaces wliero least resistance is offered, but occasionally tlie clot of blood in the interior coagulates to such an extent as to close up the I'ig. iit-4. Aneurism of the coronary artery, completely filled with coagulated clot. Natural size. — {Peacock.) Fig, 245. Section of erectile tumor. — {Miller., after ?) Fig. 244. 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. Pea- cock.* The special pathology of these growths, however, is far too extensive a subject to be entered upon in this place. 2. Erectile growths are generally soft ; for the most part situated in the subcutaneous tissue, the skin covering them being of unusual delicacy. 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 color, and pulsate during life. When the veins abound, they are of a blue or purple color. Their texture con- sists 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 areolm or spaces into which the blood enters (Fig. 245). The section of a fresh tumor is not unlike that of a sponge soaked in blood. In struc- ture 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 the intervascular structure to consist of caudate and branched cells, and in another, in the brain, I found it loaded with earthy salts. Varix is a permanently enlarged and tortuous vessel. Swellings * Monthly Journal of Medical Science. March, 1849. VASCULAK GROWTHS. 219 from this cause are for the most part venous, and may exist in various . parts of the body, but are frequent in the saphena veins of the inferior extremities, the spermatic veius {varicocele)^ and haemorrhoidal veins [hcemorrhoids). In all these cases the veins gradually enlarge, and then become distended, tortu- ous, and coiled up. Seve- ral of these, accumulated together, may produce knotty swellings in the legs, cause the testicle to assume an unusual size, or produce tumors which, during defgecation, are protruded beyond the margin of the anus. Such growths may ulcerate, and cause death by haemor- Fig. 246. rhage, 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. New vessels constitute one of the most common pathological forma- Fig. 247 tions. In the embryo the capillaries originate in independent cells, which throw out arms or prolongations that unite with one another (Figs. 252 and 253). The larger vessels originate in globular cells which be- come fusiform, and arrange themselves, some longitudinally and others transversely, to constitute the different coats of the vascular wall (Figs. Fig. 246. Yaricose vessels in the caput trigonum vesicce. — {Wedl.) 200 diam. Fig. 247. Inner layer of umbilical artery of calf, eight inches long. — {Drummond.) Fig. 248. Succeeding layer in the same vessel, composed of spindle-shaped cor- puscles. — {Drummond.) Figs. 249 and 250. Layp^=; more external in the same vessel, in different stages of development into fibres — ‘Drummond ) Fig. 251. Common caiotil artery of an embryo calf two inches in length, showing d'ffjrent directions of the fibre cells. — {Drummond.) 200 220 PRINCIPLES OF MEDICINE. 247 to 251). In the adult the observations which have been made in connection with this subject, have led to three theories. 1st, That new vessels are of independent origin, and that they, as well as the blood they contain, spring up in a blas- tema according to the general laws of cell formation. 2d, That the blood , escaping a globules of the from the vessels, channel a way through the surrounding exuda- tion, and thus form new vessels. 3d, That the walls of the old ves- sels themselves at particular places present bulgings and irregularities, which become pushed out more Fig. 253. more by the vis a tergo^ and An inquiry into this subject is surrounded with results of modern research tend to the conclusion, that in exudation new vessels for the most part have an independent origin, being formed as in the embryo ; although old vessels may occa- Fig. 252. SO form new channels, difficulties, but all the Fig. 254. Fig. 255. sionally throw 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 Drummond,* and more recently of Billroth, f by their fusion, or by their arrangement side by side, form capillaries of various magnitudes. These capillaries afterwards unite themselves with the pre-existing vessels. Cartilaginous Groivths. — Enchondroma. Cartilaginous growths were first described by Muller, under the * Monthly Journal of Medical Science, November 1854. f Billroth Ueber die Entwicklung der Blntgefilsse, Berlin, 1856. Fig. 252. Stellate cells in the tail of the tadpole, developing into capillary vessels. Fig. 253. Capillary vessels in dilferent stages of formation from stellate cells, in the eye of the foetal calf. — {Drummond.) Fig. 254. Branched cells in lymph exuded on the peritoneum. Fig. 255. Vessels in an early stage of formation, from a colloid tumor of the back. 250 diam. CARTILAGINOUS GROWTHS. 221 name of Enchondroma (Osteochondropliytes of Cravelhier). 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, althougli very rarely, in the glands, as in the parotid or mamma. In the second case they are most common in the bones of the extremi- ties. The tumors may be round and smooth, or rough and nodulated from several of them being accumulated 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 unfre- quently more or less soft, pulpy, gelatinous, and even diffluent in some parts of their substance. They are rarely met with. In structure, enchondroma presents all the cha- racters of cartilage — that is, nucleated cells vary- ing in size, isolated or in groups, situated in a hyaline substance. A network of filamentous tissue runs through the substance of the tumor, forming areolae, in which blood-vessels ramify. Fig. 257. Fig. 258. Fig. 259. Within the areolae so formed, the cartilage is found. These two elements vary as regards amount in different tumors. Sometimes the cartilage is in excess, resembling that in young animals, or that in the foetus. At others the fibrous element ab >unds, the whole being similar in structure to fibro-cartilage. Between these two extremes there is every gradation. Occasionally it presents all the characters of articular cartilage. I have .seen all the^e kinds in one tumor. The c^lls present an extraordinary variety in their size and form, being sometimes large and embryonic (Fig. 257), at others small (Fig. 260). They may contain from one to twenty Fig. 2*36. Enchondroma of the hand and fingers. The tumor, of which a section has been made, is enclosed in a bony capsule. Onc-fiflh natural size. — {Miller.) Fig. 257. 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. 258. The same, after the addition of acetic acid, rendering the whole, and especially the nucleus, more transparent. Fig. 259. The cartilage cells and fibrous tissue separated and broken up, with numerovis molecules in a nodule of the same tumor which was soft and in some places diffluent. 250 diain. 222 PRINCIPLES OF MEDICINE. nuclei. In shape they may he round, oval, irregular, or branched. They may also be associated with numerous granule cells, as in Fig. 260, Fig. 260. Fig. 261. Fig. 262. Fig, 263. from a specimen of enchondroma removed from the integuments of the neck by Mr. Miller, which on section presented the smooth and moist surface of a cut potato. — [Solanoma,) (Figs. 260 to 263.) 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 immediately, are owing originally to an excess of cartilaginous growth. Fig. 264. Fig. 265. Fig. 266. Enchondromatous tumors are continually mistaken for cancerous growths, a fact pointed out by Muller. They are usually denominated Fiej. 2G0. Small cartilage with round granule cells, in the pulp scraped from a scctio!! of an enchondroma, which in color, density, and appearance, closely resembled a potato, or so-called Solanomo.. Fig. 2G1. The same cartilage cells, after the addition of acetic acid. Fig. 2G2. Thin section of a firm portion of the same tumor. Fig. 2Go. Fine filaments which interlaced the cells, these having been washed out. Fig. 264. Thin section of an enchondroma, with a bony cap.sule, growing from the ischium and pubis. Fig. 265. Separated cartilage cells from a softened portion of the same tumor. Fig. 266. The same, rendered more opaque, after the addition of acetic acid. 250 di. CAKTILAGINOUS GROWTHS. 223 osteosarcoma. Not uufrequently they soften, and under such circum- stances present all the external characters of what is called soft cancer. 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 tumor, very much resemble those in cancerous growths. They may be distinguished, however, by the action of acetic acid, which affects 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. 258, 266). 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 ; avid Rodfern, whilst he has confirmed this statement, has described and figured all the various changes observable in tho>=ie cells, and in the inter-hyaline substance in the different diseases of cartilage in man, and many of the lower animals. In consequence of Fig, 267. Diseased human articular cartilage, from a scrofulous joint, showing the enlargement of the corpuscles, the increase of nuclei within them, and their escape into the intercorpuscular softened substance. — {Redfern.) Fig. 268. Similar alteration in costal cartilage of the dog, caused by the passage of a seton thirty-four days before death. — {Redfern.) Fig. 269. Vertical section through diseased articular cartilage of the patella; a, free surface. — {Redfern.) 224 PEINCIPLES OF MEDICINE. as Goodsir pointed out, there are gradually formed within them a mass of secondary ones. These hurst into the surrounding hyaline substance, give it unusual softness, and cause it to swell. At the 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. Fig. 271. Fig. 272. Mechanical injury inflicted on these structures produces the same results, showing that both it and disease operate by stimulating cell nutrition and growth (Figs. 2GT to 270, and 136). Fig. 270. Fibrous projection, from the flocculent surface of a diseased human semi- lunar cartilage. — [Redfern.) 250 diam. Fig. 271. Lateral view of an exostosis, removed from the posterior and inner surface of the humerus two inches from its head, by Mr. Syme. At a, a piece of the tumor has been broken off, showing the cancellated structure of the interior. — {Lister.) Real stze. Fig. 272. Part of a section through one of the prominences of the tumor, a, Superficial cartilage ; c, a portion of deep-seated cartilage surrounded by dense bone ; 6, and f/, c, calcified cartilage not so dense as the more superficial portions. — {Lister.) Real size. Fig. 273. Section of a portion of the tumor at the line of junction of the calcified cartilage, and the cancellous structure of the interior, the earthy matter having been removed by dilute hydrochloric acid, a. Cartilage with its cells changed by the pro- cess of calcification;/;, c, is true bone, containing laminae, lining the excavations in the calcified cartilage ; d, part of a spiculum of the cancellous structure ; c, and /’ spaces formerly occupied by medullary substance. — {Lister.) 200 diam. OSSEOUS GROWTHS. 225 Osseous Growths. — Osteoma. We have seen that in many of the cartilaginous growths deposit of bone may take place to a greater or less extent. In such cases the new cartilaginous tissue undergoes the true bony transformation, in the same manner that normal cartilage becomes ossihed in passing from the foetal state through the periods of youth, manhood, and old age. This we must separate from the numerous forms of calcareous concretH)iis so frequently met with. True bone may bo at once recognised by its osseous lacunao and canaliculi. Earthy concretions only consist of an amorphous mass of mineral material. (Compare Figs. 277 and d68.) Osseous growths may affect the external surface, the substance, or the internal surface of bone. In the first case they are denominated exostoses. They form prominences on the surface of the bone varying in size from a small point to that of a cocoa-nut. There is no part of the osseous frame free from them, but they are very common in the bones of the extremities. They may arise as the result of direct local injury, asfronii a blow or fall, or they may be connected with peculiar constitutional diseases. In syphilitic constitutions, exostoses more especially arise on the shafts of the long bones; in rheumatic persons, they surround the joints. Many of these growths on the surface of bones have not been shown to originate in cartilage as the bones themselves do. But in others, there can be no doubt that such is their mode of growth, viz., matter is thrown out from the blood, which is converted first into cartilage and then into bone (Fig. 273). In this manner enchondroma may be converted into osteoma. The growths in which this change is observable generally present roundish masses. They may be intensely hard or eburnated, or comparatively soft and cancellated. This is owing to the bone texture being more compact in the one case and more spongy in the other. Externally they may be covered with a layer of cartihige and a smooth membrane. Bony growths may more especially affect the substance of bones, and this in two ways. An exudation may be poured into the cancelli of the osseous texture, which is gradually transformed into perfect bone. From this cause its substance becomes much indurated and of great density, and the cancelli and medullary cavity are more or less obliterated. We fre- quently observe this in the long bones of the inferior extremity as well as in the flat bones of the cranium. Some of the latter have thus be- come upwards of an inch in thickness, and on section presented the close texture and density, although not the structure, of ivory. Sometimes, however, the bones, instead of being condensed and thickened, become spongy, the cancelli enlarge, and the whole assumes unusual lightness. In this case, the exudation poured into the cancelli is transformed into pus, and acts as a distending power, and sometimes collects in a central cavity, causing at the same time expansion and hypertrophy of the sur- rounding osseous tissue (Figs. 214, 215). On other occasions the new osseous growth assumes the form of spicula, radiating from the shaft, a result most common in cases where the bone is the seat of sarcomatous or cancerous formations, through which they ramify (Fig. 274). 226 PKINCIl'LES OF ,\l EDICFNE, Bony growths are sometimes thrown out on the internal surface of the cranial bones. This occurs in a peculiar disease first described by Boki- tansky in puerperal women. I saw this formation frequently in Berlin, on the internal sur- face of the cranial bones, in the numerous dissections which oc- curred in the Maternity Hospital of that city during an ep.dcmic puerperal fever which laged there in 1840. Unfortunately, they were not examined micro- scopically. The internal table of the skull in all these, cases ijHi-J |J. was so soft, that the knife could r penetrate it. These de- posits, when dry, assume a gra- nular laminated aspect, more or less curled up and separated from the internal lamina of the cranial bones. Very fine speci- mens of this lesion are to be found in the Pathological Mu- seums of Prague and Vienna. There is a form of growth generally originating in bone, which is soft, easily breaking down under the finger like rice- pudding or marrow (hence called myeloid by Mr. Paget). It has P'i„ 274 . frequently been confounded wuth soft cancers, as pointed out by Lebert, and in addition to fibrous and fusiform cells, contains others of a round or oval form, ^ ary- ing in size from the the 3 i;jth of an inch in diame- ter, having in their interior from two to twenty nuclei. These growths occur in va- rious situations, but are most common in bones, es- pecially of the jaw, constitut- ing certain forms of epulis (Figs, 275, 27G.) The large cells often contained in the friable matter of such growths 275 . (Fig. 276,) closely correspond to the many-nucleated corpuscles described Fig. 2T4. Spiciilar growth of bone, in an osteo-carcinomatous tumor of the tibia. One-Jourfh (he natural size. — (Syme.) fig. 275. Epulis removed from the upper jaw. Natural size. — {Syme.) Fig, 276. Cells with many nuclei in epulis. 250 diam. OSSEOUS GROWTHS. 227 by Kolliker as occurring in the marrow of foetal bones.* A remarkab'e example of it is figured by Mr. Paget, occurring in the bones of tbe cranium, and in tbe brain. f Tlie growth of now bone, after fractures or injuries, takes place in the folio ,ving manner : — An exudation is poured out from the vessels in the neigbb nmood, which at first unites the lacerated edges of ruptured periosteain, muiclc, and cellular tissue, so as to form a capsule around the whole of tlie denuded aid injured bone. Tiiis exuda- tion, at first granular, is partly transformed into fibrous tissue and partly into granular corpus- cles, which may be observed to form an internal coating to the capsule just alluded to. Tne blood extravasated is rapidly ab- sorbed, and a gelatinous exuda- tion, which is poured out from the neighboring capillaries, col- lects between the capsule and denuded bone. This, at first yellowish, becomes gradually lac- tescent and white, and assumes all the characters of fibro-carti- lage. (Fig. 277, «). This carti- lage, in its turn, is transformed into bone, by exactly the same process as the one structure passes into the other in the normal state. As solidi- fication takes place, the soft parts are absorbed and contracted, whilst the bony growth, in the form of spicula, forming the boundaries of large cancelli (Fig. 277, h), insinuates itself between and around the fractured bones, producing complete union. Certain textures have been occasionally transformed into true bone. I examined the preparation of an eye at Munich, in the possession of Professor Furg, which contained an osseous mass, attached internally to the choroid and fibrous structure of the sclerotic, and encroaching con- siderably on the space usually occupied by the vitreous humor. A thin section of it exhibited numerous bony corpuscles. A similar osseous transformation of the choroid membrane and lens has been described * Manual of Human Histology, vol. i. fig. 7. f Surgical Pathology, vol. ii. p. 222. The peculiar character and structure of these growths may ultimately warrant their being classified among the primary divi- sion of tumors, under the name of Myeloma. But at present our acquaintance with them is limited ; and the many-nucleated cells, which is their chief characteristic, I have seen in growths presenting all the characters of sarcoma, adenoma, epithelioma, and enchondroma. Fig. 277. «, Fibro-cartilage formed between the separated portions of a fracturefl cervix fem oris ; b, new osseous structure, in the form of a bony spiculum or trabecula between the large cancelli, from the same fracture. — ( Wedl.) 250 diam. 228 PRINCIPLES OF MEDICINE. and figured by Dr. Kirk,* in a diseased eye of thirty years’ standing (Figs. 278, 279, 280). I have seen true bone formed in the substance Fig. 273. Fig. 279. Fig. 280. of the dura mater, where it has been exposed after removal of a portion of the cranium by the trepan. The osseous laminae, sometimes found on the surface of tho spinal arachnoid, also possess the true bony struc- ture (Fig. 281)o Ligaments have occasionally been transformed into Fig. 281. Fig. 282. osseous texture (Ileule) ; the calcareous concretions occasionally found in the centre of fibrous tumors, though generally composed of amorphous * Monthly Journal of Medical Science, November, 1853. Fig. 278. Spieulum of bone projecting from the choroid membrane. — {Kirk.) Fig. 270. Section from tho centre of the crystalline lens, of stony hardness from osseous transformation. In the centre are spheroidal mineral masses, composed of carbonate mixed with phosphate of lime. — {Kirk.) Fig. 280. Loose membranous matter, like the collapsed pith inside a quill, found in the anterior chamber of the same eye. On one of its surfaces were projecting tubercles with a radiated structure. — {Kirk.) Fig. 281. Ossified excrescence on the arachnoid of the thoracic portion of the spinal cord ; at a portion is cut across. — ( Wedl.) Fig. 282. a. Bony laminai arranged concentrically ; 6, others arranged irregularly in partially ossified fibrous tumor of the uterus. — ( Wedl.) 250 diam. CANCEROUS GROAVTHS. 229 mineral matter, are sometimes formed of true bone (Figs. 282, h ) ; and Dr. Wilkinson of Manchester communicated to the Pathological Society of that city an instance where numerous muscles of the body had un- dergone a like transformation. In all these cases the osseous structure is formed on a hbrous and not on a cartilaginous basis, an occurrence which may be accounted for by the analogy which exists between carti- lage and certain forms of fibre cells. Many kinds of morbid fibrous growth contain cells and nuclei, which present all degrees of interme- diate formation observable in those of fibrous, cartilaginous, and osseous textures.'^ (Compare Figs. 187, 277, a, 281, 282). Of earthy depositions which to the naked eye frequently resemble them, whether a, morphous or assuming a regular form from accidental circumstances, I shall speak more at length under the head of Concre- tions. Cancerous Growths — Carcinoma. Cancerous growths present three principal forms, which result from the relative amount and arrangement of the cells and fibres forming t'lem. 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 areolae or loculi, which contain a gelatinous gum or glue-like matter [coVoid cancer). 1. Scirrhus presents to the naked eye a whitish or slightly yellowish tinge, is dense and hard to the feel, and offers considerable resistance * See Memoir on Calcification and Ossification of the Testicle, by Mr. J. S. Gam- gee, in Researches on Pathological Anatomy, etc., 8vo. 18.56. Fig. 283. Section showing the arrangement of cells and fibres in scirrhus of the mamma. Fig. 284. The same, after the addition of acetic acid. Fig. 285. Isolated cancer-cells, from the same growth. Fig. 286. The same, after the addition of acetic acid. 250 diam. 230 PKINCIPLES OF MEDICINE. to, aud often crunches under, the knife. On making a thin section of the growth, it is seen to be composed principally 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, enclosing 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 yVo oth to the y^^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 many as nine. Most commonly there is only one, which 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 of the volume of the Fig. 287. Fig. 288. Fig. 289. Fig. 290. cell. Between the nucleus and cell-wall there is a colorless fluid, which, at first transparent, becomes afterwards opalescent, from the presence of molecules and granules. On the addition of water the cell-w^all 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 dis- solved (Fig. 288), whilst the nucleus, on the other hand, either remains unaffected, or its margin becomes thicker, and its substance more or less contracted. 2. Encephaloma also presents a fibrous texture, wdiich, 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 eye. The whitish cut surface is often more or less mottled with a pinkish, reddish, greyish, yellowish, or black color. The two first colors 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 large they constitute what has been called fungus hcematodes. The yel- lowish color, when it surrounds extravasations of blood, is owing to imbibition of its coloring matter ; but when the color is spread in a reticulated form over the surface, or over masses, it generally results from fatty degeneration of the cancerous tissue, and forms the so-called Tei\Q\x\\xm {cancer retmdare of Midler). This yellow matter is usually Fig. 287. Young cancer-cells from the lung. Fig. 288. Tlie snme, after the addition of acetic acid. Fig. 289. Somcwha" older cells from the testicle. Fig. 290. The sr.nie after the addition of acetic acid. 250 mode of cell development will be perceived, yet the one takes its origin in pre- existing articular cartilage cells, whilst the other must arise in the new cells of an exudation, as the wliite sub- stance of the brain contains no corpuscles from which thej'’ could be developed. In tlie cornea and epithe- lium similar changes occur, as well as in the bones and mesenteric glands. Yet these lesions, so closely allied in their essential nature, have in tliese dif- ferent textures been called bv different names, and Fig. 302. have been widely separated pathologically. In the non-vascular cor- nea and cartilage, it has been called inflammation, but in the equally non-vascular epithelium, it has been named cancer. Again, in the vas- cular bones and glands, a cancerous exudation has received various names, such as medullary or osteo-sarcoma, enlarged glands, etc. ; whilst in the brain and other localities it has been called encephaloma, or soft 'cincer. It seems to me that in all these cases the lesion is the same, :.r,d therefore that we ought in accordance with their nature to group them together. To call some of them inflammation and others cancer, supposing the first to be innocent and the last malignant, is, I contend, incorrect pathology. True theory points out that all these lesions are equally destructive, in consequence of increased endogenous cell growth, and practical experience has long determined the question of their being alike difficult to control. As a general rule, the greater the number of cells any growth con- tains, the more rapidly it extends. Hence a tumor is subject to the laws which govern the development and multiplication of cells, in addi- tion to those connected with locality and the general powers of the con- stitution. Thus, room for expansion, and a greater or less amount of temperature and moisture, exercise undoubted influence over morbid growths. We see the influence of room for expansion in the cases of adenoma and carcinoma. In adenoma the cells are confined within l^ouches or ducts (Figs. 21-^, 219). They become crowded on each other ; and thus, by means of compression, tend to atrophy and breaking dowm, rather than to self-multiplication. This is assisted if the distension from v;ithin so irritates the fibrous stroma of the gland that it becomes hyper- trophied, and occasions a further obstacle to expansion around the seat of cell increase. In carcinoma, we observe that the growth takes place Fig. 302. Cells from a cancerous tumor of the brain. — {Redfern.) 260 diam. PROPAGATION OF MORBID GROWTHS. 237 in extent and rapidity, proportionally to the number and power of ex- pansion in the cells. If compressed by much fibrous or hard tissue they multiply slowly ; but if an ulceration occurs, say in the skin, then they become developed rapidly, and constitute the so-called soft fungoid ex- crescences. Heat and moisture, as they are essential to cell growth throughout the animal and vegetable worlds (increased temperature with fluidity favoring — cold and dryness, checking it within certain limits), so the influence of these physical agents may be observed to be equally powerful in morbid growths. Kapid augmentation of a tumor is gene- rally accompanied by increased heat and softening of the parts, whilst colder and harder swellings develop themselves slowly. Propagaf.i'm of Morbid Growilis . — It has seemed to most patholo- gists that whilst some morbid growths are local, and if removed by the surgeon do not return, others are constitutional or general, and if cut away exliibit a great tendency to come back. The former have been called innocent or benignant, and the latter malignant. So far has the notion of malignancy in certain growths been carried, that surgeons have refused to remove them, not because they were inaccessible, or so con- nected with parts as to render the operation directly dangerous to life, but simply because they thought the disease was in the blood, and that cutting away the local swelling would either be useless, or give increased activit}'^ to the lesion. Firmly believing that many lives have been sacrificed to this erro- neous principle of practice, I endeavored to combat it in my work on cancerous and cancroid growths, published in 1849. The progress of medical science since then has fully confirmed the truth of my opinions on that subject. Cases are now on record which prove that every kind- of morbid growth is malignant, even in the worst sense of those who uso that term, and that other growths, which the most experienced surgeons, as well as histologists, have declared to present the typical characters of malignancy, have been repeatedly excised with the greatest success. The establishment of these facts by the many recorded cases which may now b'e confidently depended on as having been carefully observed, and especially those of M. Velpeau, prove tke impropriety of making this distinction between morbid growths. Thus Fibroma^ consisting of absolutely nothing but fibres, in all its forms has frequently returned after operation, so that it has received the name of recurrent (Syme, Paget), and it has also invaded every part of the economy. The dermoid variety has been shown by M. Paget, not only to return in the mamma after excision, but to infiltrate itself in the form of numerous distinct nodules throughout the lung.* A somewhat similar case is given by Lawrence,! in an old man, and another in a girl aged six years. Lebertj; has recorded seven cases where sarcoma had spread to the neighboring glands of the original growth, and to various internal organs. Professor Smith of Dublin,^ in a magnificently illustrated memoir, has published two cases in which neuroma occurred in all parts * Surgical Pathology, vol. ii. p. 151, et seq. f On Surgical Cancer, p. 73, 1st edit. ; p. 26, 2d edit. \ Traite d’ Anatomie Pathologique, p. 195, et seq. § A Treatise on Neuroma, Folio, Dublin, 1849. 238 PRINCIPLES OF MEDICINE. of the body, and Virchow has given a case where neuroma returned in the arm four times, and was four times excised.^ Lipoma may be general in the form of excessive obesity, but even when local may return after extirpation.! Murchison has given three cases where multiple fatty tumors were hereditary. J Angionoma may be so constitutional, that cases have been published in which aneurisms were present in almost every artery in the body.g Nsevoid tumors, returning after operation in different parts of the body, have been described by Muller and Walther;|| and two others, in which similar vascular growths were dis- seminated among various textures, are given by Cruveilhier^ and Laurence.* ** As regards cystoma^ I have frequently been struck in opening dead bodies with the frequency and universality of cystic forma- tions in some of them. In one man I found innumerable sebaceous cysts scattered over the whole anterior surface of the thorax ai d abdo- men. The constitutional nature of cystoma^ moreover, is occasionally demonstrated in cases of bronchocelc and mollusca. Adenoma is emi- nently constitutional, the glands being differently affected in a variety of general disorders, as plague, syphilis, scrofula, typhoid fever, etc. Velpeau refers to several cases where it recurred after operation in the same or opposite breast,!! and Aitken has recorded two well observed instances where, subsequent to the growth having recurred in the mamma, it appeared in the lungs, liver, and ovaries.JJ Ep}theJioma not only spreads to the neighboring glands, but has also been shown by Mr. Paget to infiltrate the lungs and heart, after operations for the removal of similar growths in distant organs. §§ Enchondi oma has in- vaded numerous parts, and among others in the same case, the testicles and lungs. II II Osteoma^ composed of true bone (not cancer in bone), has, in a case by Mr, Swan, after affecting the femur, appeared secondarily in the pleura, lungs, omentum, and diaphragm. A similar case is given by Laurence.*** Muller!!! has also referred to such constitutional osseous tumors under the name of Osteoids. Of the constit-utional characters of carcinoma^ I need say nothing. It follows that every kind of morbid growth may be malignant in whatever sense that term be employed, whether used to signify a growth incurable, recurring after the operation or primary lesion ; or growths infiltrating neighboring or distant tissues or organs, or as continuing their progress, and destroying life in spite of all the resources of art. On the other hand, it is easy to prove that all these forms of growth may either disappear spontaneously, or be cured successfully by opera- tion, so that the individual may permanently recover. With regard to * Archiv fiir Patholog. Anat., Band. xii. p. 114, f Sedillot, Recherches sur le Cancer, 1849, obs. xxix. \ Edinburgh Medical Journal, June 1857. § Cruveilhier. Livraison, 28. Scarpa. Tab. ix. | Journal der Chir. u. Augenheilk, B. v. p, 261, 1828. ^ Anatom. Pathologique Gen., tom. iii., 1856. ** On Surgical Cancer, p. 22, 2d edit, ff Maladies du Sein, p. 404, et seq., 1st edit. Xt Medical Times, April 11, 1857, p. 359. §§ Opus. Cit., vol. ii. pp. 448,449, || || Paget in Medico-Chir. Trans., vol, xxxviii. Eichte, tJeber das Enchondrom, p. 58. Laurence, 2d edit, p 28. Richet. Gazette des Hospitaux, Nos. 71 and 95, 1855. Lond. Pathological Trans.- vol. vi. p. 817. *** On Surgical Cancer, 2d edit , p. 18. fff Archiv. fiir Anotomie und Physiologie, 1853, t. v. pp. 396, 442. PROPAGATION OF MORBID GROWTHS. 239 carcinoma this has been denied by some and is doubted by many. On this subject I wrote in 1849 as follows, regarding the permanent re- covery from cancer * “ Doubts must always exist, regarding such cases, as long as no authentic record is preserved of the minute examination of the tumor removed. Every experienced surgeon who adopts a favor- able or unfavorable view of this question can point to crowds of cases in support of his opinion ; but when he is asked whether the growth operated upon be truly cancer or not, it will be found that he has no positive grounds on which to form a conclusion. He considered it to be cancer, nothing more. In the present state of our knowledge, then, I believe that there is no possibility of pronouncing accurately whether an operation will be successful or not. It appears to me that all analogy opposes the doctrine of the necessarily fatal nature of cancer, or of any other morbid alteration of the economy. There was a time wlien phthisis pulmonalis was also thought to be necessarily fatal, and when recoveries from it led practitioners to doubt their diagnosis rather than the truth of a received dogma. Morbid anatomy has exploded that error, as it will doubtless do that in regard to cancer.” * Since then, M. Velpeau, in a work published in 1854, has proved the correctness of these statements, and has shown that cases which not only presented all the characters of scirrhoma and encephaloma, but which were proved to be so by careful histological examination, have been successfully extirpated without returning. Some of these cases are truly remarkable, the disease having advanced apparently to its last stage and involved large masses of neighboring glands, so that the operation was performed under the most unfavorable circumstances. In these cases, however, the persons operated on have lived since the local extir- pation of the disease up to this time, that is, from nine to twenty years, in perfect health.f While thus it is contended that there is no growth which may not be malignant, and none which may not be innocent in the sense inferred, it is not denied that some growths have a greater tendency to spread and affect the system than other.s. In reference to treatment, therefore, it becomes of the greatest importance to determine the laws which ap- parently govern the propagation and multiplication of different morbid growths, or the circumstances which render — say carcinoma and epithe- lioma — more susceptible of being communicated to neighboring and internal organs, than purely fibrous or osseous growths. There is o le circum stance in reference l O the removal of tumors which is frequently overlooked by surgeons, viz., that certain growths, abounding in cells, have a great disposition to infiltrate themselves among muscles and neighboring parts, and may be detected there by the micro- scope, although invisible to the naked eye. In one case I found numerous granules and commencing cells in the muscles of the tongue below an epithelial ulcer, though it seemed healthy (Fig. 232) ; and in the sterno- mastoid muscle, covering a tumor of the parotid gland, clumps of nuclei * Cancerous and Cancroid Growths, p. 233. f Velpeau, Traite des Maladies du Sein, etc., 1854; and 2d edition, 1858, in the preface to which are enumerated, p. xxx, no less than 23 cases which up to the close of that year remained well. See also note at the conclusion of this article. 240 PRINCIPLES OF MEDICINE. were developed, and the fasciculi of the muscle were converted into fibres (Fig. 303). In this case the muscle looked pearance of be- ing infiltrated with cancer. It follows Fig 303. that in many cases where the surgeon thinks he has removed a morbid growth, he really leaves multitudes of germs behind wdiich continue to propagate the disease. Dr. Handyside removed the inferior extremity of a boy at the hip joint, in June 1843, for cancer of the femur. I carefully examined a small portion of one of the upper flaps, which was subsequently cut away, on observing a piece of the tumor attached to it, and found all the muscles fatty and infiltrated with young cancer cells (Fig. 304). In short, all the muscles which formed both flaps were already cancerous, and I told the operator that the disease would probably return in the stump The incisions healed favorably, but in a few months cancerous nodules appeared not only in the cicatrix but in other places, and caused death.'" I have also seen the same mode of propagation in nerves as has been figured in muscles * Cancerous and Cancroid Growths, p. 103. Fi" 303. Fil)rc of the sterno-mastoid muscle, in tlie neighborhood of a cancerous growth, partly transfoi’mcd into fibres, with masses of young cancer-cells. This figure, published by me fifteen years ago, exhibits all the facts subsequently seen by the so-called cell pathologists. I need scarcely point out to the experienced observer how an imaginative histologist, when copying such an appearance, might — by strengthening the outlines of those fibres which surround the groups of nuclei — make the whole re.scml)lo endogenous cell growth. Fig. 301. Fasciculi of muscle, forming the flap in an amputation of the thigh, already infiltrated with young cancer colls, a, The latter, after the addition of acetic acid. Fig. 303. Granules, nuclei, and granule cells, infiltrated among the tubes of the brachial nerve, near a cancerous growth. 250 diam. pale and atro- pliied, but ex- hibited no an- PROPAGATION OF MORBID GROWTHS. 241 (Fig. 232, 303). I have found the brachial nerve in connection with a cancerous tumor of the humerus, infiltrated with granular masses and granules, some of these latter arranged in rows, and meeting together, apparently to form nuclei of new cells, as in Fig. 305. Professor Van der Kolk of Utrecht has confirmed these observations, and also traced incipient cancer-cells among the tubes of neighboring nerves. Hence one of the chief modes of propagation oi morbid growths, is that the cells in the process of development become infiltrated among neighboring tissues. But how do tliey accomplish this? Van der Kolk suggests that the fluids which they contain mingle with the juice of the parenchymatous substance around them, and that in the latter there are deposited molecules and granules, which, having received from the former certain tendencies to evolution, are ultimately transformed into similar structures. This view is not only exceedingly ingenious but very probable, and will serve to explain how the blood and distant organs are secondarily affected. The notion of solid germs floating in the blood has no facts in its support, but the idea of a fluid secreted by cells being absorbed is consonant with every known law of nutrition. The molecules in the fluid, then, of a morbid growth, formed during its development, as the result of cell or other formation, would seem to be the most probable material producing secondary growths. We have seen that many tumors which have no cells, may be recurrent and attack tissues secondarily. Still they all contain a paronch 3 unatous molecular juice, and as a general rule those that are most soft and pulpy are most liable to return. I have recorded two singular examples of cancroid growths which returned and proved fatal. In one of these, the tumor was removed from the breast by Mr. Page of Carlisle, and consisted of a pulpy fibrous substance, in various stages of development, and of granular cells. Six months afterwards a similar growth af like structure formed in both thighs, of which the patient died (Figs. 306 to 308). In another case the leg was amputated above the knee by Mr. Norman of Bath, for a fungoid tumor, below the gastrocnemius muscle. Fig. 306. Fig. 307. Fig. SOS. It consisted of fusiform corpuscles in different stages of development, m.ingled with naked nuclei, a multitude of molecules and granules, as represented in the figure (Fig. 309). Two years later a similar tumor formed in the right chest, which compressed the lung, and caused death. These, together with the cases ot sarcoma, neuroma, enchondroma. Fig. 306. Structure of the soft part of the tumor removed by Mr. Page of Carlisle. Figs. 307 and 308. Structure of the more indurated parts. 250 dlam. 16 242 PEIXCIPLES OF MEDICINE. and epithelioma, referred to, show that constitutional tendencies do exist for the reproduction of morbid growths, ! ' similar to those which have previously been formed. A recurrence of all dis- eases, and especially of apoplexy, epi- lepsy, rheumatism, bronchitis, etc., are equally common, and appear to follow the same law. But the idea that, be- cause they do so, they should be distin- guished by the name of “ malignant,’’ appears to me unpathological. We may just as correctly talk of a rheumatism being innocent or malignant, as apply those terms in different cases to fibrous, cartilaginous, osseous, or other kinds of morbid growth, for no other reason than because sometimes they are localised in a part, and at others are more general.* 3u9. Fig. 310. Decline or Degeneration of Morbid Growths . — In their decline, as in their development, the various kinds of morbid growths follow the laws which regulate degeneration of texture. Some, as lipoma and adenoma, have been known to be gradually absorbed and disappear. Others undergo the albuminous, fatty, mineral, or pigmentary transformations, to be subsequently described. To enter into the peculiarities of each morbid growth in this respect would lead me too far. They will be referred to generally afterwards. All I need say here is, that every kind of morbid growth may degenerate and prove abortive in one way or another. Cancer even has been known to slough out, and heal by cicatrix, besides having been checked in its development and rendered abortive in every known mode of retrograde transformation. (See Morbid Degenerations of Texture). Geneiial Theatment of Morbid Growths. The treatment of morbid growths may be divided into local and constitutional. The local treatment comprehends — 1st, Means of re- tardation and resolution. 2d, Means of extirpation. * The facts to which I have alluded, and others of a like kind that are daily occur- ring, have induced M. Velpeau, in the second edition of his work on diseases of the breast (1868), to speak as follows — “ J’ai dit plus haut ciue, sans avoir de conviction absolue sur les transformations cancereuses, j’etais loin, cependant, d’etre aussi decide (pdautrefois dans le sens negatif Les faits, cn se multipliant dans ma pratieiue, ont tini par ebranlcr mes croyances et meme par me faire pencher, sous ce rapport, vers la doctrine affirmative defendue avec talent en dernier lieu per M. Bennett d’Edim- bourg.” He adds, much to his honor, “ Renoncer ainsi it ses anciennes doctrines, juste au moment ou les autres savants, ou la. jeunesse active et laborieuse s’en em- l)arcnt et les soutiennent avee ardcur, pent etre peiiible sans doute, mais les besoins dc la verite doivent passer avant tout ! ” Fig. 300. Structure of a fungoid growth of the leg, removed by Mr. Norman of Bath. Fig. SIO. The same, after the addition of acetic acid. 260 diam. GENERAL TREATMENT OF MORBID GROWTHS. 243 ]. Means of Retardation and Resolution , — These consist in applying all those means which are opposed to development of tissue, such as topical cold and graduated pressure, avoiding moist applications and local irritation. Such means, as they are opposed to those circumstances which are known to favor cell growth in the animal and vegetable worlds, such as heat, moisture, stimulants, and room for expansion, might be expected to retard the progress of morbid growths. Dr. James Arnot has in consequence found much benefit from the application of frigorinc mixtures, and Dr. Niel Arnot has applied graduated pressure w th occasional good effect. Tlie difficulty of such treatment consists in the frequent impracticability of their application, as they can only be serviceable when the growth is *situated externally, at»d on particular parts of the body. Huch treatment also is counteracted by the fact, that although }mu may freeze the external parts, the growth is continually supplied with warm blood from within; and that when you compress outside, you thereby run the risk of causing extension towards the interior. Both these means, however, which may be carried on con- jointly, are eminently deserving further trial. As moisture favors, so dryness is opposed to growth, and the avoidance of local irritations, as they are a common exciting cause, is obviously indicated. 2. Means of Extirpation . — These are excision of the part, and the application of chemical agents which destroy texture. From all that we have said as to the origin, mode of development, and propagation of morbid growths, it would appear that they may all destroy life, and that those which exhibit the most rapid powers of spreading may supervene on the more indolent ones. Hence, as a general rule, so soon as it becomes evident that means of retardation and resolution have failed to arrest their progress, an operation should be had recourse to. If early excision were more practised, many of the Lament- able cases which occur in practice would not arise. Should the cancerous growth even be advanced, it should never be neglected so long as the diseased parts are external and within the reach of the knife. We have also seen that surgeons, in removing the tumors, have left un- touched tissues infiltrated with cells capable of causing their regeneration. Hence the neighboring textures should be carefully scrutinised, and all those portions of them infiltrated with cancerous germs carefully removed. For this purpose the microscope ought to be a necessary instrument in the operating theatre, and every suspected tissue in the neighborhood examined by experienced histologists, before the lips of the wound are closed. This proceeding, which I recommended in 1849, has not, so far as I am aware, yet been practised by surgeons, but its propriety has since then been supported by Van der Kolk, and it will yet, I believe, become generally practised, when a knowledge of the pathology of morbid growths is better understood. The practice of M. Girouard of Chartres, who by caustic directed towards the neighboring tissues around cancers, has sought to destroy the germs whereby they spread, and thus prevent return of the growth, is, in this point of view, highly encouraging.^ * Archiv. Gen, de Med., tom. xcv. p. Y39. 244 PRINCIPLES OF MEDICINE, The application of chemical means, as various kinds of escharotics, to destroy local growth, has been extensively tried, but without as yet having enabled practitioners to arrive at any definite results. The great obstacle is the impossibility of attacking the entire growth ; and if this is not always performed by excision, still less frequently is it accom- plished by escharotics. Of late years an opinion has prevailed that this mode of treatment deserves further trial.^ M. Velpeau speaks favorably of sulphuric acid mixed with saffron ; and Mr. Syme has proposed saw- dust as a cheaper material than saffron, whilst its action is confined superficially by a wall of gntta percha made to adhere to the skin.f By such an escharotic the whole morbid growth, it is said, may be destroyed at once. The immediate pain is prevented by bringing the patient under the influence of chloroform, the slough is subsequently poulticed until it separates, and then the granulating surface allowed to heal. Great discussion has occurred as to the value of the chloride of zinc, applied by vertical scorings or slight incisions, so that it shall gradually perco- late through the entire growth. This mode of proceeding takes from three to seven weeks, J but is effectual in removing the tumor, as all those who have examined the preparations in the Middlesex Hospital, and such as have been removed by the same method of alternate incision and application of caustic by Mr. Moullin of London, may easily satisfy themselves.^ M. Maisonneuve has employed Canquoin’s paste, composed of the chloride of zinc, 1 part; wheat flour, 3 parts ; mixed up with a sufii- cient quantity of water. This is formed into arrow-shaped heads, dried and thrust into or around the tumor, according to circumstances. || Other chemical agents have been proposed, but the experience acquired of these methods, and especially of their ultimate good effects, is as yet so limited as to preclude the possibility of forming a just estimate as to their merits. Constitutional Treatment . — We are altogether unacquainted with any means of counteracting the tendency which predisposes to morbid growths. But considering that for the most part the constitutional change is con- nected with excess of nutrition, and in this res])ect is altogether opposed to what we observe in cases of scrofula and tubercle, we may infer that lowering the nutritive processes, while we yet allow the general tissues to be supported, should be the rule of practice. In carcinoma, and rapidly formed growths, the body (unless it produce emaciation by at- tacking the chylopoietic viscera) is for the most part fatty, and a diminu- tion of this element in the food should be aimed at. But at a later period, when exhaustion makes its appearance, nutrients and stimulants wull be required to prolong life. Note. — It is impossible to over-estimate the services which have been rendered to science by M. Velpeau, from carefully watching the results of those operations he * Langston Pai’ker, on the treatment of Cancerous disease by Caustics, 1856. f Edinburgh Medical Journal, November 1857-. \ Report of the Surgical Staff of the Middlesex Hospital, etc., 1857. § I have myself been able to do this through the kindness of Drs. Van der Byl and Handfield Jones. II Journal of Practical Medicine and Surgery, March 1858, p. 485. MOKBID DEGEXERATIONS OF TEXTURE. 245 has performed, where the tumor extirpated has been microscopically examined. At a time when some surgeons were sneering at histological research, he applied to MM. Lebert, Follin, and Kobin, and obtained careful microscopical examinations of the tuino rs he reinoved. The result now is, that we have the most positive proof that cancerous growths may be successfully removed by the surgeon, and the individual still survive in perfect health, for periods varying from six to twenty years. Had the microscopic examinatio-i not been made, we should still have remained in doubt as to the true character of the tumor. But the following extract from a letter I received from M. Velpeau last October can leave no doubt in the minds of the most sckeptical. The references are to the pages in the first edition of his work on the Diseases of the Breast, where the cases will be found detailed at length. 54 Rue de Grenelle St. Germain, October 19^A, 1864. “ I can now inform you that the Demoiselle D. (p. 584), operated upon nearly twenty years ago, and at present eighty years of age, remains cured and in excellent health. It is the same wiih Madame D. (p. 584), operated on in 1847, with M™e. Q-. (p. 594), with Mad™G. L. (p. 596), operated upon twenty-eight years ago, and who are still living. Mesdames V. (p. 684), H. (p. 686), L’h. (p. 608), and the man referred to, p. 499, still live, ani have had no return of the disease.” — “To my former list I could now add 991 cases. I would especially refer to that of Madame de la Vie. . . ., who was operated on six years ago, for a lardaceous encephaloid, perfectly charac- terized, occupying the left breast. This lady, tolerably stout and otherwise strong, now possesses the most excellent health. It is the same with Madame de Mon. . . ., but the most extraordinary case is the following: — A lady B., who has been operated on nine times for a fungoid encephaloma of the right breast (four times by caustic, five times by the knife) under the same conditions as H. (p. 686), has now un- dergone a permanent cure. All these operations were practised during five years. After each of them the general health improved for some months. Then the growth re-appeared, and it was necessary to commence once more. On the last occasion, it was necessary to penetrate to the ribs, and cauterize the surface. The wound not- withstanding at length cicatrised, and the former large excavation, occupying the whole side of the thorax in this courageous lady, is now solidly healed. She has re- covered her embonpoint, and suffers in no way, and enjoys a health that leaves nothing to be desired. Everything went through the same course as occurred in the case of Madme. H. (p. 686).” “ Such is the information in my power to give you, begging you to observe that in all these cases, as in all those to which I give the name of cancer, every precaution, whether clinical or anatomical, was employed, and the diagnosis estabhs'hed by direct observation, careful dissection, and microscopical research.” It results from these facts that the views long maintained by the author, as to the possibility of permanently eradicating cancer, may now be considered to have been incontestibly demonstrated. MORBID DEGENERATIONS OF TEXTURE. In the same manner that there may be hypertrophy or increase, so there may be, although from exactly opposite causes, atrophy or diminu- tion of texture. Atrophy may consist in simple decrease of bulk, the organ or tissue otherwise retaining its usual structure and function. There may be less work to do, and less force consequently required; and for the same reason that the legs of a dancer become larger, those of a 246 PKINCIPLES Of medicine. bed-ridden individual become smaller. So also as there may be increased bulk with alteration of texture, so there may be diminished size with change of tissue. These latter atrophies, as they constitute true organic diseases, especially merit our attention; and they may be arranged in four groups, viz. — 1st, Albuminous; 2d, Fatty; 3d, Pigmentary; and 4th, Mineral Degenerations. Albuminous Degeneration. We have already seen how essential albumen is to nutrition : and that to be made assimilable in various forms to the tissues of the body, it must be subjected to certain processes. Under other circumstances it may be effused, or collect in particular parts of the system, constituting organic diseases. If transuded through the ves-els in a fluid form, that is, dissolved in water, as we find it in the serum of the blood, it produces what is called dropsy. If precipitated from its solution in a solid form, it may constitute a variety of inorganizable deposits presenting various kinds of ultimate structure. Lastly, tissues composed of various proxi- mate principles may be wholly converted into an albuminous substance, and thereby have their vital properties impaired or lost. We shall notice these shortly in succession. Albumen in solution is frequently effused from the blood-vessels as .serum, constituting dropsy. It is distinguished from an exudation by containing no fibrin. There is not, therefore, that disposition to rapid coagulation and formation of an organized blastema, although there is often a precipitation of matter, capable of assuming various forms. We have seen that an exudation depends on an alteration of the vital force Fig. 311. which governs the attraction and selection of nutritive materials from the blood. Serous effusion or dropsy, on the other hand, is always indicative of mechanical obstruction to the return of blood from the capillaries Fig. 311. Structureless membrane formed by heating the clear fluid of pemphigus. On the left hand the membrane is folded together. — ( Wedl), 800 diam. ALBUMINOUS DEGENERATION. 24 '; tlirougli the veins. Thus, pressure of a tumor on the large venous, trunks, disease of the heart and liver rendering the circulation difficult, or of the kidneys and skin diminishing the secretion or exhalation of fluid, are its most common precursors. In Bright’s disease of the kid- ney, conjoined with various changes in the texture of the organ, seiuin containing albumen passes off in the urine. Membranous Albumen . — Albumen in solution, if it exists in tolerable quantity, is veiy apt to be precipitated in flakes or membranes. x\t the onset of vesicular diseases, as pemphigus, the fluid effused has been observed on being heated to contain smooth or folded laminae (Fig. 311). The same laminae may be pro- duced artificially by bringing oil or chloro- form in contact with serum. Hence they are not fibrinous but albuminous. The mere shaking of white of egg, or manipulating serum in various ways, will often cause these laminae to form and constitute shreds, which resemble fibres, but are truly membranous (Panum, Melsens). Sometimes such mem- branes, if produced slowly, collect round a central nucleus and ultimately form a concre- tion. The same has been observed by Wedl in the scrotum, where the skin has been con- verted into a tough substance like caoutchouc (Fig 312). The concen- tric laminae which form in the interior of aneurisms present a similar structure and are probably albuminous. (See Concretions.) Fih'oid Albumen . — Many tissues, especially fibrous ones, when ex- posed to a certain amount of pressure, become unusually dense. This may be the result of an exudation, which undergoes a peculiar transfor- mation, the whole becoming white in color, hard and tough to the feel, and consists of dense fine fibrous texture. It may also be the result of a peculiar transformation, or fibrillation of pre-existing tissues, inde- pendent of exudation. It has been described by Dr. Handheld Jones under the name of fibroid degeneration. We find it in various situa- tions — 1st, in the areolar texture of the skin, producing peculiar indu- rations, as in the hide bound integument of infants. 2d, On serous membranes, where it occasions opaque thickenings, as in the arachnoid, pleura, peritoneum, and pericard:u>u. The white spots in or upon the pericardium covering the heart are of this character, and all of them have their probable origin in a chronic form of exudation, which is subsequently transformed into a white albuminous mass (Fig. 171). The thickened valves of the heart, and especially the rough indurated masses occupying their free margins, are also examples of this lesion. 3d, In mucous membranes the areolar tissue between the basement membrane and muscular coat, and even the non- voluntary muscular substance itself, is very liable to undergo thickening and induratiorK Fig. 312. Edges of albuminous laminae, in a case of hydrocele, where the skin was destroyed, a, Edges of horizontal laminae ; 6, the same in another place, with brownish-yellow pigment granules. — {Wedl.) 250 diam. a Fig. 31-2. 243 PKINCIPLES OP MEDICmE. Wo Lave scon tlie stomach and bladder upwards of an inch thick from this cause (Fig. 81o). 4th, In the areolar texture of parenchymatous organs, as in the liver, kidneys, lungs, etc., it constitutes the lesion denominated cirrho- sis, which consists of dense fibrous deposits, aud causes atrophy of the glandular sub- stance. ^^See Cirrhosis.) Dr. Handheld Jones considers the white fibrous tumors ef the uterus to belong to the same class of mor- bid alteration, which they no doubt do, as also similar formations in the placenta, spleen, and other organs. This form of degeneration gradually passes into, and may be identical with fibrous growth, as the result of exuda- tion. 5th, The remarkable change which takes place in cartilage belongs to this head, and has been ably described by Dedfern. Under the in- fluence of a stimulus, vital or mechanical, the cells enlarge and their in- cluded nuclei multiply, and the previously hyaline inter-cellular substance fibrillates and becomes transf jrnied into bundles of fibres (Fig. 269, 270). CcUoid Albumen. — Cell-walls are generally of an albuminous character, but between them and the nucleus there exists for the most part a fluid, so that interchanges are constantly going on between the three essential portions of the cell, whereby its growth is kept up, and in many cases development carried on. It fre- ([uently happens, however, that even in formative 1-uids, albumen is thrown down in globular masses, hO as to resemble cells. Thus, 1st, In pus, soft cancer, and other forms of niorbid growth, there 1 ay frequently be seen diaphanous bodies floating : bout, of various sizes, of extreme delicacy, and ] V rfectly globular in shape. Very commonly they are homogeneous and perfectly transparent, but sometimes they contain ore or more bright refractii'.g granules, and at others a cavity seems to have formed in the inte- rior, but no nucleus (Fig. 315). 2d, Fus corpuscles (Fig. 68) aud collections of blood globules may frequently be seen sur- ' rounded by a similar diaphanous coating Fig. . 317 . more or less thick. In lecent haemor- rhagic apoplexies in man, I have seen collections of blood corpuscles, sur- Fig. 813. Dense fibrous structure, with naked nuclei from thickened and indurated coats of the stomach. Fig. 314. The same after the addition of acetic acid. Fig. 315. Diaphanous albuminous bodies, with fatty cancer cells from the dia- phragm. Fig. 316. Groups of blood corpuscles from an apoplectic extravasation in tfe human brain, surrounded by an albuminous layer. Fig. 317. A similar albuminous layer, round groups of blood-cells from the brain ■^f a pigeon. 260 diam. ALBUMINOUS DEGENERATION. 248 Fig. 318. rounded as if by a cell-wall (Fig. 31G,) and Dr. J. B. Sanderson lias pro- duced them artificially in pigeons, by pricking the brain through the cranium with needles, and caus- ing extravasation of blood. A few days after such an experi- ment, groups of oval corpuscles may be found surrounded by a layer of albumen, often presenting a series of concentric rings* (Fig. 317). There can be no doubt that in these cases an albuminous precipitate is tornied round the blood corpuscles, which are beginning to break down and decay. 3d, Another torm ot celloid albu nen may be seen in certain mechanical softenings ot the brain and spinal cord, where the nerve-tubes break up, unite at their edges, and form globules bounded by double lines. I have seen them pro- duced under the microscope by mechanical pressure between glasses, in the manner represented in the figure (Fig ^318.) Molecular Albumen . — Some textures assume a peculiar kind of in- duration, which on examination, is found to consist of molecular amor- phous matter. 1st, Induration of the brain consists of an albuminous molecular matter deposited among the tubes, rendering the thinnest sections opaque, and giving to the texture a peculiar toughness. This induration is common around chronic abscesses of that organ, and may have originated in exudation, which has been transformed into the sub- stance described. 2d, Certain peculiar yellow masses, found in the kid- ney and spleen, with abrupt margins of irregular outline, appear to me to constitute a degeneration of a similar character. 3d, Certain forms of tubercle may be said to consist of the same amorphous, finely mole- cular albuminous substance. Waxy Degeneration . — A peculiar change in the pre-existing texture of various organs, known under this appellation, sometimes called brawny or bacony, as in the case of the liver and spleen, appears to me to be a form of albuminous degeneration. 1st, The liver when thus altered presents to the naked eye a pale fawn color, its tissue is of unusual density, and its section presents a smooth surface, with semi-transparent edges. The hepatic cells under the microscope are seen to be shrivelled, colorless, and of peculiar transparency, with the nucleus ab.sent, or evidently disappearing (Fig. 319). 2d, In this degeneration of the kidneys the organ presents the same general aspect ; and on minute examination, the glandular cells are found similarly affected to those in the liver, and the Malpighian bodies not unfrequently undergo the same alteration. (See Diseases of the Kidney.) 3d, In the spleen the same characters are presented, both to the naked eye and under the microscope, the cells of the parenchyma, * Monthly Journal of Medical Science, September and December 1851. Fig. 318. Substance of nerve-tube, by means of traction, broken across and form- ing two globules, with double outline. Fig. 319. Cells of the liver, in waxy degeneration of that organ. 250 diam. 250 PEINCIPLES OF MEDICINE. as well as those in the Malpighian bodies, b Jng compressed together shrivelled, and presenting a similar pale, translucent appearance. 4th, In the intestinal mucous membrane it is by no meaiis unfrequent, com- muiiicating to it a peculiarly blanched and thin appearance. Under the microscope the villi, vessels, and epithelial cells in various degrees, may be seen to have undergone this peculiar degeneration. 5th, I have seen the same transformation in the placenta, as Vfell as in simple chronic, cancerous, and tubercular exudations. By others it has been seen in bone, and there is no reason why it may not affect almost every organ and tissue of the body. It is evidently, as an albuminous, as widespread in its extent as the fatty degeneration. This lesion has received various names, having been denominated “ lardaceous degeyieration ” by Abercrombie, and rightly considered allu- minom in its nature by Hodgken, Bright, and Bokitanski. By Budd, it was regarded as The term waxy is evidently the best, derived from its resemblance in the kidney and liver to bees- wax. Under the microscope also it resembles in its translucency color- less wax or spermaceti. The term amyloid degeneration, recently employed to designate this lesion by Virchow and his followers, is not only vicious but productive of the greatest confusion. This term means resembling starch, and has been used by me to designate rounded soft mineral bodies, frequently found in the brain and in cerebral tumors (Fig. S92), and which in structure resemble starch. It has also been applied by Carter to starch- like bodies found in various tissues; and more recently by Bernard, Pavy, and others, to the substance obtained from the liver, and which is readily transformed into sugar. In both these latter cases, there is a chemical relation to the substance of starch, as seen by the actions of re-agents. But the waxy degeneration has no relation to starch whatever. I have never seen it transformed blue by iodine, either with or without sul- phuric acid, but only into a brownish or purple red, which is the color of iodine itself. The truth is, I have found that this albuminoid degen- eration has the property of fixing certain colors, like the nuclei of the textures ; so that not only when steeped in iodine is it deeply tinged as compared with the surrounding textures, but the same thing occurs wdien it is exposed to the action of carmine and indigo in solution. This degeneration was first carefully examined b}^ me, microscopically, in 1845, in the case of Margaret Clark (see Phthisis), when the peculiar translucency and degeneration of tie hepatic cells was observed and care- fully figured. It was demonstrated and aescribed at that time and since to all my pathological and clinical classes in Edinburgh. In April 1853, some of these figures w^ere published, in No, YIII. of the first edition of this work (Fig. 319). On the 17th of December 1853, I brought the subject before the Physiological Society of Edinburgh in a verbal communication, which is very imperfectly reported, but in which the announcement was made that, in the specimens of spleen, liver, and kidney then on the table, I was “ satisfied from numerous observations, that it was a primary alteration of the cells, and though frequently associated with fatty degeneration, w^as not essentially connected wdih it.”* * Monthly Journal, February 1854, p. 186. ALBUillXOUS DEGENERATION. 251 These views I have ever since maintained and taught in this school, and never failed to point out the fundamental error of Virchow and his fol- lowers, who associate it with starch, and call it amyloid. The clinical history of the waxy degeneration has yet, for the most part, to be studied ; but observations I have made tend to convince me that it may often be diagnosed in the living body with certainty. It is the frequent cause of persistent diarrhoea in leucocythemia and of a peculiar form of albuminuria, afterwards to be noticed (see Diseases of the Kidney). This lesion is not unfrecj^uently associated with the fatty degenera- tion next to be spoken of, especially in the liver and kidney, when in a cirrhosed state. (See Fig. of Cirrhosed Liver.) It wmald appear from analyses of the liver, mostly made by Dr. Drummond, and collected by Dr. AV. Gairdner,^ that the human liver, when affected with the waxy degeneration, contains less water, considerably less fat, and a greater amount of solid constituents than natural. Colloid Degeneration. — AA^e have previously seen that there is a peculiar form of cancer called colloid, in which glue-like matter is asso- Fig. 820. Fig. 321. dated with cancer cells. But colloid occurs independently of cancer, constituting the sole contents of certain cysts (see Cystoma). It would appear to vary in chemical composition, as I have observed that speci- mens of it sometimes coagulate into a solid mass, whilst at others they are unaffected by the action of spirits. If not identical, it is at least allied to the albuminous degeneration. The enlargement of the thyroid gland in bronchocele, and the contents of compound ovarian cysts, are generally owing to the formation of colloid matter (Fig. 320). Not unfrequently colloid masses become indurated, and assume a radiating striated appearance (Fig. 321). * Monthly Journal of Medical Science, Alay 1854. Fig 320. Section of the thyroid body, with some of its glandular sacs, distended with colloid matter. — {Kolliker.') Fig. 321. Radiated colloid masses from a cyst in an atrophied kidney, a. Lines radiating from a central point : 6, radiated mass surrounded with a clear border ; c, radiated mass with a central granular substance and radiated border c ; J, the same with an external clear border ; c, a mass with two granular globules in the centre. — ( Wedl. ) 250 diam. 252 PKmCIPLES OF MEDICINE. General Pathology and Treatment of the Albuminous Degeneration. It lias been previously pointed out that albumen is essential to nutri- tion, and that it forms the basis of the blood and of the tissues. The flesh which constitutes the food of carnivora, and the albumen which comprises so large a portion of the fodder of graminivora, are alike, by the solvent action of the digestive juices, reduced to a fluid state. In this condition it passes into the blood, forming the walls of the blood corpuscles, besides entering largely into the constitution of the liquor sanguinis, as serum, that is, albumen dissolved in water. During the building-up process, it undergoes various transformations, among which those of its conversion into the fibrin of flesh, and the gelatine of bones, are perhaps the most important. By its association with the other proxi- mate principles, also, it enters into the composition of every texture and organ in the body, and again joins the blood as albumen, mixed with a minute portion of effete matter as fibrin. There can be no doubt, as we shall subsequently see, that under certain circumstances it may be changed into fat also, so that from multitudinous transformations this important element is susceptible of undergoing, it well merits the term which, in its pure state, Mulder bestowed upon it, namely, that of “ proteine.” As albumen, we have seen how it may produce abnormal conditions of the tissues, in various forms. The essential conditions for this kind of degeneration appear to be — 1st, Extreme slowness of effusion from the blood-vessels, as in cases of chronic tubercle and fibroid transforma- tion ; and 2dly, Mechanical obstruction of the veins, in some part of the circulation, giving rise to dropsy. In the former case, it is favored by excess of acidity in the primae viae, which by its power of dissolving the albuminous compounds, must assist in adding this element to the blood in undue proportion. Why, on the other hand, muscles, cartilage, and the exudations, should sometimes pass into the albuminous fibroid degen- eration, under much the same circumstances that at others they become fatty, is a point in pathology which is still involved in obscurity. The treatment will depend on the cause, nature, and seat of the degeneration, but these in the living body are so obscure and deceptive as frequently to afford no indication for remedies. In the albuminous tubei-cular exudations, correcting excess of acidity in the stomach and bowels tends to check its excess, whilst the administration of animal oils favors its transformation into the nutritive molecular basis of the chyle. Wherever mechanical causes, or interruptions of the venous circulation, give rise to dropsy, recovery will depend on the means at our disposal for their removal. F ATTY Degeneration. I have previously described fatty growths (see Lipoma), wLich, by encroaching on neighboring tissues, and especially muscles, cause their atrophy. 1 have also shown how fatty matter accumulated within c}'sts, undergoes various transformations, both histological and chemical, at one time presenting a granular form, and at another a crystalline one, com- FATTY DEGENERATION. 253 posed of cholesterine or margarine (see Cystoma). It is now ascertained that there is no kind of tissue, whetlier healthy or morbid, that may not undergo a fatty degeneration. Such alteration frequently causes one of the most formidable organic diseases which the physician is called upon to treat. Deposition of Fatty Molecules and Granules . — Fat is as necessary a constituent of the food and of the tissues as albumen, and its universal presence in the organs, texture, and fluids of the body, renders it easily capable of precipitation and of accumulation, if in excess. The moment the smallest particle of oil is formed, and comes in contact with an albu- minous fluid, a membranous precipitation of the latter takes place around it, which tends to keep the various fatty molecules distinct and separate from each other. No doubt, under the action of heat, trituration, press- ure, or the action of acids, which dissolves the albuminous envelope, the molecules are sometimes fused together, and con-stitute smaller or larger globules. The great predominance of the molecular form of fatty depo- sition, however, is evident in all morbid alterations of texture. In this state we find it constituting the substance of the atrophied suprarenal an 1 thymus glands in the adult ; the exudation in chronic softening of the brain, and other parenchymatous organs ; accumulated within cysts, the result of transformation of their con- tents; in the centre of colloid masses; in chronic exudations, and extravasations of blood, present- ing a milky, yellow, or fawn-colored 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 D generation of Cells . — It was shown by Keinhardt, 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 b c (1 e f a h i k Fig 322. Fig. 323. granules. The nucleus is now no longer visible, and in many cases wastes away, as if from pressure. Occasionally, this fatty deposition of Fig. 322. Fatty molecules in groups, from the opalescent or white opaque centres of large colloid masses in the ovary. Fig. 323. Granular corpuscles and masses from cerebral softening, a. Nucleated cell with a few granules ; 6, granules within the cell, partly obscuring the nucleus ; e, granules over the nucleus ; d, granules within the cell, no nucleus visible ; c, cell nearly filled with granules ; /, cell completely filled with granules ; g, cell contracted in its middle ; A, granular mass, the cell-wall having dissolved ; i and A, granular masses peeled off from the vessels. 254 PRINCIPLES OF MEDICINE. molecules tal^es place within the nucleus in the first instance (Fig. 323.) In either case the cell-wall, distended by the accumulation of fatty particles, at length gives wa}’^, and the included oil granules either abed e separate, or for a time adhere together in granular masses. Sometimes these bodies are easily ruptured by external violeoce ; at others they are more re- sistant, and the oily matter is forced through the cell-wall, and collects outside, whilst the cell itself is more or less collapsed (Fig. 324, e). In this way collections of fatty granules and grannie cells take place in the ducts of all glands which are lined by epithelium ; in the air vesicles of the lung and in the bronchi; in the cells of the liver, causing fatty degeneration of that organ ; in the shut sacs of vascular glands, as the spleen, and in all cell formations from exudation, especially those of pus and cancer. In stall-fed animals, a moderate accumulation of fatty granules in the interior of the hepatic cells is a normal condition ; and the amount of fat in various tissues, which separates health from disease, is, under a variety of circumstances, impossible to determine with exactitude. Fatty Degeneration of Muscle . — There can be no doubt that the fibro-albuminous substance constituting flesh is capable of undergoing a transformation into fat. Of the exact chemical nature of that trans-- formation we have yet to be informed ; but it may not only be observed ill 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. 325. Fig. 826. Fig. 327. voluntary muscle, we observe that the degeneration commences with diminished distinctness of the transverse striae, especially at the circum- ference of the fasciculus. As this extends inwards, minute molecules of fat occupy the position of the striae, and at length obliterate them ; gradually these coalesce, globules of various sizes are formed wdthin the Fig. 324. Granular corpuscles acted upon by pressure, a. Some of the oily granules made to coalesce ; 6, oil forced through the cell-wall ; c, the same with collapse of the cell-wall ; J, rupture of the cell-wall ; e, dislocation of the nucleus. Fig. 326. Early stage of fatty degeneration of voluntary muscle. «, The muscle breaking across ; h, the fibrillae, easily separated. In both specimens the tissue is soft although the transverse stria' are still visible. — {Wedl) Fig. 326. Advanced stage of fatty degeneration in the muscular fasciculi of the heart. The transverse striie have disappeared, and the fasciculi are wholly composed of oil granules and globules more or less aggregated together.— ( Wedl.) Fig. 327. Another example of advanced fatty degeneration of voluntary muscle, the fasciculi presenting various degrees of the alteration. 250 dtam. FATTY DEGENERATION. 255 sarcolerama, and the normal structure of voluntary muscle disappears. Durino- the early changes the fasciculus becomes soft, exhibits a ten- dency 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-colored, and at length yellow, and its normal density is greatly diminished. These changes are easily observed in the heart, in which organ they have been made the subject of special research by Onnerod, Paget, Quain, and others. The histological and clinical researches of Dr. R. Quain* on this subject ai-e 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 ex- tremity 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 sub'tance adds to the rapidity and com- pleteness of the transformation. In such cases the muscles are of a pale Fig. 328. Fig. 829. yellow color, yielding on section large quantities of oil, while they pre- serve their usual form and fibrous look. I have seen all the muscles of the lower extremities so affected. Occasionally, while some muscles exhibit this transformation in its most advanced stage, others close be- side them present their normal red color, 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 adipose cells, with nuclei, as seen in Fig. 329. * Med. Chir. Trans., vol. xxii. Fig. 828. Fatty degeneration of the psoas magnus muscle of a lad, who died with morbus coxarius. a, Muscular fasciculi in which no traces of transverse striae are per- ceivable. The longitudinal striae are still not quite obliterated, although mingled with numerous fatty granules. 6, Muscular fasciculi, wholly composed of minute molecules and granules, with no traces of either transverse or longitudinal striae, c, Fat cells of various sizes running between and encroaching upon the fasciculi. Fig. 329. Other fasciculi from another portion of the same muscle, after the addi- tion of ether. The adipose cells have been made round and somewhat flaccid ; the nucleus consists of a congeries of brownish granules. 250 diam. 256 PRINCIPLES OF MEDICINE. In involuntary muscles fatty degeneration may also be observed, although it is by no means so common as in voluntary ones. In this case oily molecules are deposited in the elongated fusiform cells com- posing the texture, and by their pressure on the nucleus cause its disappearance. Whether the dis- tended pregnant uterus shrinks to its normal proportions after deliv- ery 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. 165) do become more or less crowded with fatty granules (Fig. 380). Fatty Degeneration of Blood vessels. — T\iq larger blood-vessels, espe- Flg. 333. 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, depos- ited between the coats of the vessel, and often protruding on its inner surface. This deposit consists of numerous fatty granules, mingled wdth crystals of cholesterine (Gulliver), to which, when hard and brittle, are added calcareous amorphous salts (Figs. 331 to 333). The smaller vessels and capillaries are frequently seen to be covered Fig. 330. Enlarged fusiform cells of the pregnant uterus, after delivery, filled with fatty granules. 250 diam. Fig. 331. Atheroma of a blood-vessel. Natura size. Fig. 332, Fatty granules, oil di ops and granule cells, with crystals of cholesterine from broken down atheroma of an artery. Fig. 333. Transverse section through the coats of the popliteal aidery of an aged woman, who had gangrene of the feet, a, Inner coat; b, longitudinal fibres ; c, circu- culai fibres ; r/, fimbriated and elastic coats loaded with fatty granules ; c, external areolar tissue. — {Wedl.) 200 diam. FATTY DEGENEEATIOX. 257 with patches of fatty granules, which vary in number from two or three, to large masses of them, which infiltrate the ne’ghboring tissue. The various appearances of these were carefully described and figured by me in 1842,"^ and attributed to exudations thrown from the vessel. In 1849 Mr. Paget f 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 of fatty molecules within the nuclei, it may l eadily be seen that for the most part the fatty granules are outside the vessels. Indeed, the extreme tenuity of the capillary wall does not permit of their forma- tion in its substance, as it is much thinner than the granules them- selves. Besides, it may frequently be observed that the largo 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 ofiFby 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, cm stituting softening of the brain. (See Fig. 150.) Of these Mr. I'agct wiote in 1853,1 — “ 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 grey), 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. 167), is consonant with every known fac4-. The true * Edin. Mod. and Surg. Journal, vols. Iviii. and lix. f Medical Gazette, f Surgical Pathology, vol. i. p. 146. Fig. 334. Cerebral vessels of an aged individual who died of apoplexy, a, Ulti- mate capillaries; A,. larger vessel ; c, small artery, with fatty granules scattered over its surface. — ( Wedl.) Fig. 335. Vessels from softening of the corpus striatum, coated with granules and granular masses. — ( Wedl.) 258 PRINCIPLES OF MEDICINE. softening of the brain from deficiency of nutrition frequently exhibits structural changes altogether difierent, as I shall subsequently demon- strate. (See Ui'cases of the Nervous System — Softening.) Fatty Degeneration of the Placenta . — Tlie lesion which has received tins name from Dr. Barnes and others, was figured by me in 1844,* and likened to that which occurs in cer- tain softenings of the brain. I still hold the same opinion in regard to it, and con- sider the fatty mole- cules and granule cells not to be formed 'by a transformation 'of the placental tis- sue itself, but of the exudation or extra- vasation of blood which is poured out F from its vessels. The yellowish or fawn-colored deposits may be in- filtrated throughout the tissue of the placenta over a greater or less space, or they, may occur in isolated spots forming nodules. They are generally somewhat indurated, and give rise to the idea that they Fig. 338. Fig. 339. are coagulated fibrin. I have frequently examined them and traced all * Treatise on Inflammation. Plate — Fig. 10. Fig. 336. Villi from the placenta of a six months’ fcet-us. a and 6, The vessels coated with molecular fatty matter ; c, exudation from the vessel, nearly occupying the whole substance of the villus ; d, chronic exudation outside the vessel converted into brown ])igmcnt. — ( Wedl.) Fig. 337. Fatty granules coating the blood-vessels, within the placental villi. — {Cowan.) Fig. 338. Groups of fatty granules scattered through the substance of a placental villus. — {Cowan.) Fig. 339. Fatty granules both coating the vessels, and scattered through the villus substance. — ( Cowan . ) FATTY DEGENERATION. 259 the changes intermediate between a coagulated exudation or extravasa- tion of blood, and the ultimate conversion of the foreign matter into a mass of molecules filling up the intervascular spaces. Similar observa- tions have been more recently made by Drs Handheld Jones * and Cowan. f 111 many cases the fatty material may be eeen forming a layer SO} arate from the vessel and inside the limitary membrane of the villus. In most cases, also, the texture of the placenta is pale from compression, or shrunken, but still intact, and the vessels, though coated externally with oil granules, are themselves quite healthy. Occasionally, in atro- phied placenta, a quantity of browmish pigment is deposited between the vascular wall and limitary membrane or the villus, which is probably owing to a modification of the fatty matter or of the coloring material of the blood (Fig. 352, a). (See Pigmentary Degeneration.) Fatty Degeneration of Cartilage . — The cells of cartilage are liable to undergo the same fatty degeneration as is observable in other cells. Tlie molecules at first formed, how'ever, are exceedingly minute, thus communicating a brownish opaque aspect to the interior of the cell (Fig 340). Subsequently they coalesce and form larger gra nules, which again unite to produce drops of oil of con- siderable size. During this Fig. 340. change the nucleus disappears, and sometimes the hyaline intercellular substance presents a multitude of brownish points, which communicate to it a marked opacity (Fig. 351). At others it undergoes the fibroid transformation formerly described (Fig. 137, and Figs. 269, 270). Fatty Degeneration of Done . — Wedl has described the cancelli of bone in syphilitic caries as being dilated and filled with fat, owing to the exudation poured into them having undergone the fatty degeneration (Fig. 341), and in most cases of ulcerated bone a large fciniation of oily molecules and loose globules of oil may frequently be observed. Virchow has detected similar molecules in the lacunae and canaliculi. The molities ossium, or malacosteon of adults, is also a form of fatty degeneration of bones (Paget), in which the cancelli are loaded with large oil drops, often tinted red. Combined with these, there is a formation of numerous cells, which vary in size from the 5 00 ^^^ of an inch in diameter, and contain a round nucleus, also varying much in size, and occasionally showing various stages of division and of endogenous deve- lopment (Fig. 344). This, like so many other of the so-called fatty degenerations of texture, is probably owing to an exudation from the blood-vessels, mingled with more or less extravasation of the colored corpuscles, in which we find new cells developed, combined wdth fatty transformations of the albuminous and fibrinous materials. In this * British and Foreign Med. Chir. Rev., voi. ii. p. 354. f Edin. Med. and Surgical Journal, April 1854. Fig. 340. Cells in fatty tracheal cartilage. They are filled with fatty brown mole- cules, and the secondary cells contain oil globules. — ( Wedl.) 250 d'lam. 260 PRINCIPLES OF MEDICINE. Fiy. 341, Fig, 343, Fig. 344. regarded as arrested development of bone with increased growth of car- tilage cells (Kolliker) FatUj Degeneration of other Textures. — It would occupy too much space for us to describe or even particularise every tissue that is now known to undergo a fatty degeneration. All the glands may undergo this change. Nervous texture may soften, break up, its fatty material be liberated, and accumulate in oil drops of greater or less size. In emphysema, the pulmonary texture is sometimes fatty. (Rainey.) The cornea (Canton) and the lens (Dalrymple, Lebert) also may be similarly affected, forming soft cataract. Indeed, under various circumstances, it may be said that there is no organ or texture of the body, which in some form or other may not undergo this degeneration. Fattg Degeneration of the Exudations. — We have already seen that what has often been called fatty transformation of tissue, is, in fact, fatty transformation of the constituents of the blood, which have been exuded or extravasated. Simple exudation is constantly undergoing fatty de- generation. I have seen the false membrane of pleurisy converted into a creamy substance, composed of innumerable fatty molecules, granular masses, and granule cells. Pus cells may frequently be observed to contain fatty granules, and to present all the intermediate stages of conversion into the granule cell, and the same may be observed in the pus and fibre cells of granulating sores. In Cancerous exudation., the fatty degeneration is so common, as to have attracted peculiar attention, under the name of “ Reticulum.” This occurs in two forms. In one it is seen on a fresh cut surface, scattered throughout the growth to a Fig. 341, Horizontal section of the occipital bone in a case of syphilis, a, Dense external table, the internal composed of dilated caucelli filled with fat, seen by re- flected light. — ( Wcdl.) 3 diam. Fig. 342. Thin section of the same bone showing one of the cancelli enlarged and filled with fat globules, surrounded by empty lacunae. — (IIW/.) Fig. 343. Thin section of the outer table of the same bone. — ( Wcdl.) Fig. 344. New cells I'ormcd in inalacosteon. a, From the marrow of the femur ; b, others with developing nuclei ; c, fiom a rib in anoth.cr case, in which some organs were cancerous. — {Wcdl.) 250 diam. FATTY DEGENERATION. 261 greater or less extent, as a network, more thick and abundant, however in some places than in others. In the other it exists in masses of a bright yellow or orange color ; sometimes closely resembling tubercle for wnicii it has often been mistaken. In the first form, granule cells’ loose oil granules mure or less mingled with decayed and broken-down canc.r-ceiis, are cuimnon. ^ In the second, irregular bodies, resembling tubeicie corpuscles, resulting from alteration in the form of the nucleus after the ceil-wall has been broken down, are numerous (Fig. 848). In son: 3 retrograde cancers I have seen large portions of the growth Fig. 347. Fig. 345. Fig. 346. Fig. 348. entirely composed of such corpuscles, and not unfrequently these, as well as cancer-cells in all stages of decay, are associated with crystals of cholesterine or margarine (Figs. 345, 346). Tubercular exudation may always be observed to contain a greater or less number of fatty granules embedded in it, as well as contained in the tubercle corpuscles. AVhat is called the softening of tubercle is owing to an increase of these, by the gradual transformation of the albuminous part of the exudation into fatty molecules, whereby the whole is rendered soft and pulpy. (See Fig 158.) Fatty Degeneration of Morbid Growths. — All these are susceptible of becoming fatty, and consequently soft and pultaceous ; the transforma- tion is accomplished in a manner exactly similar to what we have described as occurring in the tissues of which they are composed, or of the exudations which are conjoined with them. General Pathology and Treatment of Fatty Degeneration. The causes of fatty degeneration .vre to be sought in all those cir- cumstances which weaken the vital action of a part, but do not interfere materially with the assimilation of hydro-earburets. The disease, how- ever, is not purely local, as it may frequently be observed that the kid- neys, liver, heart, and other textures, are prone to undergo the fatty change in the same person. Hence everything that increases fatty Fig. 345. Ketrograde cancer-cells, granules and granular masses, with crystals of cholesterine, from the reticulum of cancer of a lymphatic gland. Fig. 346. Fatty and broken down cancer-cells, with crystals of margarine, from the reticulum of cancer of the liver. Fig. 347. Fatty granular matter from the softened reticulum of a cancer of the breast. Fig. 348. Liberated and altered nuclei, with fatty molecules, from the reticulum of a cancer of the testicle. 250 diam. 262 PRINCIPLES OF MEDICINE. matter in the blood, such as its introduction bj means of assimilation, or its not passing off in consequence of diminished excretion, tends to its deposition. Thus indulgence in rich food, and alcoholic liquors abounding in carbon, especially if there be little exercise, occasions it. Whether the fatty matter be deposited directly from tne blood, or whether it he the subsequent result of a chemical transformation of tissue or exudation, has excited discussion. Dr. Qiiain supports the latter view, and has performed experiments, whereby it would seem that healthy muscular fibrin may be rendered fatty artificially, by digesting it for a fortnight in water. I have repeatedly seen muscles and bones converted into adipocere, during the maceration in water necessary to clean the latter, and have frequently examined the former during the process, so as to satisfy myself that the fibrinous material of fiesh under- goes a chemical transformation into fat. I believe with Dr. Quain that the same thing occurs in the living body, not only when dead tissues are enclosed i.i it, as in the experiments of Wagner, but slowly in living texture, until its vigor is at length so impaired that it is incapable of performing its function. This view in no way excludes the probability of the fact that in certain cases fatty matter may transude through the vessels in a fluid state, and collect outside, or be infiltrated to a certain extent among neighboring textures in a molecular form. Further, we have seen that fat may occur within cells as a secretion, and by its accumulation cause not only atrophy of the nucleus, but also obstruction of tubes and an endless variety of organic and functional derangement ill the eccnomy, according to the extent and seat of the degeneration. The treatment of this lesion is a field of inquiry which as yet has scarcely been entered upon. In most cases, indeed, its diagnosis in the living subject is very uncertain. But the cultivation of histology, by gradually enlightening us concerning those degenerations which are essentially fatty, and enabling physicians to recognise them as the cause of symptoms with which he has been long familiar, will assuredly at no distant day lead to more correct principles of practice. Already we begin to see indications of this in our notions regarding Bright’s disease, and in the results of organic chemistry applied to clinical medicine. At present it would be premature to speculate on this subject, and what little there is to be said will be found under the head of special diseases. (See Obesity.) Pigmentary Degeneration. The formation of pigment in plants and animals is essentially con- nected with that of fat, most colors either being different kinds af tinted oil, or secreted in cells at the expense of carbonaceous products, which are readily transformed into fatty compounds. In morbid conditions we find several of the textures of different tints, but more especially red, yellow, brown, green, or black, from chemical alteration in the coloring- matter of blood or bile. Sometimes the change of color is the result of peculiar secretions ; at others, of the deposition of carbon. Red Figments . — All red coloration in the human body is owing to the presence of blood, the coloring principle of which has been called hematine. When observed in an isolated blood corpuscle, in which it PIGMEJNTAKY PEGEJS PKATIOX. 2G3 is secreted, the real color is seen by transmitted light to be yellow, although, as occurs with a strong infusion or tincture of saffron, it looks red to the naked eye when concentrated. Unless, how- ever, it were known that the real color of the blood is yellow, it would be impossible to understand the pre- sence of this latter tint around ecchymotic spots, and in other situations. Virchow first described in extra- vasations of blood prismatic crystals, with rhomboidal bases, often approaching a needle shape, of a yellowish or deep ruby color, which he denominated hemaioi- dine. They are most frequently found in the sangui- neous extravasations of the brain, in the corpora lutea of the ovaries, and in chronic haemorrhages of the liver, of hydatid cysts, and of other textures, but rarely in pulmonary or cancerous extravasations. In size, they vary from the gfj’ooth to the ^^oth of an J inch in their long diameter (Fig, 349). They are ^ transparent, and strongly refractive, insoluble in alcohol, ether, dilute-mineral acids and alkalies. Con- centrated mineral acids cause them to assume the ” shades of green, blue, rose-tint, and finally a dirty yel- Fig. 349. low. Yellow Pigment . — The real color of the blood corpuscles is vellow, 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 coloring matter becomes less intense, it generally assumes a yellowish tint, as around ecchymotic spots and old extravasations. Hence, also, the color of the corpora lutea, and the yellow soften ii gs of the brain, as well as the deep orange tint occasionally observed as the result of haemorrhages. The adipose texture, and morbid accumu- lations of fatty matter, assume 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 color in the bile, as it con- tains a deep yellow pigment, which, when absorbed into the blood, tinges all the textures, and passes off in large quantities by the skin and kid- neys. The urine when impregnated with it in considerable quantity, lias the color of porter to the naked eye. When bile, diluted with water, is treated with nitric acid, a marked series of changes in color ensue. A little acid renders it green, a larger quantity blue, purple, violet, and lastly, a dull red or brown yellow. These changes are supposed to be owing to the existence of three coloring matters in the bile— one brown, the cholepurrhin ; another yellow, the hilifulvin — both discovered by Berzelius; a third the hiliphoeln of Simon. Whether these pigments are derived from, or converted into hematine, has not yet been ascertain- ed, 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 decomposition of extravasated blood, Fig. 349. Crystals of hematoidine. a, Large oblique rhombic prisms ; at -p, oblique six-sided prism ; 6, smaller forms. — {Wedl.) 250 diam. 264 PRINCIPLES OF MEDICINE. 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 color. Different ganglia scattered through the nervous system owe their color to the formation of brown pigment mole- cules, which are deposited in the nerve-cells. The skin in some races, is naturally brown or swarthy ; the areolae round the nipples assume this tint during pregnanc}^ ; exposure to the sun induces this coloration 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 color. In all these cases the color arises from the deposition of a brown molecular pig- epidermis, and sometimes, as in warty najvi, from accumulation of dark pigment in minute sacs (Fig. 350). Not unfrequently brown pigment may be observed collected within cartilage cells, when that texture is diseased iu the nei«-hborhood of Fig 350, ment, in the deeper cells of the Flg.351. ^ ^ ^ Fig. 352. necrosed bone, or in death of cartilage itself (Fig. 351). Occasionally, also, it is found covering placental villi, or situated between the vessel and limitary membrane of the tuft, evidently the result of changes oc- curring in extravasated blood (Fig. 352). Dr. Addison has de.scribed a form of anmmia, in which the skin Fig, 350, Wartlike brown n(evus maternus of the female mamma, a, Epidermic cells, with their nuclei concealed by a dark brown pigment ; h. ttie nuclei surrounded with similar pigment; c, cells witliout pigment; E(iKN EK A I'lON. 265 assumes a peculiar coloration, in connection with a diseased condition of the supra-renal capsules. It presents “ a dingy or smoky appearance, or various tints or shades of deep amber or chestnut color ; and in ore instance 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 more subsequently by Mr. Hutchison, Dr. Wilks, and others,! where, co-inci- dent with this bronzing of the skin, the supra-renal capsules were indu- rated, cancerous, or otherwise diseased. The presumed connection be- tween 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 not shown that there is any true 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. Nu- merous cases also are now on record of bronzed skin without alteration in the supra-renal capsules, and of extensive lesion of these glands without bronzed skin. Green Pigment . — The cause of green pigment has not yet been determined. We have seen that nitric acid produces a grass green color when added to bile, and it is possible that the addition of some acid matter to heinatine in certain states of combination may produce a similar result. Abscesses of the brain not unfrequently contain pus of a decided green color, and vomited matters occasionally present the same hue. The fmces in young children are sometimes of a spinach green, which is supposed to result from an altered condition of bile, or from the pre^jence of blood. The contents of cysts frcc|uent]y contain fluid of different shades of green. In mortification and putrefaction after death, the integuments frequently assume a greenish hue. Lastly, morbid growths, especially in the bones of the cranium, have been de- scribed and figured of a decidedly green color {Chloi traob) by Balfour,^ King, II and Lebert.!" Black Pigment . — Black pigment is b}'' far the most cemmon degen- eration met with, and is found in various situations. Thus ecchymotic extravasations generally assume a dark purple or black color. Vomit- ings of blood in yellow fever and gastric cancer are frequently dark brown or black ; so also are the faeces after blood has been mixed with them [Melcena]., or taking ferruginous medicines; certain softenings of the stomach itself, of the intestinal glands, and of the entire mucous membrane in cases of dysentery; the contents of ovarian cysts and other encysted tumors; intestinal and ovarian cicatrices; the sordes on the teeth and gums in cases of fever ; and mortified or dead parts. When morbid growths are black they have received the name of Melanoma^ * On the constitutional and local effects of disease of the supra-renal capsules. 1855. f Medical Times and Gazette. Guy’s Hospital Reports, 1862. t Brit, and P’or. Med. Chir. Review, vol. xxi. 1858. § Edin. Med. and Surg. Journal, vol. xliii. p. 319. II Monthly Journal of Medical Science, Aug. 1853. ^ Anatomic Pathologique, Planche xlv. 266 PRINCIPLES OF MEDICINE. and the black coloration of the collier’s lung and bronchial glands ha?> been called False Melanosis or Black Phthisis Nothing is more common than to see chroiiio 6 353). Black patches have occasionally been produced on the skin, apparently from the secretion of pig- mentary matter on the surface, which is capable of being washed off, A case of this kind is recorded by Mr. Teevan,* in the person of a young girl, aged 15, the upper part of whose face was covered with a black discoloration. The coloring matter was analysed by Dr. Bees, who found in it carbon, associated under the microscope with short hairs, epithelial scales, and granules and globules of fat. Portions of necrosed bone are often of a black color, a change which according to Wedl commences at the external portion of the systems of bone corpuscles, disposed round the Haversian canals. The blackening is probably owing to a chemical change of the osseous texture, similar to what occurs in caries of teeth from the action of acid saliva. It is not tubercle surrounded by black pigmentary deposit. Scattered tubercles on the peritoneum are often surrounded by a black ring, which, when magni- fied, present the appearance represented (Fig. Fig. 354. dependent on an exudation, which in sections of a bone so affected is nowhere visible (Fig. 354). Black pigment may exist in the form of minute granules (Fig. 355), * London Medico-Chir. Transactions, vol. xxviii. Fig.^ 353. Ring of black pigment masses {a) and molecules {h) round a tubercle of the peritoneum. The black tint disappeared after some days’ immersion in alcohol. 250 diam. Fig. 354. Transverse section of a necrosed tibia. «, Medullary canals divided transversely ; 6, pigment, formed at the junetions of the concentric bone systems : c. radiating bone canaliculi. — {Wedl.) 90 diam. Fig. 355. Black pigment molecules from the lung. Fig. 35G. Black pigment irregular masses semi-crystalline, from an intestinal ag- gregate gland. Fig 357. Polygonal cells loaded with pigment, from the surface of the pericardium. Fig. 358. Cells loaded with pigment, having clear nuclei, from a melanotic tumor of the horse. 250 diam. PIGMENTARY DEGENERATION. 2G7 or of irregular masses scattered tliroughout a texture (Fig. 356). Some- . times the former are fouud within cells which may be round, flattened, many-sided, or have irregular prolongations (Figs. 357, 359). 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. 358), in the epithelial cells of the collier’s lung, and in certain forms of cancer (Figs. 359, 360). In alt these cuses the nucleus is sometimes clear and colorless, and at other times ob-cured by the black pigment. Black pigment may also occur in the cry^ talline form, associated with hematoidine, in old sanguineous extravasations. It has then been called Melanin. It may be easily shown that the black pigment granules, cells, and crystals, found in morbid products, althougb they may closely resemble each other to the naked eye, and even under the mici oscope, are difi’erent in their chemical compositions. Thus one kind of black pigment loses color on the addition of nitro-muriatic acid or chlorine wat(;r, whilst another resists not only these agents, but even the action of the blow- pipe. It follows that the latter consists of carbon, as in Fig. 360, while the former is a peculiar secretion formed within cells, or a trans- formation of the coloring matter of the blood, as in Fig. 359. Blue^ purple, and other pigments. — Blue pigment has been described as occasionally occurring in urine. This was first ascertained by Prout to be due to blue indigo, and it appears probable from the researches of Schunk and others, that all the blue and purple colorations 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 colorations. — (Carter.) General Pathology and Treatment of Pigmentary Degeneration. The formation and modifications of pigment, as observed in plants and animals, is a subject which has been little studied, and opens up a Fig. 3.59. Cells in a melanotic cancer of the cheek, the black pigment in which disappeared on the addition of hydrochloric acid. i ig. 360. Cells in the black sputum of the collier, the pigment in which is persis- tent under the action of every known chemical agent. 250 diam. 268 PRINCIPLES OF MEDICINE, wide field of inquiry for tlie chemical histologist. In endeavoring to ascertain the causes which give rise to change of color in the textures, we must attend to the following circumstances : Is^, Coloring matter bears a certain relation to the non-nitrogenous and oily constituents both of plants and animals. Thus vegetable oils and resins are seen to form in plants where starch or 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- ciated with fat. The brilliant colors of the invertebrata are so many colored 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 epider- mic appendages, which are generally colored, are always covered with fat, secreted by a special apparatus — the sebaceous glands. The blood corpuscles are intimately associated with the chyle, which is an oily emulsion, and the bile is rich in fat. In diseased conditions of the liver, the hepatic cells often contain oil to the exclusion of the yellow pigment. 2(i, It would appear that light, heat, and exposure to atmospheric air, are connected with the production of pigme it. The young leaves of plants are much lighter in color than those which are older, and the h lir of young animals is not so dark as that of the adult. In autumn the leaves fade, and become brown, reddish, or yellow, and in man we observe that the pigment of the hair ceases to be formed in advanced age, which at length becomes white. Young fruit is green, and as it ripens, the part exposed to the sun is most colored. Exposure of the skiu of man, as is well known, renders it darker, and the fairest sldnned individuals (whose integuments are well loaded with fat) are those who are most subject to freckles. Then it must be remem- bered, that while light evolves color in living, it destroys pigment in dead textures. New the decomposition of the atmosphere is carried on in vegetables by the leaves, under the stimulus of light, and in animals by the lungs and skin. In plants the leaves fix the carbon and give off the oxygen ; in animals the lungs receive oxygen, while carbon is separated in the form of carbonic acid by the same organs, and oxygen in combination with water, in the form of exhalation, is given off both by the lungs and skin. That the skin is connected with respiration is proved by the fact, that if its functions are interrupted, pulmonary diseases and even asphyx- ia are the common results. Carbon is also separated in the form of oily matter largely by the skin and by the liver, an org \n also connected with respiration Hence why Europeans in tropical climates, by breath- ing a rare atmosphere, eating much, and taking little exercise, are liable to hepatic diseases. Thus the lungs, skin, and liver, are intimately as- sociated, in the function of excreting carbon, and it is curious that these arc the three organs in which pigment is formed. 3i?, There seems to be a certain connection between the materials in- troduced 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 vari- ous salts originally derived from the soil, and we have seen that these re-agents operate on coloring matter. Although this subject has been very slightly investigated, we can still perceive how, by the evolu- MINERAL DEGENERATION. 269 tion of chemical products, acting on different pigments, the various shades of color 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 for- mation 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 vital properties of cells, may eliminate more or less color. Accord- ing to Heusinger, carbonaceous food used in excess tends to the pro- duction of pigment, and hence he explains how the Greenlanders, notwithstanding the cold, are dark colored, from their constant con- sumption 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 Car- bonaceous 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 tumors. 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 accidental collections in hollow viscera, although undoubtedly they insensibly pass into one another. There is scarcely perhaps any tissue, whether elemen- tary or compound, that may not undergo the mineral degeneration. But it is frequently observed in the coats of blood-vessels more or less asso- ciated with atheroma; in exudations; in certain morbid growths — rarely in nervous texture. Mineral Degeneration of Blood- Vessds . — Nothing is more common than to find the large arteries brittle from the deposit of mineral matter in their coats, often associated with fatty degeneration or atheroma; sometimes the one lesion and sometimes the other having the predomi- nance. Plates and patches of mineral matter may in this way often be observed, which on stripping off the internal membrane (Fig. 362, a) may be seen embedded in the middle coat h. These never present the structure of bone, but either an amorphous conglomeration of mineral matter, or an amalgamation of round globules, similar to those which Czermak has described as sometimes occurring in dentine (Fig. 362, cf Occasionally, though more rarely, the smaller vessels undergo a similar degeneration. In this case mineral matter is deposited in their coats, 270 PRINCIPLES OF MEDICINE. which when widely scattered also presents a globular form, closely re- sembling drops of oil, for which they are apt to be mistaken, unless mineral acids are added, when they dissolve with effervescence. Fig. 361 represents this degene- ration in the small ves- sels of the brain as de- scribed by Dr. Bristowe and Mr. Bainey.* Mineral Degenera- tion of Nervous Texture. Deposition of mineral matter in the tubes or ganglionic cells of ner- vous substance is a rare occurrence in man, although more common in sheep and other of the inferior animals. Foerster, however has recorded the case of a boy who Fig. 362. had paralysis of the lower extremities, and in whose spinal cord after death, the nerve-cells and tubes were found encrusted with mineral de- posits, as seen in Fig. 363. In this case, also, the cretaceous closely * London Pathological Transactions, vol. iv. p. 118. Fig. 361. Incrustation of the small vessels of the brain, with carbonate and phosphate of lime, in the form of globules, some masses of which are separated, whilst others are aggregated together outside the vascular wall . — [Bristowe and Rainey.) Fig. 362. Structure of mineral degeneration of the walls of an aneurism, a. The internal membrane with groups of fatty granules ; 6, horizontal section of the creta- ceous middle coats, presenting irregular spaces, of various dimensions, filled with carbonate of lime ; c, globular masses of mineral matter, in the lighter portions of the section b . — ( Wedl.) 250 diam. MINERAL DEGENERATION. 271 resembled fatty matter; but on the addition of hydrochloric acid, the grauules were dissolved ’ with effervescence,’*' In other Textures min- eral matter may be depos- ited 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. 229), it IS usually the re- sult of an exudation. The fibrous membranes of the brain not unfreqiiently in this way contain calcareous laminated depositions. In certain parts of the pia mater, and the choro'd plexus especially, we often find mineral bodies of a round or oval form re- sembling starch corpuscles. (See Amyloid Concretions, Figs. 392 to 395.) Mineral D- generation of the Exudations. — All the forms of exuda- tion 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 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 aggregated together, and form laminge on membranes, or nodules in parenchymatous organs. I have seen the gall-bladder in this Fi?. 365. Fig. 366. way converted into a calcareous shell, and the pericardium into an un- yielding mineral box, inclosing the heart. The cardiac valves are also especially liable to these mineral incrustations. A cancerous ex'udation in the same manner undergoes the calcareous transformation. The mes- enteric glands may not unfreqiiently be observed to be partly cancerous * Mikroskopischen Pathologischen Anatomie, Taf xv. Fig. 363. Mineral degeneration of the nerve-cells and tubes of the spinal cord. — {FoernUr^ Fig. 364. Mineral masses in a degenerated cancerous tumor of the omentum. Fig. 365. The same, in a degenerated cancerous mass in the liver. Fig. 366. Cancer-cells infiltrated with cretaceous molecules, in a mesenteric gland. 250 diam. 272 PEIA^CIPLES OF MEDICINE. and partly cretaceous. On one occasion I examined a large cancerous growth of the omentum and peritoneum, which was so loaded with phos- phatic salts, that slices of it when dried lost little of their bulk. The juice squeezed from this tumor, 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 aod some mineral (Fig. 3G4). On another occasion I found the cancer-cells em- bedded in and infiltrated throughout with minute cretaceous molecules (Fig. 3CG). In cancer, as in atheroma of arteries, the mineral is often associated with the fatty degeneration. A Tubercular Exudation passes more readily into cretaceous 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 Fig 367. Fig 368. matter. I possess specimens of miliary as well as of infiltrated tubercle, arrested in all stages of their progress, by cretaceous tran.^formation, 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. 3G7). Alineral Degeneration of 3Iorbid Growths . — Mineral deposition may occur in all kinds of morbid growths, but is most common in fibroma and cystoma. In enchondroma the tendency is to form bone. The white fibrous tumors of the uterus, we have previously seen, may undergo the osseous transformation (Fig. 282) ; but this is an occurrence of extreme rarity. Far more commonly the centres of such growths are composed of amorphous mineral depositions (Fig. 3G8), which frequently increase, and invade their whole substance, causing arrest of their progress. 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. CONCRETIONS. Ry concretions are understood non-organized and non-vascular pro- ductions, formed by the mechanical aggregation of various kinds of matter, generally in the ducts or cavities of the hollow viscera. It has Fig. 367. TMineral masses in a cretaceous tubercle of the lung. Fig. 36 ■!. Section of an amorphous mineral mass forming a calcareous nucleus of a uterine fibrous tumor. — [Wcdl.) 250 diam. COI^CEETIONS. 273 already been pointed out, that although they pass gradually into the class of degenerations, several of which closely resemble concretions, still they are distinguished from them by their never having been organized, or formed out of an organic structure. They possess a remarkable disposition, how- ever, to collect round a central nucleus, which may be organic or non-organic, aud often present as the result of pure accident. Hence they geuerally exhibit a tendency to assume the globular or oval shape. AlhuminousConcretions . — It has already been explained that albumen may be precipi- tated from its solutions in the form of mem- brane (p. 246.) This is sometimes so effected as to produce concretions, of which I have long possessed a remarkable specimen, found Fig. 369. loose in the cavity of the abdomen. Mr. Shaw has described a similar specimen, about one-half the size of mine, containing a nucleus of fat — also formed in the peritoneal cavity.* It was excised from a hernial sac, and consisted of aggregated layers of albuminous substance, as seen in Figs. 369, 370, 371. The concentric layers of aneurismal coagula, and some so-called fibrinous depositions on the valves of the heart, which Fig. 370. Fig. 371. subsequently become white and indurated, are of a similar character. The section of the nucleus in my specimen (Fig. 372) is represented magnified fifty diameters. Fig. 373, showing the adipose cells of the structure, loaded round the circumference with mineral matter. In all other respects it resembled Mr. Shaw’s specimen. Fatty Concretions . — These constitute gall-stones, which for the most part are formed of laminae of cholesterine, associated with inspissated bile. They are found in the gall ducts or bladder, and vary in color, size, form, and number. They may be perfectly white, and then they consist almost wholly of pure cholesterine. Sometimes they are brown, * London Pathological Trans., vol. vi., p. 205. Fig. 369. Longitudinal section of the albuminous concretion, referred to, and its encysted nucleus of fat. — {Shaw.) — Natural size. Fig. 370. Portion of one of the concentric lamellae, of the same concretion. Fig. 371. Transverse section of the edges of the concentric lamellae.— (>S'/e.‘| 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 tumor 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 Fig. 392. Fig, 393. 394 ^ a b c d e Fig. 395. the yJ^jj^th to the o diameter. Their fracture was exactly like that of starch corpuscles, but they were not rendci-ed blue 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. 395). They were embedded in a fibro-nucleated structure, which formed a sheath round each concretion. Since then, I have frequently seen similar bodies in the arachnoid mem- brane and substance of the brain, and they have also been observed by Drs. Qnain, Cleland,|j and many others. These are amyloid Virchow^f was the first to point out that several similar-looking bodies in the brain assumed a pale blue tint on the addition of iodine, and subsequently became violet-color on being treated with sulphuric acid. He considered them to be cellulose, a principle which he also had shown * Handworterbuch der Physiologie, Taf. 1, Fig. 2. f Physiologie Pathologique, PI. xi. Fig. 10. I Pathologische Anatomie, Liv. 16, Taf. 2. § Proceedings of Pathological Society of London, 1846-47, p. 17. II Glasgow Medical Journal, July 1863. ^ Archives, Band. vi. s. 125. 1854. Fig. 392. Mineral amyloid bodies embedded in a seemingly amorphous matter. Fig. 393. The same, after dilution with water, now seen to be invested with a fibrous sheath and surrounded by fusiform cells and naked nuclei. Fig. 394. The same after the additon of acetic acid. Fig. 395. The same, after the addition of nitric acid, a. One of these bodies with a thick investing capsule ; 6, e, and c?, others showing the various ways in which they crack on pressure ; e, cylindrical form produced by rolling them between glasses. 250 diam. CONCRETIONS. 283 to exist in other pathological formations. Mr. Busk* demonstrated that these bodies were optically as well as chemically identical with starch, and that they were true corpora amylacea. They have been found in various tissues and fluids by subsequent observers, and have been made the special subject of research by Dr. Carter,! who has demonstrated Fig. 396. Fig. 397. 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) re.sembling 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, whetiier the amyloid concretions are not colloid bodies, which have subsequently become im- pregnated with mineral matter, or whether they are not 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 which have not yet been investigated. All speculation on this subject, however, is at present highly hypothetical, and it is only from the progress of organic chemistry that we can hope t-o derive a satisfac- tory explanation of those transformations which go on in the blood and tissues, so that we may determine the laws regulating the production of the amylaceous and amyloid concretions. (See Waxy Degeneration.) * Quarterly Journal of Microscop. Science, vol. ii. p. 106. 1854. I Edinburgh Medical Journal, August 1855, and Graduation Thesis, 1856. Fig. 396. Small corpora amylacea^ in the auditory nerve of a deaf individual, with several granule cells. — {Foerster.) Fig. 397. Variously-shaped and sized corpora amylacea^ from the human pancreas, a, Nucleated; 6, c, d, variously-shaped; e, seen edgeways. — {Carter,) 250 diam. SECTION III. GENERAL THERAPEUTICS. In the two previous sections I have endeavored, to give a condensed account of the present state of the art of diagnosis, and of the pathology of organic diseases. A practical knowledge of the one, and a better appreciation of the other, have been very widely diffused during the last twenty 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 is and with what it is represented to be, even in modern books on the theory and practice of physic, the discrepancy must strike even the least observant. The time, therefore, has now arrived for calling the attention of the pro- fession, 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 neces- sarily be based. In endeavoring to estimate the means at our disposal for the cure or relief of disease, there are several circumstances which demand our attention, such as the influence which the mind exerts over the body ; the natural progress of disease ; the knowledge derived from an improved diagnosis and an advanced pathology. It is chiefly from an inattention to these points, and an illogical disregard of their effects upon our general views as to treatment, that much of the contradiction and uncertainty which prevail as to the effects of remedies in the present day are to be attributed. The more capable we are, therefore, of appreciating the in- fluence these circum.stances exert upon the patient and upon ourselves, the better position we shall occupy in our attempts to emancipate our- selves from the mere authority of the past, and to assist in establishing a true therapeutics for the future. These points, therefore, require our attention before we enter upon a consideration of the existing knowledge of the treatment of maladies. THE INFLUENCE WHICH THE MIND EXERTS OVER THE BODY. Although such influence has long been recognized, it has been proved in recent times to be far greater than was formerly supposed. Thus, INFLUENCE OF THE MIND ON THE BODY. 285 althougli it is universally known that mental emotions exercise a stimu- lating or depressing effect on all the bodily functions, and that various feelings, desires, a.id appetites increase or diminish the sooretion of dif- ferent giands, it has been reserved for modern times to domonsbrate that ill certain persons mind, sensation, and volition can be thoroughly con- trolled by the suggestive ideas of another individual. If, for example, twenty persons chosen at random from the population, are 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 affected may be made to act in accordance with any train of ideas which may be suggested to them, their motion and sensation being influenced in a variety of ways."^ It seems as if their mental faculties became fatigued, in consequence of which they lose the power of controlling any idea that becomes predominant. The peculiar mental condition thus produced manifests itself while 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 stiffness of the eyelids, and in a third class by deep-drawn sighs, hurried respiration, heaving of the chest, or other signs of general excitement. If now such persons are repeatedly told, in a con- fident manner, that they cannot open their eyes, it will be found that they cannot do so, especially if the operator directs particular attention to the eyelids by touching or pointing to them. But on receiving permission, or on being commanded to open them, they will do so at once. In the same manner, an individual so affected may be made to make every conceivable kind of motion against his will, or, on the other hand, such movements as he may wish to make can be impeded, arrested, or perverted. Thus I have seen a person unable to speak, from inability to open the jaws ; not able to bend an arm or a leg ; fixed to a chair, or prevented from sitting down ; unable to approach a particular object, or irresistibly impelled towards it ; unable to cross a real or imaginary line on the floor ; the arm suspended an.d fixed in the act of drinking, or the body arrested in the act of dancing ; the individual made to walk, dance, or run, as directed ; to imitate riding on horseback, when seated on a chair ; or to stagger about the room in a supposed state of intoxication, etc. Many of the lower animals also appear to be susceptible of being impressed by what strongly arrests their attention, in such a way that they are rendered incapable of voluntary motion, or irresistibly impelled towards the object. Hence the long glittering bodies of serpents, or the glaring eyes of other fascinate birds or small quadrupeds, and render them an easy prey to their enemies. Hares and all sorts of animals, also, are often run over by railway trains. Similar effects are * The mode of producing this condition may be varied, but it is in all cases essen- tially the same. Thus Mesmer caused individuals to sit in a kind of trough, and they were dii’ected to look at a wire placed in their hand. The Fakirs of India throw themselves into a trance by looking at the extremity of their own noses. Mr. Braid of Manchester held an object a little above the eyes, so as to cause fatigue 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-called passes which arrest the attention. 286 GENERAL THERAPEUTICS. produced in individuals wlio look from heiglits and precipices, and ex- perience an uncontrollable desire to leap down, although they know it will be to certain destruction. In like manner, during this condition all the sensations may be in- creased, perverted or destroyed, through the medium of suggestive ideas communicated to the mind. By fixing attention on any part of the skin it may be made to feel hot or cold, tingling and painful^ or benumbed and destitute of sensibility, according to the ideas communicated. Sight may be lost or rendered painful, spectral images may be presented to the vision, or various objects made to resemble others to w'hich they bear no analogy. Smell also may be perverted, and any kind of odor given to inodorous substances. A rose, in the hand of such an individual, may have the smell of an onion, and plain water the fragrance of eau de Cologne. Various noises, in like manner, may be heard; hearing is frequently very acute, at other times it is apparently abolished. Lastly, the taste may be affected, and plain water made to present to such a person the sweetness of honey, the bitterness of wormwood, or the acidity of vinegar. Then, as regards the mental faculties, memory may be lost, whilst judgment and comparison for the time being cannot be exercised. The imaginative faculties, on the other hand, may be very vivid, so that the individual readily assumes the manners of other persons in various walks of life — goes through the operations of different mechanical trades, con- ceiving himself to be an artisan — endeavors to escape from imaginary dangers or tries to repel them — and acts as he himself or others might be naturally supposed to do under any given circumstances or conditions. Thus he may be made to fight, to swim, to run, to stagg«^r as if intoxi- cated, and so on. Even the sex may in this manner be mentally changed, and a lady may assume the manner, tone of voice, and language of her husband. Such persons also may readily be conducted in imagination to various distant countries or cities, when they will act and talk as if they were really there ; or they may be led through a very complicated series of actions, such as a quarrel termit ating in a duel ; a fishing or shooting excursion in which they catch numerous fish; or bag a quantity of game, etc. etc. In the same way sleep may be most readily induced, and become so sound that all ordinary stimuli will not awake the sleepers ; sensation even being occasionally annihilated for the time. Yet it often happens, that at the command of him who has communicated the suggestive ideas, they immediately awake from a condition of sopor out of which local painful applications failed to arouse them. Susceptible persons may be even commanded to sleep at a particular hour on a certain day, and awake at a particular time, and this they will do under the idea that at the hour named some peculiar influence is exerted on them. This con- dition is analogous to that of somnambulism, trance, or ecstacy, and presents all the intermediate gradations between these states and ordinary dreaming and reverie. What is very curious in connection with many of these nervous aberrations is, that a person may be perfectly conscious during the whole time of what he is doing, and even of the absurdity of his actions. He INFLUENCE OF THE MIND ON THE BODY. 287 may know that the water he drinks is not milk or syrup, and yet he declares it to have the taste of those liquids. Frequently, when his movements are influenced, he evidently resists, but seems to be controlled by a will stronger than his own. He even laughs at his own ridiculous actions, but acknowledges his helplessness. The efforts at resistance only induce fatigue, and tend to render him more certainly the victim of the influence by which he is governed. This condition is certainly closely allied to the incipient stage of monomania. It should also be noticed that, although young and nervous persons are undoubtedly those who are most commonly affected, such is by no means always the ease, as many individuals apparently in good health and robust, have been made to exhibit all the phenomena described. Such are only some of the phenomena which may be produced in those affected with the peculiar nervous condition which I am describing. They admit of infinite modifications, but the symptoms are all r;-ferable to increase, diminution, or perversion of intelligence, sensation, or volun- tary motion, variously combined, according to the endless train of sug- gestive ideas that may be communicated to the individual. Similar phenomena have occurred in all ages, produced in certain persons by predominant ideas, and variously modified according to the education, politics, or religion of the period. Thus the effects produced on many votaries during their initiation into the ancient mysteries ; the ecstasies of the Pythian and other priestesses ; the influence of religious enthusiasm, of the evil eye, and of the divining rod; the dancing epi- demics of St. A'^itus, or of Tarantism, in the middle ages; the hallucina- tions of the Convulsionaries at the tomb of St. Medard, in Paris, etc. etc., are of a like character.* Numerous perversions of the nervous functions, identical in their nature with those described, consisting of sensory illusions, muscular convulsions or rigidity, and peculiar trains of thought influencing acts and conversation, may also be found in the his- tories of witchcraft or demonology, in the legends of the saints, the journal of Mr. Wesley, and in the accounts given by travellers of the religious camp-meetings in the woods of America. The same occur among our modern revivalists, and may be seen among the mesmeric, table-turning, and spirit-rapping communities of the present day. They are perhaps more common now than previously, and excite even more astonishment among the ignorant, the only difference being that the same phenomena which in a dark age were attributed to divination or incantation now assume the garb of science, and are ascribed to Magnetism or Electricity. I consider it unnecessary to enter into any lengthened argument to refute the numerous hypotheses which ascribe these effects to external influences. I know of no series of well-ascertained fa,cts capable of sup- porting such a doctrine. I have made numerous experiments with the aid of those who believe in Animal Magnetism, all of which have only convinced me that no such principle exists, and that all the pheno- mena really occasioned depend on suggestive ideas communicated to the person affected. But while these theories scarcely merit atTention, the facts themselves are highly important, and demand the careful con- sideration of the physiologist and medical practitioner. Let us, then, * Hecker’s Epidemics of the Middle Ages. 288 GENERAL THERAPEUTICS. examine into wliat can reasonably be advanced in explanation of these nervous phenomena. We have seen that sensation may be defined to be the consciousness of an im,pression. and we know that the mind strongly intent upon an object is unconscio.us of those impressions which are going on around — so that no sensation results from these. Every physiologist is aware that the body of a decapitated animal may be thrown into violent con- vulsions, and cases have occurred even in man of the limbs having been thrown about, as if in the greatest agony, although in reality no pain whatever has been experienced. All-absorbing mental ideas prevent sensation of local impressions unconnected with them ; hence wounds are not felt in battle, blows and falls are unheeded during the excite- ment of intoxication or of nitrous oxide gas, and Indian warriors and religious enthusiasts, intent on particular trains of thought, have not suffered from any of the supposed torments which were inflicted on their bodies. These facts, then, offer a sufficient explanation to the physiolo gist of the occasional insensibility of somnambulists, or others laboring under some predominant idea. Whilst, however, an individual may be unconscious of impressions unconnected with his particular train of ideas, ( verything in relation to these is often perceived with extraordinary readiness. The abolition of sensation with regard to general impressions seems to be counterbalanced by an excpiisite sensitiveness relative to the one impression either actually made or suggested. Dr. Holland has very ably j.ointed out the effects of mental attention on the bodily organs, showing that there are few persons who do not experience irritation or some imagii.aiy feeling ill parts to which their attention is much directed.* If at right, owing to some unusual position, we feel a beating at the heart or at the temples we easily imagine there is something alarming ; the inspirations are altered, if we think about them ; if we suppose the mouth is dry, we immediately swallow the saliva and render it so ; if we tai cy we have a cough, we cough immediately, and clear the air passages ; and if we sup- pose any source of irritation exists on the skin, we involuntary apply our hand to and rub the part. Nothing is more common for medical students, when first studying individual diseases, than to imagine them- selves to be the victims of each in succession. Then, in certain condi- tions of the system, it is well known that actual pain n ay be produced ill a part by fixing our attention upon it. Hypochondriacs are martyrs to these erroneous impressions. Supposed pains in the limbs or stomach prevent their walking or eating, and their health suffers from want of exercise or want of food. Sir Benjamin Brodie has given some singular cases where so-called nervous pains of this description have actually led to tenderness and swelling of the integuments covering the part. It may easily be understood how facts of this kind may be made to assume the appearance of prophecy, and how informing a valetudinarian that he will certainly have a rheumatic or neuralgic pain on any given day, is likely to produce it. As illustrative of the strong influence of predominant ideas even in healthy persons, I may mention the following circumstances : — The late * Medical Notes and Reflections, chap. 6. INFLUENCE OF THE MIND ON THE BODY. 289 Mr. Mcfarlan, druggist, North Bridge, Edinburgh, informed me that on one occasion a butcher was brought into his shop, from the market-place opposite, laboring under a terrible accident. The man, on trying to hook up a heavy piece of meat above his head, slipped, and the sharp hook penetrated his arm, so that he himself was suspended. On being examined, he was pale, almost pulseless, and expressed himself as suffer- ing acute agony. The arm could not be moved without causing excessive pain, and in cutting off the sleeve he frequently cried out, yet when the arm was exposed it was found to be quite uninjured, the hook having traversed only the sleeve of his coat. The Bev. Mr. Stevenson of St. George’s Church, Edinburgh, told me, that some time ago suspicions were entertained in his former parish of a woman, who was supposed to have poisoned her newly-born infant. The coffin was exhumed, and the procurator-fiscal, who attended with the medical men to examine the body, declared that he already perceived the odor of decomposition, which made him feel faint, and in consequence he with- drew. But, on opening the coffin, it was found to be empty, and it was afterwards ascertained that no child had been born, and consequently no murder committed. Numerous instances might be given of individuals engaged in duels, or on other occasions, who have supposed themselves to be wounded, and have fallen down as if dead, without having received the slightest injury. Then, as regards irregular movements in connection with predomi- nant ideas, the phenomena of hysteria and chorea will at once suggest themselves to you. In the latter disease, peculiar movements are always occasioned by the exercise of volition, or by certain impulses which cannot be controlled. In hydrophobia there is a remarkable susceptibility to the most minute circumstances, which give rise in any way to the idea of drink, and invariably excite the most fearful spasms. Numerous singular instances of occasional and partial perversion of the voluntary movements might be quoted, either arising spontaneously, or acquired by habit, or produced in animals by injuring certain parts of the nervous system, or by giving particular drugs ; but I shall content myself with relating two cases, formerly under the care of Dr. Christisou, which he was so good as to communicate to me. The first was that of a gentleman, who frequently could not carry out what he willed to perform. Often on endeavoring to undress, he was two hours before he could get off his coat, all his other mental faculties being perfect. On one occasion, having ordered a glass of water, it was presented to him on a tray, but he could not take it, though anxious to do so, and he kept the servant standing before him for half an hour, when the obstruction was overcome. In the other case the peculiarity was limited. If, when walking in the street, he came to a gap in the line of houses, his will suddenly became inoperative, and he could not proceed. An un-built open space in the street was sure to stop him. Crossing a street was also very difficult, and in going in or out of a door he was always arrested for some minutes. Both these gentlemen graphically described their feelings to be “ as if another person had taken possession, of their will.” These and similar perversions of motion, whether of excess or diminution, however produced, cannot always be governed by 19 290 GENERAL THERAPEUTICS. predommant ideas, but that they frequently are so is proved by a mul- titude of facts. The old story of Boerhaave is as apposite as any other, who is said lo have immediately cured several girls at school of chorea, by threatening, in a loud voice, that the next who was attacked should have the actual cautery applied. The power of imitation, which must operate through the mind of the individual, is known b}’ medical men to be very strong, however inex- plicable. Immoderate laughter is very catching ; few can resist even a well-imitated yawn, and on board ship nothing more certainly brings on sea-sickness than seeing others ill. Habits, modes of expression, dialect, carriage of the body, and peculiar movements, are also readily acquired from those around us. On visiting the Bosjesmen, who were exhibited here some years ago, the effect of their dance on the audience was strik- ing. Beginning slow, to the rhythmical beatings of their clubs, the noise became gradually louder, more and more exciting, every step and ges- ture keeping exact time. I myself, and some friends with me, at length felt a peculiar jar all through our systems, our own feet involun- tarily kept time with the dancers, and from the feelings then experi- enced, we could at all events comprehend the nature of those impulses, which have caused multitudes to join in the dance of St. Vitus or of Tarantism. In all these, and various other cases which might be cited, it must be evident that the effect is produced by operating on the mind of the individual, and through that on his bodily powers. In short, pre- dominant ideaSj whether criginating spontaneously or suggested by the words and actions of others, seem to be the exciting cause in individuals affected with a peculiar condition of the cerebral functions. As regards the nature of this condition, it seems analogous to that of sleep or dream- ing, in which certain faculties of the mind are active, and may be even stimulated into excessive action, whilst others are suspended. Hence it has been called Hypnotism by Mr. Braid.* All the phenomena pro- duced are strictly analogous to what medical men are acquainted with in various morbid states; and it must now be considered as well established, that in certain conditions of the nervous system they may be induced at will. This conclusion, however, is something new, for it has but recently been admitted in physiology or pathology, that a condition of the cere- bral functions may be occasioned in apparently healthy persons, during which suggestive ideas are capable of producing those phenomena we have described, and which render them, for the time, as irresponsible as monomaniacs. Yet such is really the fact, which, once admitted into physiology, must have an important influence on the theory and practice of medicine. This condition may probably be accounted for physiolog- ically in the following manner : — We have previously seen that the cerebral lobes contain white fibres, which run in three directions. 1st, Those which pass from below up- wards, and connect the hemispherical ganglion with the spinal cord. 2d, Those which pass transversely, forming the commissures, and which unite the two hemispheres. And 3d, Those which run from before backwards, uniting the anterior with the posterior lobes on each side * Neurypnology, or the Rationale of Nervous Sleep. 1843. INFLUENCE OF THE MIND ON THE BODY. 291 (p. 139); these fibres being also probably subservient to that combina- tion of the mental faculties which characterises thought (p. 140). Now all metaphysicians and physiologists are agreed that the mind is com- posed of various faculties, and that different portions of the nervous mass are necessary for their manifestation. True, it is by no means determined of how many faculties the mind is made up, and still less is it known which parts of the brain are necessary for the manifestation of each individual faculty. But let the first proposition be granted, then there is no difficulty in supposing that one or more of these may be paralysed or suspended, whilst others are entire, any more than there is in knowing that sensation may be lost whilst motion remains intact, although the nerve fibres of both run side by side. I presume, then, that certain mental faculties are, as the result of exhausted attention, temporarily paralysed or suspended, whilst others are rendered active in consequence of being stimulated by suggestive ideas ; that the psychical stimuli of the former make no impressions on the cerebral conducting fibres, while those of the latter are increased in intensity ; that the proper balance of the mind is thereby disturbed, and thus the individual for the time being acts and talks as if the predominant idea was a reality. The condition is analogous so far with ordinary somnambulism, certain forms of hypochondriasis and monomania, but admits of infinite changes according to the nature of the idea suggested. According to this theory, therefore, we suppose that a psychical stimulus is generated, which, uncontrolled by the other mental opera- tions, acting under ordinary circumstances, induces impressions on the peripheral extremities of the cerebral fibres, the influence of which only is conveyed outwards to the muscles moved. In the same manner the remembrance of sensations can always be called up by the mind ; but under ordinary circumstances we know they are only remembrances, from the exercise of judgment, comparison, and other mental faculties ; but these being exhausted, in the condition under consideration, while the suggested idea is predominant, leave the individual a believer in its reality. In this manner we attribute to the faculties of the mind a certain power of correcting the fallacies which each is liable to fall into, in the same way that the illusions of one sense are capable of being detected by the healthy use of the other senses. We further believe that the appa- ratus necessary for the former operations consists of the nerve fibres, which unite different parts of the hemispherical ganglion, whilst that necessary for the latter are the nerve fibres connecting together the organs of sense and the ganglia at the base of the encephalon. A healthy and sound mind is characterised by the proper balance of all the mental faculties, in the same manner that a healthy body is dependent on the proper action of all the nerves. There are mental illusions and sen- sorial illusions, one caused by predominant ideas, and corrected by proper reasoning ; the other caused by perversion of one sense, and corrected by the right application of the others. Both these conditions are inti- mately united, and operate on each other, inasmuch as voluntary and emotional movements and sensations are mental operations. This tlTeory, if further elaborated, appears to me consistent with the 292 GENERAL THERAPEUTICS. facts described at the commencement of this lecture, and capable of explaining them on physiological principles.'^ We may now ask ourselves whether the facts which have been ascertained, and the generalisations which flow from them are capable of being rendered useful in the practice of medicine ? The beneficial influence of hope and confidence over disease is as well known to medical men as is the injurious tendency of fear and despondency. This effect of mind on the body has from the earliest periods been seized upon by individuals as a ground for veneration or astonishment. In ancient times the heathen priests were the physicians, and the temples were con- verted into so many dispensaries, at which the sick applied for relief. In catholic countries, during the middle ages, the offices of priest and physician were frequently united in one person, so that the powerful effects of certain shrines, and the benefits of pilgrimages in cases not admitting of simple cure, met with every encouragement. From what has preceded, it must be allowed, that, so far froui its being improbable that real cures were so effected, all that we know of the effects of con- fident promises on the one hand, and belief on the other, renders it very likely that many such occurred. The legends of the saints, the history of witchcraft, the journal of Mr. Wesley, the accounts of celebrated pil- grimages, and of the virtues of particular shrines, and the WTitings of religious enthusiasts generally, abound in wonderful recoveries. Charms, amulets, and relics, are stated to have at once banished all kinds of agony, and removed numerous nervous diseases ; and the same has re- sulted from intense religious, political, or martial excitement. Many of these tales are certainly incredible, whilst others are perfectly conceiv- able. The royal touch, the bezoar stone, zinc rings, wearing the mistle- toe and other sacred plants, have all been lauded as means of cure. The benefits of the royal touch are confirmed by the observations of Richard Wiseman, and the cures performed by Greatrakes are warranted by Robert Boyle. In all these cases, there can be little doubt that any benefit which did occur may be attributed to a strong belief, on the part of the patient, in the efScacy of the means employed.! * It was proposed by Mr. Braid to call the condition of which we have been speaking, and which results from a dominant idea — m on oi deism.. The term monoi- deology would indicate the doctrine of the influence of dominant ideas in controlling mental and physical action. To monoideise might express the act of performing pro- cesses for inducing monoideism., and monoideiser designate the person who monoi- deises. Then monoideised will indicate the condition of the person, and monoideody- namics the mental and physical changes which result from the process. f The wonderful cures performed by Mesmer, and all those who have convinced themselves and others of the advantages of the ephemeral systems which are contin- ually springing up around us, are much indebted to belief in their eflScacy on the part of the patient. Dr. Haygartli, of Bath, performed all the cures of Mesmer and Perkins with two bits of wood made to resemble the metallic tractors of the latter, — that is, so long as he kept the secret, — for the moment he published his book, and the imposition was known, no more cures were accomplished. In the same manner there is every reason to believe that the efficacy of many public nostrums resides in the reputation which surrounds them. Miss Harriet Martineau, in publishing her own case, naively remarks : — “ If at any time during my illness I had been asked, with serious purpose, whether I believed there was no resource for me ? I should have replied that Mesmerism might perhaps give me partial relief.” — {Letters on Ales- INFLUENCE OF THE MIND ON THE BODY. 293 In recent times more systematic attempts have been made in this way to relieve pain, control nervous excitement, lessen muscular debility, and stimulate certain secretions. If it be considered, that the power of producing profound sleep, and acting on the nervous functions, may be manifested in so many individuals as one in twenty of the whole popu- lation, it must be evident that in a class of persons particularly predis- posed, the nuiiiber capable of being affected would be much greater. This subject, however, is yet in its infancy, and has to be separated from the charlatan ism which has hitherto been mingled with it. The labors of Dr. Eislale am mg the natives of India, and of Mr. Braid in Man- chester, exhibit a worthy commencement to the rational treatment of disorders by the means now alluded to ■ and there can be little doubt that in no long time its influence, when further studied, will be acknow- ledged. Bat how far this influence is dependent on the confidence of the patient ; on the belief in some mysterious circumstances, which is presumed to produce the effect, or on some unknown law-regulating function through the mind, further observation alone can determine. In the meantime, it seems to me that we are indebted to Mr. Braid not only for having first clearly demonstrated that the phenomena described are wholly occasioned by predominant ideas in the individual, but for the first contribution of any value to the mode of applying this theory to the cure of disease. By suggesting thoughts to our patients in various ways, sometinies by speaking so that they may hear what is said, at others by directing their thoughts to certain subjects, and occasion- ally rendering these more vivid by repetition or by definite physical im- pressions, we can fix certain ideas strongly in their minds. These ideas act as stimulants or sedatives according to their purport, and the cur- rent of thought directed to or withdrawn from particular organs or func- tions. liemarkable cases have been met with, where a judicious appli- cation of this doctrine has removed insomnolence or various kinds of pain, spasms, and other evidences of excitement ; where hysterical paralysis of the limbs or special organs of sense have been relieved or cured, and where the torpid functions of lactation, perspiration, defseca- tion, menstruation, etc., have been rendered more active.'^ That such results may be induced must be admitted by all who reflect — 1st, On the uido.ibted fact that certain persons are and can be made slaves of dominant ideas; and, 2d, On the equally undoubted fact, that such mental ideas are known by universal experience to exercise a stimulat- ing or depressing effect on all the bodily functions. Hence, many drugs and systems of treatment, which are really inert or uncertain in their action, and which are supposed to act through the blood or on the tissues directly, operate, sometimes beneficially, by exciting expectant ideas, and through these ideas, indirectly on the part disordered. A.S an illustration of what can be done in this way, I may mention merism, 1854, p. 4.) No wonder, therefore, that when at length it was tried, it pro- duced the desired effect ; and the medical attendant, seeing the delusion that existed, perhaps acted judiciously in bringing the lady en rapport with the first magnetiser he could procure. * See Braid on Hypnotic Therapeutics — Monthly Journal of Medical Science, July 1853. 294 GENERAL TEEEAPEUTICS. the case of a young lady under the charge of the late Dr* Johnston, of Berwick-upon-Tweed, affected with hysterical paralysis, who had for several years been under the care of Sir Benjamin Brodie, Mr. Syme, and other eminent surgeons, who recognised the nature of the case, but could do nothing. Dr. Johnston read some remarks on “ Hypnotic Therapeutics,” published in the Edinburgh Monthly Journal by Mr. Braid, and sent his patient to him at Manchester. By giving confidence to this lady, inducing her to walk freely and trust herself, so to speak, on her limbs, a perfect cure was eftected in four days, when she moved about without any lameness, or, as it was said by the reporter, “ with the grace of a queen and the agility of a sylph.” I venture to say that cases of this kind constitute one of the great therapeutic advancements of modern times, being not only directly appli- cable to the cure of maladies, but indicating a most important principle explanatory of innumerable recoveries hitherto too much neglected by the medical profession, and accounting for the well-known fact that in many instances he is the best physician who succeeds in gaining the con- fidence of his patient. On the other hand, the indiscriminate performance of experiments on nervous individuals may be injurious. During the session 1850-51, society in Edinburgh was greatly agitated by this subject. Fashionable parties were converted into scenes of experiments on the cerebral func- tions. Noblemen, members of the learned professions, and respectable citizens, amused themselves in private, whilst public discourses and ex- hibitions to an unusual extent were got up for the entertainment of the public. On one occasion the Royal Medical Society was operated on ; and if a proof of the correctness of the facts described be required, it would be found in the circumstance, that the nervous aberrations noticed were readily exhibited in some of its most sceptical members. The result of this excitement was an increased degree of nervousness in many individuals. In some educational establishments, girls and boys threw themselves into states of trance and ecstacy, or showed their fixed eye- balls and rigid limbs, for the amusement of their companions. Sensitive ladies did not object to indulge in the emotions so occasioned, and ex- hibited themselves in a like way for the entertainment of evening parties. Several instances were known to me where intelligent young men — students in this University — were, for a longer or shorter time, incapaci- tated from following their ordinary occupations, and obliged, from want of attention and mental power, to stay away from their classes. Some of these, from a feeling of the injury they have sustained, very properly refused to allow any experiments to be tried on them ; and the parents of very sensitive young persons, from the obvious detriment their health has sustained, also forbade a repetition of these scenes. One young man of great promise, who was at that time frequently operated on, became insane, and subsequently died in an asylum. I thought myself warranted in calling such a state of things “ The Edinburgh Mesmeric Mania of 1851.” Such experiments cannot be considered as free from danger. The great object of all who seek proper self education is to control the emo- tions and passions, and regulate the imagination by the severer faculties THE NATUKAL PEOGEESS OF DISEASE. 295 of judgment, comparison, and attention. Hitherto medical men, so far from exciting, have done all in their power to prevent such phenomena as have been described ; but now, that it has been clearly shown that they may be produced in numbers of people by the ignorant and mer- cenary, every effort should be made to discourage them. It is well known that cases are on record of individuals who, commencing by the imita- tion of hysterical or epileptic convulsions, have at length found them- selves really laboring under those diseases ; nor is it unreasonable to suppose, that the mental faculties will be greatly injured in persons who frequently surrender up their own wills, and act in accordance with the extravagant ideas suggested to them. After all, the pleasure of excite- ment principally consists in feeling that it can be regulated, and is under command. The moment it ceases to be so, a sense of the imperfection becomes most agonising to the mind, and gives rise to that despoiidency so common among the insane. Hence those only who have studied this subject, and are prepared as medical men to exercise judiciously the influence they may possess on the minds of their patients, ought to attempt the cure of diseases in the manner now referred to. THE NATURAL PROGRESS OF DISEASE. It may be laid down as a general law, that diseases are seldom stationary, and that their tendency is to get better or to get worse. While many disorders, from their trifling character, or in consequence of being well known, are at once recognised as capable of disappearing spon- taneously, others have been supposed actually to have a destructive or injurious tendency, or to be necessarily fatal. Now the study of disease in modern times has led to a great change in our views on these heads. For example, it was formerly supposed that acute inflammations had, for the most part, a destructive tendency ; that suppuration was a great evil, and always required the interference of the surgeon, because an abscess, if so deep-seated that it could not be reached with the knife, seldom got well, and if it burst into an internal cavity caused death. Again, if in- flammation visited the skin, the mucous or serous membranes, or the in- ternal organs, the great object was to prevent it spreading by using the most violent remedies, such as blood-letting, purging, antimony, and low diet, which received the name of antiphlogistics. On the other hand, a tubercular disease, especially when it attacked the lung, was supposed to be almost uniformly fatal, and altogether beyond the reach of art. Now these conclusions are erroneous. We have previously seen that an analeptic treatment frequently cures tubercular diseases; while the antiphlogis ic treatment, formerly supposed capable of cutting short in- flammations, not only fails to do so, but constitutes a most fatal practice. Much of this error depended on an acquaintance with the natural progress of disease. Most diseases in vigorous constitutions, so far from having a tendency to destroy, have a marked tendency to get well of themselves; whilst instead of loss of blood, weakness, and prostration being remedies, they are the sources of danger, and the chief causes of the fatal result. Again malignant growths were supposed to be seated in the blood — 296 GENERAL THERAPEUTICS. an idea which rendered operating useless; whilst innocent growths were supposed to be capable of going away of themselves, or to be the only ones admitting of surgical interference. In this, also, a great change in opinion has been eifected ; so that cancers, like other growths, are now known to have been successfully extirpated. But further, how is it possible to know the effect of any remedy what- ever, unless it be ascertained, in the first instance, not only what is the natural termination, but also the natural duration, of a disease? We know that small-pox, scarlatina, measles, and similar affections, run a certain course, and no one thinks of cutting them short, or proposes dif- ferent kinds of remedies for that purpose. The real principle of treat- ment is to conduct them to a favorable termination. Should not the same rule apply to many other diseases ? Some years ago Dr. Hamilton Bell stated,^ that fifteen drops of the tincture of muriate of iron was a valuable remedy in erysipelas, but how valuable was not shown, because it was not attempted to be proved that the remedy diminished the mortality, or shortened the progress of the disease. Notwithstanding, this remedy was at once largely given, and, it was said, with universally good results. I remember ac(ompanying M. Louis, many years ago, in his visit to the Hotel Dieu, and was much struck by seeing many cases there of severe erysipelas of the scalp. On asking him what treatment he pursued, he answered, none at all, because they all rapidly get well of themselves in healthy constitutions. And, in fact, on following these cases from day to day T found that they all did so get well. I need scarcely say that in the Royal Infirmary I have seen many severe cases of erysipelas. I have never given the tincture of muriate of iron, or anything but good diet, with lotions of acetate of lead, flour, or oil locally to alleviate irritation, and I have not h‘*d a fatal case. Nor has it ever appeared to me that the tincture of muriate of iron could have shortened the progress of the disease. I need scarcely say that any remedy might easily obtain a great reputation if given in diseases that almost always get well of themselves. Delirium tremens is a disease which, within a few years, has under- gone several modifications in its treatment. I remember when it was supposed to arise in drunkards from leaving off the accustomed stimulus, and the treatment consisted in giving it in smaller regulated doses. Then it was found that the disease was treated just as well with tartar-emetic, and subsequently opium was mainly depended on. Ever since Dr. Peddie showed the inutility of these drugs, I have given nothing but nourish- ment as soon as the patient can take it, and all the cases that enter my wards recover. Again, look at rheumatism. Every drug and every system of treat- ment has been tried. In acute cases, bleeding, purging, antimony, mercury, the whole class of sedatives and narcotics, stimulants, quinine, and lemon juice, large doses of alkalies, numerous specifics, hot baths, cold baths, dry frictions and moist applications in every form. Yet under every one of these remedies, however opposite in their nature, notable cures have been performed. Is not the conclusion obvious, that the disease follows a certain progress, and that although many of these * Monthly Journal of Med. Science, June 1861. mFLTJENCE OF IMPROVED DIAGNOSIS AND PATHOLOGY. 297 remedies may retard convalescence, it has yet to be proved which, if any, shorten its duration, even one hour ? There are numerous hospitals scattered through the country, founded and supported at large expense, for the purpose of carrying out some supposed beneficial treatment, or giving to the poor the benefit of some celebrated bath or spring. Many persons are treated in them, and are apparently benefited, both physician and patient firmly believing that in every case the cure is attributable to the special treatment. Yet in no instance has it ever been shown that such patients have ever recovered one day sooner than they would have done in atiy other hospital, or than would have occurred if left to the powerful effects of rest, warmth, good food, and cleanliness. One method of prosecuting therapeutics, therefore, is to investigate — 1st, How long a disease naturally takes to get well of itself under favorable circumstances; 2dly, What is its progress under unfavorable circumstances ; and lastly, this being known, how far remedies are capable of shortening its duration. If every young practitioner would dedicate his life to the careful elucidation of the natural progress of only one disease, he would do more for medical practice than has been accomplished by centuries of empirical trials of remedies. THE KNOWLEDGE DERIVED FROM AN IMPROVED DIAGNOSIS AND PATHOLOGY. This, perhaps, more than anything else, has tended to alter our ap- preciation of the value of drugs. When we consider the progress made in recent times in the art of detecting diseases with exactitude, and re- member that it is daily becoming more and more manifest that mere symptoms or functional disturbances frequently bear no relation to the pathological lesion which produces them, we shall not be surprised at this. Instead of guessing at what was probably the matter, we now often determine with certainty what exists. Diagnosis is daily becoming less and less conjectural by the use of instruments which bring organic disease directly under the observation of the senses. Percussion and auscultation, specula, the microscope, chemical tests, and other appli- ances, enable the well-educated clinical student to act with convictions altogether unknown to his predecessors. A person complains of dyspnoea on exertion, pain or uneasiness in the precordial region, with palpitations and unfrequent or irregular pulse. Formerly a lowering treatment — leeches, and especially certain sedatives, such as digitalis or aconite — was adopted to remove these symptoms. At present, if we recognise by auscultation that these symptoms depend on disease of a valve, with more or less cardiac hypertrophy, we see that such treatment can neither remove the disease nor relieve the symptoms. Nay more. Pathology tells us that it is likely to be prejudicial. The ventricle of the heart, not being able to expel its contents as formerly, in consequence of the obstruction or regurgitation in a valve, follows the law producing increased growth ; having more work to do, its walls are strengthened and increased in bulk and power — hypertrophy is the 298 GENEEAL THEEAPEUTICS. result, and thereby an adaptation of means to an end, which is the sal- vation of the economy. The heart’s action is increased for the wisest of purposes ; nothing hut an acquaintance with pathology could induce any one to lessen it. That can only be done by removing the obstruction at the valve; and, as we cannot do this, sound practice requires that we should abandon all attempts to act on the heart itself, and direct our efforts to lessen the concomitant symptoms by precautions which will at least prolong life. But if the same symptoms are induced without organic lesion in the heart, we recognise that they are the effect of weakness, arisemia, or chlorosis. Here, again, sedatives and lowering the constitution only add to the exhaustion ; a tonic and strengthening treatment is required, and above all, directing attention away from the disordered organ, tranquilliz- ing the mind, and inspiring hope and confidence. It would be easy for me to adduce instances where not only the stethoscope has in this w^ay, conjoined with pathology, completely changed our practice, but how almost every ingenious instrument which has been invented has done the same thing. What it has effected for pulmonary and cardiac disorders, the microscope has accomplished for renal and integumentary diseases — the speculum for uterine and aural, and is commencing to do for laryngeal, affections. By means of the ophthalmoscope we now explore the retina and transparent lenses of the eye ; and these and other instruments, conjoined with a knowledge of chemistry and morbid anatomy, have in every instance modified, if they have not revolutionized, the mode of treatment. In all these cases the result has been brought about by improving diagnosis, and extending our knowledge of pathology. Here also I would endeavor strongly to impress upon you the value of first to cure, and, should his attempts in that direction fail, then to relieve his patient. If both objects can be accomplished, so much the better ; but if the means of relieving symptoms are opposed to those of curing the disease, then to obtain the latter, the former must be unhesitatingly sacrificed. I have pointed out in another place how NATURAL PROGRESS OF INFLAMMATION. 313 much this principle has been overlooked in the treatment of pulmonary tuberculosis;* and in no case does it appear to have been more dis- reo-arded than in inflammation. For assuming it as granted that in some cases the pain is for a time relieved by bleeding, and that in pneu- monia the respiration temporarily becomes more free, at what a cost are these advantages obtained, should the patient be so weakened as to be unable to rally. Even if he does rally, a large bleeding almost always prolongs the disease. Of course I am now speaking of a true pneu- monia, and not of that combination of symptoms which was called pneumonia by Cullen and Gregory. I do not consider it necessary to cite cases in proof of the fact that in many instances bleeding has done great mischief, because this will be readily admitted by all candid medical men. But whilst large and repeated bleedings, practised with a view of arresting the disease, appear to me opposed to a correct pathology, small and moderate bleedings, directed to palliate certain symptoms, and especially excessive pain and dyspnoea, may reasonably be had recourse to, and unless there be great weakness, without any fear of doing injury. I have often been struck, especially in cases where large thoracic aneurisms cause these symptoms, with the small loss of blood which will occasion marked relief. The same result may be hoped for in other cases where there is much congestion, either with or without exudation. But I need scarcely remark that this mere palliative object of blood-letting is not the ground on which the practice has hitherto been based, and that in this point of view it requires to be very differently explained. To this subject I shall again allude. (See p. 317.) In the meantime it follows, from the arguments which have been adduced under the present head, that the principles which have hereto- fore guided the practice of bleeding in inflammation are erroneous. It now remains for me to advance and endeavor to establish to the satis faction of my readers what appear to me to be the true principles of treatment in inflammation. Proposition 4. — That an inflammation once established cannot he cut short, and that the object of judicious medical treatment is to conduct it to a favorable termination. There was a time when it was supposed that the progress of typhus fever, small pox, and many other diseases, which are now alwa^'s allowed to run their natural course, could be arrested by medical interference. But with regard to them, there has been established the principle, 1st, of prevention, and 2d, when this fails, of simply conducting them to a favorable termination. It appears to me that the same rule ought to hold with regard to internal inflammations, and that this will be admitted when it is made apparent, not only that every inflammation once formed runs through a definite course, but what that course is. This I now proceed shortly to consider. If, then, we watch the natural progress of inflammation in any of * On Pulmonary Consumption, by the Author. Second edition. Edinburgh, 1859, p. 143, et seq. 314 GENERAL THERAPEUTICS. the textures of the body, we observe that it terminates in two ways, viz., 1st, by vital changes of growth of different kinds in the exudation, constituting what has hitherto been called suppuration, adhesion, granulation, cicatrization, the healing processes, etc. etc. ; and, 2dly, by death of the exudation, which, if rapid, putrefies, producing gangrene, or, if slow, disintegrates, causing ulceration. (See p. 164, et seq.) The first series of changes are not destructive, but formative and reparative. Suppuration especially should be looked upon as a kind of growth, which enables the exuded and coagulated blood-plasma to be rapidly broken up, and eliminated from the economy. If so, instead of being checked, it should be encouraged as much as possible — a very differei t doctrine from what has hitherto prevailed. Again, every thing that lowers the vital strength and weakens the economy, must impede the nutritive processes of growth, and tend more or less to a slow or rapid death of the exudation. Blood-letting especially has this tendency, and must therefore be wholly opposed to the rapid disappearance of inflam- mation ; for example — If a bone be fractured, inflammation occurs around the injured part, and exudation is poured out, which undergoes vital changes, whereby ultimately it is transformed into bone. If soft parts are destroyed or removed, the exudation poured out from the injured vessels undergoes other vital changes, whereby it is transformed into fibrous tissue, consti- tuting first granulations, and then a cicatrix. After subcutaneous’ section of tendon, with separation of its extremities, the transformation is more perfect, producing, as in the case of bone, a growth exactly similar to the one which was injured. If a violent blow or ii jury has been received, a greater or less amount of exudation is infiltrated among the contused and torn tissues, which is transformed by cell growth into pus, which, if it can be evacuated externally, is soon got rid of, but if not, is on the disintegration of the cells absorbed and excreted from the economy. If, under other circumstances, pus is absorbed soon after it is formed, the inflammatory swelling is said to be resolved or dis- cussed; if not, it collects in the form of a fluid, and constitutes an abscess. Surely it cannot be maintained that, in any of these cases, we can favor these reparative processes by blood-letting and lowering the strength of the economy? On the contrary, they have always been found to be best perfected in individuals of vigorous constitution, whilst in scrofulous or broken-down and weak persons, they proceed slowly or not at all. But in internal inflammations, say of the lungs or pericardium, are the processes different ? Certainly not. In the one case the exudation is converted into pus cells and absorbed, and in the other into fibrous texture, causing adhesions. (See p. 165.) But because these processes have been hid from view, physicians have supposed that, instead of treating the inflamed parts as the surgeon does, he ought to attack the general symptoms which result from the lesion. In cases of fracture and contusion, there are also febrile symptoms, increased pulse, and so on ; but does the surgeon imagine that callus will form better, or an abscess be resolved, or reach maturity sooner, by general blood-letting and antiphlogistics ? Experience teaches him otherwise, and in the NATUEA.L PROGRESS OF INFLAMMATION. 315 same manner it may be most reasonably argued that such treatment cannot favor the natural termination of internal inflammations. But, argued Dr. Alison, if we abandon blood-letting, as recommended by so many practical authors in obedience to this doctrine, “ we shall be trusting to a pathological view of a vital process, still very imperfectly known, in opposition to a therapeutical principle, founded no doubt on empirical observation only; requiring no doubt, as all powerful remedies do, an exercise of judgment of the practitioner in applying it ; because it may easily do harm by enfeebling, and at the same time render- ing more irritable, all the vital actions involved in the disease, more than good, by restraining the amount of the exudation; but, nevertheless, much more to be depended on, as guiding practice in these circumstances ^ than any principle in pathology.” If, however, instead of being imper- fectly known, as he supposed, it should turn out that the pathological view I am contending for is true, and is extensively known among the younger members of the profession, then the admission here made by Dr. Alison of how easily blood-letting may do harm and enfeeble, may be expected to produce an effect prejudicial to its employment. Besides, the moment a pathological law can be successfully established, empirical rules are overthrown. Dr. Alison, who has done so much in attempting to establish the supremacy of vital laws, is too good a logician not to know this. Hence his objection is directed against the uncertainty and want of general information of the theoretical view as a guide to practice, when compared with the advantages which he considers the empirical rule has produced, as tested by past experience. This, then, leads me to abandon pathological research and deduction, and inquire how far actual facts indicate which is the best practice — blood-letting in obedience to empirical rules, or abstaining from it, in accordance with the pathological principles now brought forward. Proposition 5. — That all positive hnowledge of the experience of the past^ as well as the more exact ohservcition of the present dag^ alike establish the truth of the preceding principles as guides for the future. In endeavoring to determine from experience what is the value of bleeding in acute inflammations, it must be remembered that, whilst past experience has declared it to be the sine qua non, the smnmum remedium, the only certain means of cutting short the disease, and so on — present experience declares by almost universal consent that now-a-days in- dividuals laboring under them recover rapidly without bleeding at all. This admission constitutes the basis of the theory advanced by Dr. Alison, viz., that acute inflammations within the last twenty years have changed their type. So that the question now is not whether no bleeding is good practice, but how the admission of this fact is to be reconciled with the experience of twenty years ago. But inasmuch as for the reasons pre- viously given we cannot suppose for a moment that inflammation has ever undergone any change whatever among mankind, it necessarily follows, if modern practice in this matter be correct, that former bleed- ings must have been inert or injurious. 316 GENERAL THERAPEUTICS. Before it is possible, however, to determine with exactitude the value of any practice, it is essential to ascertain the natural duration of the disease we propose to treat. Fortunately we have now some data which will enable us to arrive at this information with regard to one of the most frequent and important kinds of inflammation, viz., pneumonia. Very severe cases of this disease were observed by Dr. Geoi-ge Balfour, in the Homoeopathic Hospital of Vienna, under a treatment that no reasonable medical man can suppose to be anything else than inert. Yet most of these cases got well, and may be considered as excellent studies of the disease left entirely to nature.^ We have also the accounts of the expectant systems of treating this disease in Vienna under Skodaf and Dietl.| Here it is important to consider that the violence of the symptoms bears no necessary relation to the extent or intensity of the disease. Some persons present great fever and constitutional disturbance when one lung is only slightly involved, and recover rapidly ; whereas others may have an entire lung inflamed, or portions of both lungs, and exhibit comparatively trifling fever and few marked symptoms, until impeded respiration occurs, ushering in death. It is a knowledge of this im- portant fact which serves to clear up much of the discrepancy existing between past and present practice, especially when conjoined with another, viz., that however bleeding may relieve symptoms, it has no influence in shortening the duration or diminishing the extent of the disease. Of this fact the observations of Louis, Grisolle, and Dr. Alison, can leave us in no doubt; and I have frequently satisfied myself of their correctness. It follows that, as the past race of practitioners considered pneumonia only demonstrable by symptoms, which furnished the sole evidence of the advantage of bleeding, as soon as these symptoms were diminished by venesection, they thought benefit was accomplished. Whereas now it has become apparent that such is no certain evidence of recovery from the disease, which may linger, notwithstanding, for weeks, give rise to a tedious convalescence, and even induce death by exhaustion after active functional symptoms have for the most part disappeared. The real tests of successful practice, therefore, are not to be sought for in the relief of symptoms, but in the removal of the disease; and that treatment will be best which cceteris parihus^ causes fewest deaths, and recovery in the shortest time. Now on looking at the results — 1st, of the antiphlogistic treatment as formerly practised by bleedings, and tartar emetic ; 2d, at the expectant system, or what ought to be called a dietetic system ; and 3d, at the treatment directed to further the natural progress of the disease — we find that a vigorous antiphlogistic treatment of pneumonia as formerly practised, was followed by a mortality of 1 in 3 cases; that the result of a treatment by tartar emetic in large doses, according to Rasori, and more recently according to Dietl, is a mortality of 1 in 5 cases — but according to Laennec, 1 in 10 cases; that the result of moderate bleedings, as in the treatment of Grisolle, is a mortality of 1 in cases ; and that the result of a dietetic treatment with occasional * Brit, and For. Medical Review, vols. 22 and 23. f Dr. G. Balfour in Edin. Medical and Surgical Journal. 1847. X Der Aderlass in der Lungenentziindung. Wien, 1849. BLOOD-LETTING USEFUL AS A PALLIATIVE. 31'J bleedings and emetics in severe cases, as with Skoda, is a mortality of 1 in 7, and if pure, as under Dietl, a mortality of 1 in 13 cases, all carried on in large public hospitals. Further, that the mortality from pneumonia in the army and navy, occurring generally among healthy able-bodied men, has been also a mortality of 1 in 13 cases. Lastly, that the result of a treatment directed to further the natural progress of the disease as I have explained it, is, in the clinical wards of the Royal Infirmary of Edinburgh, when under my care, up to this time (July 1864) a mortality of 1 in 40 cases ; but, taking only uncomplicated cases, presents no mortality at all. From these facts it fallows that uncomplicated pneumonia, especial- ly in young and vigorous constitutions, almost always gets well, if, in- stead of being lowered, the vital powers are supported, and the excre- tion of eifete products assisted. It is exactly in these cases, however, that we were formerly enjoined to bleed most copiously, and that our systematic works even now direct us to draw blood largely and repeat- edly in consequence of the supposed imminent danger of suppuration destroying the texture of the lung. Such danger is altogether illusory, and t'lj destruction to lung tissue, so far from being prevented, is far m)re likely to be produced by the practice. In fact, the only cases in waich it occurs are in aged or enfeebled constitutions, in which nutrients and not antiphlogistics are the remedies indicated. We can, however, readily understand how blood-letting, practised early and in young and vigorous constitutions, does less harm, or, to use a common expression, “ is borne better,” than when the disease is advanced or the patient weak, and this, because then the vital powers are less afi’ected by it. Hence the diminished mortality in the second series of Louis’s cases, and probably in the army and navy cases. But that it cures the greater number of persons attacked, or shortens the duration of the disease, is disproved by every fact with which we are acquaint- ed. At the same time there are cases, which were formerly often mis- taken for inflammation, in which blood-letting may still be useful. I allude to those where an obstruction to the circulation exists in the heart and lung dependent on over-distension of the right side of the for- mer organ, or on venous congestion, engorgement, and perhaps oedema of the latter; also certain cases of bronchitis preventing aeration, of an- eurisms, and of asphyxia. Although even here the true value of the remedy has yet to be positively ascertained, the special cases de- manding it more carefully discriminated, and the mechanical principles which justify the practice determined. The temporary benefit occa- sioned in many of these cases by the loss of a trifling amount of blood is often very remarkable, and has been previously referred to (p. 313). I have seen instances where great dyspnoea and pain, caused by large thoracic aneurisms in vigorous men, have been greatly alleviated, and inexpressible relief produced for from twelve to twenty-four hours, by a bleeding to the extent of only five ounces. It seems probable that this may arise from diminishing for a time the tension of the whole vascular system. But whatever be the explanation of this fact, I hold that, as a palliative, and practised to a limited extent in cases where 318 GENERAL THERAPEUTICS. HO great debility exists, blood-letting may still be had recourse to. So with regard to antimonials, although in the large doses, which weaken the heart and force of the pulse, they are not serviceable — in smaller doses, together with other neutral salts, they may assist in diminishing the viscosity of the blood, and in favoring the excretion of the effete matters by the skin and kidneys. As to mercurials, the confident belief in their power of causing absorption of lymph, by operating on the blood, is not only opposed to sound theory, as formerly explained, but, like blood-letting, is not sup- ported by that experience which has been so confidently appealed to in their favor. They have been most praised in the treatment of serous inflammations and in iritis. But recent careful observation has demon- strated that the moment these diseases are treated without mercury, they are uninfluenced (except in certain cases for the worse) by this drug. Thus, from an analysis of 40 cases of pericarditis, treated with mercury, and recorded with unusual care by the late Dr. John Taylor, only 4 appear even coincidently to have benefited in any way.* And of 64 cases of iritis, of every degree of severity, including its idiopathic, traumatic, rheumatic, and syphilitic varieties, treated without mercury, by Dr. H. W. Williams of Boston, U. S., the results — with four exceptions, which were neglected at the commencement — were perfectly good.f. I cannot, therefore, resist the conclusion that the principles which led to an antiphlogistic practice in acute inflammations were erroneous, and are no longer in harmony with the existing state of pathology. I think it has been further shown that in recent times our success in treatment has been great, just in proportion as we have abandoned heroic remedies, and directed our attention to furthering the natural progress of the disease. Thus, in our large public hospitals, under cir- cumstances pretty much the same, it has been shown that the mortality of pneumonia has been diminished from 1 in 3 to 1 in 7 cases, then to 1 in 13, and lastly, to 1 in 40 cases. In other words, death from this acute inflammation is now very rare, whereas formerly it occurred in one out of every three cases, a high rate of mortality. I am satisfied also that deaths from acute pericarditis are far less common now than for- merly, and that post-mortem examinations as a consequence, demon- strate adhesions of the pericardium much more frequently. This great improvement in practice, it appears to me, is attributable — 1st, To the greater accuracy with which we can now detect inflammations of the lung and heart ; and 2d, To our better acquaintance with their patho- logy — and the result is not the less certain with men of experience, because these causes operate insensibly to themselves. How often, during the last twenty years, have we been asked, of what use are your stethoscopes, your microscopes, and your chemical analyses at the bedside ? In reply we point to the revolution now going on in the practice of medicine, to the establishment of scientific laws instead of * British and Foreign Medical Review, vol. xxiv, p. 566 ; and Lancet, May 1846 to October 1846. f Boston Medical and Surgical Journal. 1866. THE BLOOD-LETTING CONTROYEESY. 319 empirical rules, and to the abandonment of a palliative in favor of a curative plan of treatment. Note. — F or an account of the blood-letting controversy which followed the author’s enunciation of the preceding views in 1857, he must refer to the last edition of this work, and to the Monthly Medical Journal for the years 1857-58. Conceiving that the lengthened argument then given would now excite little interest, he has consider- ably shortened the text, and placed several of the descriptions of facts under other heads, in order to avoid repetition. So far from retracting anything however of what was then stated, he is bound to say that extended discussion has only tended to con- vince him of the correctness of his statements, which now seems to be tacitly ad- mitted. Anxious however to furnish the most rigorous proof as to the exactitude of his statistics, he will occupy the space gained by the omission of controversial matter, in giving a table containing all the cases of pneumonia he has treated in the Royal Infirmary since the year 1848. This he trusts will satisfy his medical brethren as to the value of his cases, and serve to establish the important practical conclusion to which he has arrived. The recent observations and criticisms of M. Grisolle, in the second edition of that physician’s work on pneumonia will also be referred to. (See Pneumonia.) It would appear, however, that his lecture on the diminished amount of blood- letting, etc., has excited warm discussion in America, France, and in other countries. In the United States more especially Professor Lawson of the Medical College of Ohio, Cincinnati, has distinguished himself by his vehement opposition to the author’s doctrines. He has been spared however from the necessity of replying to it, in con- sequence of a most able and temperate paper published by Dr. llibberd of Richmond, Ind., in the Cincinnati Lancet and Observer for April 1860, in which every one of Professor Lawson’s arguments are refuted. Dr. Hibberd is of opinion that the change of practice in acute inflammations, was initiated by the experience physicians obtained through witnessing the practice of charlatans. Without denying that many physicians, more especially in America, who may have had opportunities of observing such practice, might be predisposed to alter their opinions on that account, I do not believe that such was the case to any extent in this country. I am satis- fied it was no such observation that induced change in my own views previous to 1848, but that it entirely resulted from a careful study and long-continued research into the nature of the inflammatory process. There is only one point in Professor Lawson’s paper which it is necessary to notice, and this merely to explain an occurrence which has doubtless tended to excite some surprise. Referring to the author, Professor Lawson concludes his paper by saying, “ Inflammation came stealthily upon him, when lo ! Dr. Bennett’s case demands blood-letting ! His colleague. Professor Miller, informs us that his sthenic constitu- tion nobly sustained depletion. Thus, the hand of Providence becomes a more potent teacher than statistical tables or microscopical revelations.” Dr. Hibberd observes of this passage, “ The inference is, that God afflicted Professor Bennett with inflammation as the most efficient means of convincing him of the error of his thera- peutical opinions. Passing by the impiousness of this sentence, there are two other reasons why it should not have been written. In the first place. Professor Bennett admits that bleeding relieves pain, and is proper for that purpose, if it can be so used, without protracting the disease or retarding convalescence ; and, secondly, when he placed himself under the care of Professor Miller, he was, doubtless, treated according to Professor Miller’s views, and not his own.” The facts are, that having in 1858 been attacked by a slight pleurisy in the left side, the author was induced by his medical attendant (who was not Professor Miller) to try the effect of applying six leeches for the relief of his pain. Only four of the leeches took blood, and he might have lost altogether about two ounces. Certainly he obtained no relief of any kind from the operation. The blood-letting controversy was then at its height, and the rumor that the author had himself been bled for a pleurisy, was too good a joke to be lost sight of. Accordingly, it may be judged with what intense amusement the following passage was received by the Medico-Chirurgical Society, when, in his valedictory address. Professor Miller said, “ The antiphlogistic abstraction of blood has not wholly ceased in the skilful practice of medicine and surgery. Even in the former, cases ever and anon emerge — though much less frequently than of yore — in which bleeding is greatly conducive, if not 820 GENERAL THERAPEUTICS. absolutely essential, to speedy and satisfactory cure. We grieve to think that this fact has recently met a confirmation in the personal experience of the very Coryphseus of the abolitionists. We grieve that for such a malady he should have needed such a remedy ; and yet we are glad to be assured thus certainly of what, from his ante- cedents, we had confidently predicted, that his system remains wholly of the sthenic type,— not only permitting but demanding the heroic remedy, and bearing its applica- tion with perfect impunity. Long be it so ! ” AN INQUIRY INTO OUR PRESENT MEANS OE TREATMENT. The recent advances in diagnosis and pathology have not failed to suggest to medical men the reasonableness or unreasonableness of former modes of treatment, for when the principles which guided our prede- cessors were shown to be incorrect, there was every reason to suppose that their practice was incorrect also. Accordingly, modern experience has demonstrated that many of those rules for treating various disorders which were almost universally sanctioned by the profession twenty years ago, are not applicable, and that the properties ascribed by tradition to numerous drugs are, in not a few cases, fabulous. The time, therefore, has now arrived for ascertaining the results of former teaching and of past empirical observations, so that we may not only continue to study disease at the bed-side, with all the aids of our existing knowledge, but do what we can to arrive at other and better rules of practice for the future. To this end I propose making a few observations on the means of treatment at our disposal, arranged under the three heads of Dietetica, Hygienica, and Materia Medica. Dietetica. It has been previously stated that of all the means of cure at our command, a regulation of the quantity and quality of the diet is by far the most powerful (p. 126). So little, however, has this fact been con- sidered, that, generally speaking, food has been too little regarded as a remedial agent. In many histories of disease, and in most of our re- corded cases, no notice whatever is taken of the diet, all the improve- ment being ascribed to the drugs administered. There can be no question, however, that there are many diseases that require nothing more than a properly regulated diet to secure their removal, and one of the next great advances in our art will be a knowledge of what those diseases are. We may consider this subject under the two heads of food and drink. Food . — Several of those diseases formerly treated by antiphlogistics are now ascertained to be removable by introducing at the proper time a carefully graduated nutritious food. Among these I would class the great majority of inflammations, internal and external; the essential and eruptive fevers, and numerous nervous diseases characterised by delirium, convulsion, and perversion of sense. A considerable number of disorders arising from morbid poisons require the body to be supported until the poison has time to be eliminated. This is the explanation of many recoveries from small-pox, measles, and similar alfections. The same treatment applies to poisoning by opium, mercury, lead, alcohol, and the DIETETICA. 321 like, all attempts to discover antidotes having failed, as we shall subse- quently see. For many years my only treatment for delirium tremens has been the administration gradually of nutritive substances, and almost every uncomplicated case now recovers. (See Delirium Tremens.) There are other diseases which are curable by adding to or sub- tracting from the diet those constituents of the food whieli have been in diminution or excess. The whole class of scrofulous and tubercular diseases appears to me to be of this kind. They originate in deficient or imperfect nutrition, in which we find non-assimilatioii of fatty matters to be the faulty ehmaut. These we supply either directly in the form of cod-liver oil, or by milk, eggs, bacon, and other substances rich in fat. Cod-liver oil, therefore, may be regarded as a dietetic remedy. In the same way scurvy breaks out from deficiency of fresh animal or vegetable food. In supplying lemon-juice and fresh vegetables, we simply restore to the diet what was deficient, and thereby cure the disease. In the Perth Penitentiary, Dr. Christison discovered that scurvy originated among the prisoners from substituting treacle for fresh milk. On re- storing the latter fluid the malady was removed. In the same manner numerous diseases originate in an excess, either of the whole or of particular substances in food. A too highly animal- ized diet predisposes to gout and plethora. Indulgence in wine or spirits leads to indigestion and various diseases. The constant drinking of tea excites the nervous system, and so on. Abstinence in such cases from the exciting cau^e is often sufficient for the cure. In other cases, promoting exercise, or stimulating some excretion or secretion to remove the residue of digestion becomes necessary, in accordance with the physiological knowledge of the function of nutrition previously detailed (p. 124 ) It is enough to have here indicated how a regulation of the diet is remedial and directly curative of many diseases. It should not, there- fore, any longer be considered as subordinate to a treatment by drugs, but recognised as a principal means of cure in many of our severest dis- eases. The notion that whatever is cured by diet is cured by nature, independent of the assistance of the physician, is erroneous. In one sense, it is true, all diseases are cured by nature. But it often requires a higher medical knowledge to regulate diet in special disease in order to promote recovery insensibly, than it does to give drugs which produce more evident, though perhaps less efficacious results. Indeed, the con- stant recourse to drugs to remove symptoms, though they may cause tem- porary relief, not unfrequently ends in rendering the latter permanent, and even produces lesions that did not previously exist, of which the abuse of purgatives offers constant examples. The recent researches of Dr. E. Smith have exhibited the great in- sufficiency of the knowledge which prevails as to what constitutes a good and sufficient diet, for individuals under varied circumstances — especially for soldiers, sailors, laborers, })risoners, and paupers. Not only are the diets of these classes often improper, but young persons at our schools — public and private — are too frequently underfed at a period when growth requires abundant nourishment. The mistaken prejudices of some parents, also, have led them in many cases to restrict their children’s food, with the idea of benefitmg them, but with the effect, in 21 322 GENERAL THERAPEUTICS. fact, of producing a constitutional debility under which sooner or later they have all sunk. The public ignorance of dietetics has recently been well illustrated by their rash adoption of a system recommended to them to reduce obesity by a Mr. Banting. Had this gentleman been a medical or scientitic man, it is probable that not the slightest attention would have been paid to his suggestions ; but for no better reason than because he is neither the one nor the other, his system has been largely adopted, and the experiment thus presented to us has shown that what proved beneticial to one person, has greatly shaken the health of numer- ous othei s for whom it was not adapted. These and similar facts can only tend to convince us of the paramount importance of diet, not only in preserving health, but when correctly used, in curing disease. An exact knowledge, however, of the therapeutical effects of diet, including the albuminous, fatty, and mineral constituents of food, wheth- ■ er animal or vegetable, and of the various kinds of drinks, is yet to be arrived at. For certain physiological generalizations regarding it, I must refer to p. 125 ; but these are far from pertect. What we require to learn is the influence of the various substances which enter into our food on the molecular constituents of the tissues, as well as the chemi- cal and structural metamorphoses these undergo during the acts of as- similation, secretion, and excretion. As our investigations proceed, these will be rendered apparent, and then we shall be better prepared to determine in what way dietetic substances may be en)ployed in the treatment of pathological conditions. Attention in recent times has been strongly directed to this topic, and I trust its practical bearing, not only in reference to nutrition, but as a means of preventing and of curing disease, will constantly be kept in view. Drinks . — Under this head we may consider — 1st, Nutritive cbhiks, including milk, soup, broths, as well as farinaceous and mucilaginous drinks. These are liquid or diluted food, the stomach having first to absorb the water, and then act upon the residue as it does upon solid food. On this account they are not applicable for use in certain cases of indigestion; where the gastric juice is deficient, or secreted with diffi- culty. 2d, Alcoholic drinks.^ including beer, wine, and spirits. Great discussion has taken place as to whether these beverages are nutritive or only stimulant; that is, whether their carbonaceous elements enter into new combinations with the tissues, and support growth, or wdiether the alcohol is excreted as alcohol, undergoing no change in the animal economy. It is admitted that much of the alcohol is exhaled or passes out of the body unchanged, but all that enters cannot be shown to do so. However this discussion may terminate, there can be little doubt that these drinks are of great importance in a therapeutic point of view, most persons allowing that they are useful as medicines in disease, even should they be injurious or unnecessary as food in health. In all ex- hausted conditions of the body, whether from acute or chronic disease, they frequently support the system under circumstances in which food, or even nutritive drinks, cannot be tolerated, and their large consumption at present as tonics and restoratives constitutes a leading feature in modern medical practice. 3d, Aromatic or astringent drinks^ include HYGIENICA. 323 tea, coffee, chicory, cocoa, chocolate, and acidulated drinks, such as lemonade. It is a curious fact that in proportion as the use of beer and spirits has diminished among civilized nations, that of tea and coffee has increased. Chemistry has failed in telling us why, and all that physiology informs us is, that they are highly stimulating to the ner- vous system, without the narcotizing effects of alcohol. Like the latter, however, if used to excess, they tend to produce indigestion, diminished appetite and disordered stomach. Their therapeutical effects are most valuable. 4th, Mineral waters. All kinds of water contain in solu- tion certain mineral constituents, and being used as drink, these, on en- tering the body, are absorbed, and form combinations with the animal fluids and tissues. When such constituents are in excess, the term min- eral water has been used ; and as they vary greatly in their chemical composition, so do they in their therapeutical effects, some being laxa- tive, others astringent, some impregnated with earthy salts, others with various metals. Even new metals have been discovered in certain min- eral springs, by means of spectrum analysis, such as coesium, rubidium, thallium, and indium, to minute quantities of which some persons have not failed to ascribe medical virtues. On this point we cannot here enter. We need only remark that in the same manner that improper food is a fertile source of disease, so is an impure or bad water, to which also in recent times the attention of sanitarians has been strongly directed. Hygienica. Under this head I would group numerous physical conditions, neces- sary not only for maintaining animal life, but for preserving it in a state of health. These conditions also, though not neglected, lave been too much undervalued by medical practitioners, who, in their desire to discover remedies in the materia medica, have too often overlooked those causes of disease, the removal of which is the obvious method of induc- ing recovery. I can only venture to allude shortly to the more impor- tant of these. Exercise . — The necessity of keeping the muscular system in a suffi- ciently active condition must be obvious to the physiologist, who is acquainted with the fact that the constant pressure thus kept up upon the veins is one of the direct forces which secures the return of venous blood to the heart. But in connection with this important influence on the circulation, we must consider its effect on the respiration, the condition of the blood, and nutrition generally, and through that on animal heat. Then muscular exercise involves a certain expenditure of the contractile, electrical, and nervous forces, while it more or less in- fluences the mental powers. We observe that persons who spend their lives in bodily labor are for the most part incapacitated for mental exer- tion, whilst such, on the other hand, as overstrain the intellectual facul- ties, are generally thin, weak, and indisposed to personal activity. In medical practice we are constantly meeting with ill health originating from a disturbance of the correct balance which ought to be preserved between a certain amount of muscular exertion and the strength of the 324 GENERAL THERAPEUTICS. individual. It may be in excess or in diminution, may be general or local. In cases of debility, either of the whole or part of the body, various kinds of exercise have been enjoined, and will be found detailed in special works on this subject. Its benefit in different kinds of dis- tortion in the young is unquestionable. In the numerous forms of dys- pepsia and weakness, originating in too much application to business or sedentary employments, as a stimulant to appetite in cachectic maladies, in cases of paralysis and innumerable other forms of disease, active exercises, such as walking, riding, running, swimming, climbing, gym- nastics generally, etc. etc., are most beneficial. In other instances passive exercise has been found useful, as in driving, having the body shampooed, kneaded, rubbed, etc. etc. To enter into the multi- tudinous modes in which exercise, active or passive, is applicable as a therapeutic agent, is here impossible. They will be found detailed at great length in works on Hygiene, and as a system of treatment for almost every known malady, they have been treated of by Ling and others under the name of kenisipathy — (Kevew, to move ; Traces, disease.) Best . — In the economy of the organized world, we especially observe that periods of activity alternate with periods of repose. This depends upon the circumstance that action produces waste of tissue, and hence the necessity of pause in action, in order that substance may be added. All growth and secretion seem to proceed by a succession of actions and pauses. The movements of the heart, which appears to be continually beating, really consist of contractions, relaxations, and pauses, which follow each other in regular order. The functions of the nervous system follow the same law. After exercising the powers of thought, after the reception of sensations or the performance of voluntary motion for any time, we are not only disposed, but are imperatively obliged, to submit to their suspension for a certain period. This state of suspension is sleep. . On awaking we feel refreshed, — new strength is imparted to the muscles, higher sensibility to the nerves, and greater power to the mind. Now, disease is also a state of action, and more especially predisposes to waste of tissue, so that not only is exercise opposed, but rest is conducive, to recovery. Nothing so rapidly exhausts the body as a high fever. To Mr. Hilton we are indebted for an excellent work, entitled, “ On the Influence of Mechanical and Physiological Rest in the Treatment of Accidents and Surgical Diseases,” etc., the perusal of which I strongly recommend to you ; therein, also, he alludes to the diagnostic value of pain. I believe a very interesting chapter might also be written on the therapeutical value of pain, which, in many cases, by constraining the individual to keep motionless, thereby provides for that rest so necessary for recovery. But the principle or rule treated of by Mr. Hilton as a surgeon, admits of equally wide application in medical practice. In- ternal organs, when diseased, should for the most part not be called into action. Sometimes, however, this is necessary ; when, for example, in order to remove mechanical obstruction, we must stimulate them, as in the case of constipation, or blocking up of the renal tubes. No wider error prevails among mankind than the idea that incipient disease HYGIENICA. 325 of a part being manifested, continued or increased exertion may get rid of it. Among the laboring population, as we find them in our hospitals, how often are pneumonias and other severe disorders neglected in the beginning, under the hope that they will go away ? They continue their exhausting labor, struggle against the disease as long as possible, and when at length they are obliged to yield, the morbid condition is intensified, whilst there is diminished vital force to resist the evil. Such are the worst and most tedious cases of recovery from acute aifec- tions iUv*t with. On the other hand, cessation from exhausting pursuits, and immediately g >ing to bed and remaining there, are, under similarcir- cumstances, the best aids to successful treatment. Another idea of rest should not be overlooked, viz. — that implied in giving repose to one organ by calling others into action, as is exemplified by the pleasure ex- cited in the minds of those employed in bodily labor or monotonous toil, by literary pursuits, or change of scene. Or, again, the refreshment and invigorating result of walking, rowing, or other muscular exertion, to those condemned to sedentary employment or long-continued mental labor. Thus it may happen that, to some men, true rest consists in digging a garden or climbing a mountain — in having a hard day’s sport, or taking a long journey. Climate . — The influence of climate in therapeutics, involves the con- sideration of many circumstances connected with the physical condition of numerous localities, such as their dryness or humidity, the purity of the atmosphere, t|ie amount of wind, equability or changes in temperature, the elevation or depression of the land, its geological formation, quality of the springs, nature of the vegetation, etc. etc., which cannot, from its extent, be entered upon in this place. At the same time, there can be n ) doubt that the production and progress of diseases are greatly in- fluenced by locality, some existing in one place, while they are absent in another. It may also be observed that particular circumstances in a 1 )cality have modified existing disorders, have banished some and intro- duced others. Thus, draining the various lochs and marshes that for- merly existed in Edinburgh, has entirely removed intermittent fever, which used to prevail, while, within the last twenty years, we have seen typhoid fever become common, which was formerly unknown. The geographical distribution of disease is a subject which has scarcely been studied medically, although the labors of Mr. Keith Johnston of this city have done much to introduce it to the notice of scientific men. The wide possessions of the British empire have made us familiar with the fatal or injurious effects upon Europeans of a residence in particular localities, more especially in the swampy plains of the East and West Indies, on the coasts, and in the interior of tropical Africa, in the more temperate regions of Australia, and in the prolonged winter and extreme cold of North America. The public and private enterprising spirit of the nation, has also led to numerous exploring expeditions in all parts of the world, which have exhibited to us under what opposing conditions of climate and surrounding circumstances man may contrive to exist. But when, in any given case, the question comes to be, to what place 326 GENERAL THERAPEUTICS. you shall send your patient in order to save or prolong his life, it -must be confessed we are often puzzled by contradictory or erroneous informa- tion. When in foreign countries, the health becomes impaired from the long excessive heat, a return home for a period is the obvious proceeding. When malaria causes fever in swampy jungles or pestiferous marshes, hastening from the spot to healthy plains or to the open sea becomes necessary. And when, in our own country, the question arises, where we shall send the consumptive patient, in order to avoid our changeable climate and cold winter winds, in winter, we naturally say, to a land where, during that portion of the year, the weather is warm and equable. On this point, I shall speak at length under the general treatment of phthisis, to which I must refer the reader, as well as to the numerous works written on climatology. Ventilation . — I believe that a proper ventilation of the rooms, and especially of the sleeping rooms, occupied by invalids is a matter of the greatest importance in treatment. The prevalent notion that coughs and colds, sore throat, and indeed most diseases, should be combated by wrapping up, confinement to close heated apartments, or to beds sur- rounded by curtains, is most injurious. A perfect oxygenation of the blood by the introduction of pure air into the lungs is not only neces- sary to healthy persons, but is especially so to those who are unhealthy. When it is considered that most persons spend one-third of their life in bed, the importance of breathing a pure air during that long period must become evident. Yet how frequently do we see families make great sacrifices to obtain what is called fresh air, by going into the country for some months or weeks every year, yet when there crowd three or four persons together in confined sleeping-rooms. They get their fresh air, it is true, in the day, but never think of avoiding foul air at night. In bronchitic and phthisical cases, the relief experienced by sleeping all night with the window slightly open at the top, is often remarkable, as was first pointed out by Dr. M’Cormack of Belfast. On this account I have satisfied myself of the great superiority, as means of ventilation, of the sash windows in England over the windows formed of two lateral halves, opening side ways, so common on the continent. On the other hand, while securing free air, the utmost care should be taken to avoid draughts, and violent currents of wind so frequently encountered in foreign hotels, with long corridors, and doors exactly facing the windows. Although much still remains to be done notwithstanding the labors of Arnot and others in bringing about a perfect system of ventilation in English houses, they must be admitted to be more comfortable, and by means of their sash windows capable of renewing fresh air with less risk to the delicate than what exists elsewhere. In Italy, where the climate is so fine, the houses are too often unbearable. Heat and Gold . — The influence of the atmospheric temperature belongs essentially to climate. Here, I shall only refer to the therapeutic effects of heat and cold applied locally. In this respect they operate in three -^ays — 1st, As stimulating or retarding growth ; 2d, As alleviating pain ; and, 3d, As a nervous stimulant, or sedative. An elevated temperature, HYGIENIC A. 327 especially when combined with moisture, is well known to favor growth both in the vegetable and animal worlds, and thus I pointed out many years ago — (Treatise on Inflammation) — is to be explained how warm poultices favor suppuration, that is, the growth of pus cells. On the other hand, cold and a low temperature are opposed to growth, and act as astringents, and hence why their application immediately after the receipt of blows or injuries restrains inflam- matory action, and checks exudation and its subsequent development. The immediate good effect of cold water applied to the eye, when it has been irritated by dust or sand, is a good example of the therapeutic action of cold. The influence of cold and heat in alleviating pain is difficult to explain, especially how in some cases a diminished, and in others an elevated temperature causes so much relief Thus some kinds of cepha- lalgia 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 headache, as gently pouring cold water over the scalp. In other cases, apparently similar, it is warmth which operates. I was summoned to a married lady who, during the day, had expe- rienced 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 what- ever. 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 preg- nant. The only practical rule I know as to this matter is, if cold fails, to try warmth. Most assuredly, as alleviators of local pain they are among the most powerful means possessed by the physician. Both heat and cold in excels, by their application to the skin, may be made either stimulative or sedative. Thus the actual cautery acts as a counter-irritant, and exposure of any part of the surface to a high temperature causes redness and congestion of the part. In this manner heat excites the functions of organs, and favors the external flow of blood, as in menstruation, or after the application of leeches. In the same manner the sudden application of cold is one of the most powerful exciters of reflex action. Dashing cold water on the face or breast excites inspiration, and favors recovery from syncope or apnoea. The slow and long- continued action of these same agents is sedative, the tendency to somnolence in warm weather, or in front of a good fire, and the benumbing effects of cold are well known. Dr. James Arnott has ably pointed out that congelation of parts from intense cold constitutes a means of producing insensibility in surgical operations, without the danger arising from the inhalation of narcotic vapors. Clothing . — Medical men have too frequently an opportunity of ob- serving not only how habitually deficient or improper clothing is a cause of disease, but in satisfying themselves how under certain circum- 328 GENEEAL THERAPEUTICS. stances extra clothing is often therapeutic. The carelessness of young and delicate women at balls and parties, renders it necessary to caution them as to shawls and coverings. In bronchitis a piece of flannel worn over the chest, and in rheumatism over the shoulders, have ameliorated and even removed these aifections. Respirators are, in truth, extra pieces of clothing, and carrying a shawl in the hand to protect the face from wind or cold chills, is at once preventive of accessions of cough. Keeping the lower extremities warm also, when driving or riding, may prevent or check disease. Bathing. — From the earliest times bathing has been employed as conducive to health, as a means of cleanliness and as securing the proper action of the skin. In recent times it has been more attended to than ever, and even raised into a special system of treatment for almost every malady, under the name of hydropathy. This, however, also includes attention to dietetic rules, exercise, and even medication when necessary, in consecjuence of which any good effects produced by the system are often attributable to a variety of circumstances not comprised in the meaning of the name it bears. The skin is not an absorbing membrane, and it has been proved by experiment that long immersion of the body in water causes a very trifling addition to its weight. Even with the aid of friction, medicines diffused in grease or oil enter only in minute quantities. The constant application of water to the cutaneous surface, however, care being taken to prevent dryness by a layer of oil-silk, or gutta percha, is emollient, removes irritations, favors the natural secre- tions of the texture, and is highly conducive to slow and perfect healing by granulations, as shown in what is now called the water-dressing of sores. For this reason in 1849"*' I introduced this method of treating vesicular and pustular eruptions of the skin, which I have successfully practised ever since, (See Treatment of Skin Diseases). JJ^arm Baths combine with the effects of water those of warmth, and are highly emollient, soothing to the nervous system, and relaxant. They are taken advantage of to relieve muscular spasm and rigidity, as in the convulsions of children and strangulated heruim of adults. Cold Baths^ on the other hand, if used for a short time, are tonic and astringent, pro- ducing reaction and warmth of the body, but if too long continued, occa- sion all the bad effects of prolonged cold, continued pain, feebleness of pulse and coma. The exercise of swimming in cold water would, to a certain extent, counteract these effects. Affusion — the shoiver hath., the douche^ and washes of various kinds, whether warm, cold, or tepid, are other modes of bathing the surface generally or topically. Mineral Baths — these, like mineral waters, have been greatly extolled, but there are grave doubts whether any salt of an earth or a metal can, to any extent, enter the body in this way, and the same may be said of medi- cated baths. Locally, these latter baths may be useful, as in the case of the alkaline bath which, in certain skin diseases, is directly curative by its superior emollient properties. Vapor Baths have long been em- ployed as sudorifics, and the bath in chambers of heated air called the Turkish bath, has recently been extensively introduced among us. This * Monthly Journal of Medical Science. August 1849. HYGIEXICA. 329 also, after producing perspiration, is combined with friction, shampooing, the tepid and cold douche in a variety of forms. The therapeutical ad- vantages of these baths have yet to be determined. Oil, mud, and numerous other kinds of baths, have been employed in special cases, as well as the electro-chemical bath, by which it has been pretended that mercury, lead, and other metallic poisons may be drawn out of the body. Light . — The remarkable stimulating effect of solar light to the animal and vegetable worlds must also, under certain circumstances, be thera- peutical. It is difficult to estimate this, although its exhilarating influ- ence may often be observed in sick persons. On the other hand, dark- ness is advisable in acute affections of the eye, and in cases of mental irritation. It is also favorable to sleep, and depression of the vital powers. Death most fre(|uently occurs during the night. I was much struck when examining the private asylum of Messrs. Falret and Voisin, some years ago, near Paris, to observe how carefully their melancholic cases were placed in light rooms, with brilliant-colored papers, and that the private garden outside was blooming with the gayest flowers, whereas the maniacal and excitable cases inhabited sombre apartments, while the garden outside was furnished only with dark evergreens. Electricitg . — The living tissues of the body are saturated with saline fluids, whereby the operations of static, galvanic, and electro-magnetic currents easily reach them, producing two orders of phenomena — viz., 1st, chemically decomposing or destructive ; and 2d, alterative or stimulant. In the latter case the peculiar property of each texture is excited by action on its molecular constituents. The sensible effects of electricity, how- ever, are greatly modified by the mode of its application. That is to say, whether the individual subjected to it, be or be not insulated — whether the form of application be that of sparks, shocks, aura, or current — the shape and nature of the electrodes employed — whether the current be continuous, interrupted, or reversed ; its direction, amount, duration, and how introduced or drawn from the economy. Though electricity has been employed empirically in a great variety of diseases since the year 1745, when its accumulation within the Leyden jar was first known, we are still deficient in such exact observations as wdl positively determine its therapeutical value. It would appear, however, to be most useful in the various forms of nervous and muscular paralysis, neuralgia, and different kinds of spasm and convulsion. One of the most interesting facts which the experiments of John Reid demonstrated was, that in cases of muscular paralysis from injury to the nervous system, the muscles will, if left to themselves, become atrophied in a certain time, and lose their contractility ; but if from time to time they be galvanised so as to contract, they will remain contractile and well nourished for months. Hence the importance, in cases of paralysis, of calling the limbs into action from time to time ; and hence the therapeutic effects of electricity in such cases. It is important, however, in applying this agent, to re- member that what is required is its stimulating, and not its exhaustive influence ; and that as the former, if too long continued, produces the latter, so action thus occasioned must be carefully proportioned to the 330 GENEEAL THERAPEUTICS. muscular strength and general health. This has not been sufficiently at- tended to. Many persons have been subjected so long to the influence of an interrupted current that increased weakness rather than vigor has been the result. The proper use of electricity in any of its forms, galvanic orgalvano- magnetic, requires not only a profound knowledge of the natural laws regarding it, but of anatomy and physiology. If applied locally to the muscles, their origin and insertion must be well known to the operator, and if made to act through the nerves, their connection with the nervous centres, their course, anastomoses, and termination, must also be familiar to him. The brilliant researches of Metteuci, Becquerel, but more especially of Du Bois Beymond and his numerous followers, have advanced science by the discovery of many laws which regulate the electrical currents in the muscle and nerve tissues, and the relation of these laws to the vital and physical forces. Among these the following may be considered as important — A single electrical shock may last only the y^^’^^th part of a second, but the muscular shortening reaches its maximum, and returns to its former state in about one-fourth of a second. If two shocks are given, the one immediately after the muscle has returned to a state of rest, then there are two contractions. If the second stroke is given during the muscular movement caused by the first, and there is either contraction or relaxation, it causes increased shortening. But if the second stroke follow very rapidly on the first (that is, within the g i^tli of a second), the shortening is not greater than with one stroke. If several shocks are given before a muscle has time to be relaxed, it becomes hard, and permanently contracted, constituting tetanus. The less fatigued the muscle, the more rapid is the shortening. Interrupted currents or shocks of electricity therefore cause permanent or tetanic spasms in muscle, whether applied directly to itself, or indirectly through a nerve, and the intensity of this will depend on (1) the intensity and rapidity of the cur- rent; (2) the amount of contractile power in the muscle; and (8) the mechanical resistance the muscle may have to overcome, as from the distance or weight of parts to which it may be attached. On the other hand a continuous current of electricity only excites muscular contraction when the electrical circuit is closed or broken. In the interval it seems to flow through the tissue without causing any sensible effect. When a continuous current of electricity is caused to pass through a portion of nerve, it is thrown into a peculiar condition, which Du Bois Beymond called an electro-tonic state. If this current be sent through a portion of a nerve in the same direction as its own proper current, then the latter is increased, as may be shown by the galvanometer ; but if in the opposite direction, it is diminished. Again, where the nerve comes in contact with the positive electrode, the electro-tonic state is diminished {aneletrotonus) ; where it comes in contact with the negative pole, it is increased (catelectrotonus). Between the poles, at the point where the two variations meet (point of indifference), the normal state of the nerve is preserved. Both the increased and diminished excitability of the nerves so caused bear a relation to the force and rapidity of the current. Further, the power of conduction in the nerve is diminished in the state of aneletrotonus ; but on breaking the current, the con- MATERIA MEDICA. 331 ducting power returns there, while it is diminished where formerly it was in the state of catelectrotonos. Hence we can influence the con- tractions of muscles by a continuous current through the nerve, accord- ing to its force and direction. It can also be easily shown that the further from a muscle a motor nerve be irritated, the greater is its ex- citability, so that a feeble current applied to a nerve at a distance from a muscle will excite more contraction than a stronger one applied close to it. The stimulation of sensitive nerves by electricity excites their special functions, on the forming and breaking a circuit in proportion to its amount and rapidity. Hence we can excite pain through the ordi- nary sensitive nerves, flashes of light through the optic, noise through the auditory, and taste through the gustatory nerves. As with muscles also during the interval, no sensible etfect is occasioned. With regard to the proper method of applying electricity in disease, great difference of opinion prevails. Huclienne strongly supports the use of an interrupted current applied locally to the muscles ; while Remak maint.iins the importance of a strong continuous current applied to the nerves and nerve centres. Both modes of procedure require to be more generally tested by experience. In one class of cases originating in the nervous centres, as in hemiplegic paralysis, Remak’s plan may be most useful ; whereas in another class dependent on a primary mor- bid action affecting the muscles, as in saturnine paralysis, that of Duchenne may prove the best. It has also to be ascertained what is owing to direct and what to reflex action during the topical application of electricity. I need scarcely remark that a thorough knowledge of diagnosis should be possessed by him who undertakes the difficult task of employing so powerful, although manageable, an agent for the relief and cure of diseases. On this head medical practitioners should consult the practical works of Remak, Duchenne, Althaus, and Garratt. In concluding this short summary of what may be considered our chief hygienical means of cure, it may be observed, that although their influences on the human economy, in its diseased as well as healthy con- ditions, cannot admit of doubt, there is scarcely any of them with which we are so thoroughly acquainted as to render their application exact in any given class of cases. On the medical applications of nearly any one of them volumes might be written, and several have been raised into sys- tems of treatment, under the names of Kenesipathy, Climatology, Hydro- pathy, Electro-pathy, etc. Their sanative influence on morbid conditions, however, as determined by a careful diagnosis, and by prolonged observa- tion as to their superiority over the natural progress of disease, is a work yet to be accomplished. In this point of view there is still open for the clinical student, favorably circumstanced, an extensive field, which, if properly cultivated, cannot but prove rich in useful therapeutical results. Materia Medic a. By the Materia Medica we understand those agents derived from the animal, vegetable, and mineral worlds, which, forming no essential part of diet, or being necessary to life or health, are used as medicines or reme- 332 GENERAL THERAPEUTICS. dies for tlie relief or cure of diseases. It is to the discovery and employ, ment of these means that medical men have, for the most part, directed their energies, and, in consequence, a multitude of substances have been extolled by some and repudiated by others, with the qualities of which medical men are expected to be familiar. Several of these are of un- questionable value in the treatment of diseases; many of them possess doubtful qualities, which have been ascribed to them by tradition or by long usage, whilst a vast number are positively worthless, if not injuri- ous. Bichat says, “ There have been no general systems in the materia medica ; but this science has been alternately influenced by the prevail- ing theories in physic. From hence proceeds that indefiuiteness and un- certainty which mark it even in the present day. It is an incoherent mass of incoherent opinions, and, probably, of all physiological sciences, that in which the inconsistencies of the human mind are most glaring. What do I say ? It is not a science for a methodical and philosophical mind; it is an incongruous combination of erroneous ideas, observations often puerile, means, at the least fallacious, and formulae as fantastically conceived as they are preposterously combined. It is said, that the practice of com- bined physic has something repelling in it. I will say more : in those principles which connect it with the materia medica, it is absolutely re- volting to a rational mind.”^ Magendie observes that one chemist is in accord with another as to his fundamental facts, and that the pheno- mena observed in his laboratory are the same in Paris as in New York, in London as in Calcutta. But, he adds, it would be a painful task to pass in review the different modes of medical treatment employed in different localities for the same disease. Even in Paris, should an indi- vidual be attacked by typhoid fever, the treatment would vary, accord- ing as he was sent to this or that hospital. f Most of our scientific anatomists and physiologists, like Bichat and Magendie, have continued to distrust the influence of medicines in disease, and have taken too little interest in therapeutics. The consequence has been, that the generality of medical practitioners are educated in a blind faith as to the proper- ties and uses of drugs, a faith which has, in most cases, descended to us from a barbarous age, has become traditional, and possesses no relation to the present state of medical science. All those who have acquainted themselves, in recent times, with what is known of the structure and chemical composition of the tissues, the laws of nutrition, and the pathological changes which occur in organs during disease, must feel astonished at the unfounded assumptions, want of evidence, and even unreasonableness which characterise writings on the action of medicines. They are constantly asking, on what grounds the assertions as to the properties of this drug or that treatment are based, and too frequently can obtain no response whatever. We observe also that what now occurs in our hospitals is so often at variance with such assertions, as to create a wholesome scepticism as to the correctness cf what is taught of the materia medica. As an example of the writings and teachings on this branch of our subject, let us examine the third and last edition of a work by Dr. Head- * General Anatomy, Translated by Coffyn, p, xiv. \ Phenomenes physiques de la vie. Tome 2me, pp. 4 et 6. MATERIA MEDICA. 333 land, which gives what is admitted to be one of the best and most recent systematic accounts of the actions of medicines in our language."^ We may at least regard it as an intelligent and careful resume of the present state of our knowledge. At p. 161, he says : “ Another remedy has been used in all the dis- eases in which quina is admissible, proving in some cases superior and in other instances second only to it in its beneficial action. This is mercury ; used in remittent and yellow fevers ; of the first importance in dysentery ; employed by Dr. Baillie in ague, and pronounced by him to be in some cases superior even to quina. In small doses it is frequently of use in cases of debility and scrofula. And mercury is a cholagogue ; i. e., an agent which is known to have the elfect of promoting the secretory function of the liver.” “ Under such a course, judiciously enforced, we may see the dilated pupil contract to its normal size, and the pale ener- vated countenance become rosy and lively, and feel the weak compressible pulse become hard and firm. Perhaps mercury in such a case may be indirectly tonic, by restoring to the blood the natural tonic principle of the bile.” Again, at p. 213 — ‘‘ Mercury, which restores the secretion of the liver, may be for this reason useful in arthritic diseases.” Here, you will observe, that arguing on the principle that whatever restores to the blood such of its constituents as are deficient is tonic, mercury is recom- mended in cases of debility, scrofula, and gout, because it is a cholagogue. But no facts are given to show that mercury is a cholagogue, and if that assumption be incorrect, its alleged value in those diseases falls to the ground as a speculation, while no cases are given to demonstrate it as a matter of observation. At p. 383, it is said, that mercury has been found in the bile of dogs by Burcheim. But any facts to show that the drug increases the flow of bile, I have vainly sought for. At p. 373, Headland says: “It is by the production of nausea that antimony becomes so valuable an agent in the control of high fevers and acute inflammations. The force of the heart being diminished, the fever is allayed ; and the active congestion of the vascular system, whether local or general, which was produced by the inflammation and maintained by the violent action of the heart, is eff’ectually subdued. At the same time absorption is favored by the removal of the pressure from the capillary circulation.” Here, you observe, it is said that inflammation is cured by nauseants ; that subduing the force of the heart subdues fevers, and so on. I trust you have satisfied yourselves in the clinical wards that all depressants and nauseants are opposed to the correct treatment of inflammations and fevers, and that recoveries take place just in pro- portion as we can support the system, and sustain rather than subdue the heart’s action. At p. 385, we are told that in treating inflammation, “ the imme- diate effect of bloodletting is mechanical ; that of antimony, nervous ; that of mercury, haematic. Bloodletting weakens the force of the heart, by diminishing the pressure on the blood-vessels; antimony diminishes the pressure on the vessels, by weakening the force of the heart ; and mercury does both of these things, by impoverishing the blood.” But it is nowhere shown that any of these drugs either act in the way stated, * London, 1859. 334 GENEEAL THERAPEUTKIS. or cure inflammation at all. So far as modern experience is concerned I hold it on the other hand to be demonstrated, that weakening the pulse, or impoverishing the blood to cure inflammation, is a most fatal practice. I hope you have satisfied yourselves from the results of treat- ment carried on in these wards, that inflammation may be successfully combated without the use of bloodletting, antimony, or mercury. At p. 390, we are told that mercurials “ no doul3t stimulate the for- mation of the pancreatic secretion, which is similar in nature to the saliva.” Now, as to their causing salivation we can have no doubt, because we see it; but as to its causing a flow of pancreatic juice, is it sufl&cient to say there can be no doubt it does, because that fluid resem- bles saliva ? At p. 425, it is said : “ In delirium tremens, and in all cases of delirium unattended with high fever, opium may be said to be our sole reliance.” Our sole reliance ! Why, gentlemen, during this summer ses- sion of three months (1864), you have seen no less than twenty cases of delirium tremens enter my wards — some of them very severe, and yet they have all got perfectly well without the use of opium in any way. Nay more, I will venture to say that this favorable result is in great part attri- butable to no opium having been administered. (See Delirium Tremens.) At p. 284 we are told of hemlock, that its “ paralyzing action on the nerves of motion is directly the reverse of the stimulating action of strychnia; it is thus of use in cases of convulsion and spasm.” Now the poisonous effects of hemlock are very peculiar, paralyzing motion from the feet upwards, as was shown in the case of Socrates, and in another well observed case I have myself recorded subsequently in this work, whereas strychnia produces no such progressive effect in any direc- tion. Neither is there one single fact in the annals of medicine which proves that hemlock is of the slightest use in such convulsions and spasms as strychnine produces. I should weary you by further quotations from a book, which, excellent as it is in many respects, is replete with similar statements. Look at any other work on the same subject, and you will find the like kind of asser- tions equally at variance with the present state of our knowledge.* But if objections, such as we have ventured to offer, can be made to carefully prepared works on therapeutics, by gentlemen who have made that sub- ject a careful study, what confidence can be placed in the assertion of practitioners generally, or of hopeful young men entering into the pro- fession. Only read the accounts of distinguished medical men, teachers, and hospital practitioners, men of large experience, as to the effects of bloodletting and other remedies, and then compare them with what you * For example — nothing can be more opposed to the present state of our know- ledge and to the numerous facts contained in this work, than the following sentences which meet us in the first few pages of a work published in 1860, by another distin- guished author on Therapeutics, Dr. Stille : — “ It is not pretended that any human resources can secure the arrest of tubercle” (p. 41). “Depletion everywhere modi- fies, at least, the forming stage of inflammation ; mercury everywhere acts upon its products ” (p. 48). “ Depletion is held to be the capital remedy for pneumonia, and experience has for centuries appeared to agree with reason in sanctioning this prac- tice” (p. 49). CURATIVE ACTION OF REMEDIES. 335 have seen with your own eyes of the successful treatment of inflamma- tions m the clinical wards. Andral tells 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 con- dition of the pulse, no apparent debility of system, no age, which forbids its practice.” Alison no less emphatically says : “No proposition in medical science is more certain, and certainly none more practically im- portant than that which regards the power of large and repeated blood- letting to arrest the progress of inflammation in its early stage.” “ In pneumonia, the utmost confidence may be placed in general bleeding, which should always be large and almost always repeated.” Now, the proposition which my experience has demonstrated in the clinical wards of the Royal Infirmary, is the very converse to this, and that is, that the rate of mortality in inflammations, and especially in pneumonia is large, just in proportion to the amount of bloodletting and of other antiphlogistic remedies employed. So powerful and so persistent, how- ever, have been the doctrines of the past, that notwithstanding the facts, which I made public in 1857 as to my results in the treatment of pneumonia, and notwithstanding the fact that an antiphlogistic practice in this country is almost universally abandoned, every systematic and compiled work on medicine up to this date (1861) still recommends for that disease bloodletting, to be followed by the administration of anti- mony and calomel. Looking therefore at the discrepancy which exists between systematic teachings and writings on the one hand, and the actual practice in our hospital wards and in private on the other, as to the employment of the materia medica in disease — regarding also the differences of opinion which exist among practitioners of the highest respectability and expe- rience, it will be admitted to be a difficult task to determine what posi- tive knowledge we possess of the value of drugs. Still, I think the time has arrived for attempting it, and, in doing so, I have only to assure you that my views on this subject are the result of long and anxious consideration. I shall describe what is known first of their curative, and, secondly, of their physiological action. First, then, are there any drugs or medical preparations whose effects are unquestionably beneficial in particular diseases ? I think there are, as witnessed by the influence of — 1, Quinine in ague ; 2, Pitch ointment in psoriasis ; 3, Male shield-fern in tape-worm ; and 4, Sulphur ointment in scabies. I think no one who has used these remedies in the diseases named can doubt their curative power as a matter of fact, however they may differ as to the mode of their action. Of a similar unquestionable char- acter are the following, although, for the reasons previously stated, the two first should be placed among the dietetica, and the third among the hygienica. They are — 5, Cod-liver oil in scrofulous and tubercular dis- eases ; 6, Lemon juice in scurvy ; and 7, Constant moisture in eczema' tons and impetiginous diseases of the skin. These seven remedies I put into the first, and the following in the second class — 8, Colchicum in acute gout ; 9, Iodide of potassium in certain forms of periostitis; 10, Iron in chlorosis and amenorrhoea; 336 GENEKAL THERAPEUTICS. 11, Arsenic in scaly skin diseases ; 12, Copaiba and cubebs in gonorrhoea; 13, Nitro-inuriatic acid in oxaluria; 14, Supertartrate of potass in Bright’s disease, with diminished urine and dropsy; and 15, Oils and fats in para’ sitic diseases of the skin. These remedies, though not so valuable, must, I think, be admitted to be also curative in certain cases, by the majority of practitioners. As to bloodletting in inflammation, mercury in syphilis, and iodine in scrofula, I consider their \alue, though highly lauded by some, to be more than questionable. The fifteen remedies named, therefore, I consider to constitute all the positive agents we possess capable of curing diseases or morbid states when they are once fairly established. Many other drugs relieve symp- toms — are palliative and most useful during our treatment of disorders — but, I repeat, as curative^ I shall only be too happy to hear of any I have omitted. But there are other agents which, although they do not possess direct curative powers, remove pain and particular symptoms, and enable us, with the assistance of the dietctica and hygienica, indirectly to bring about recovery. Among these may be cited — Bismuth and alkalies in heartburn; Purgatives in constipation ; Opium, chalk, and astringents in diarrhoea; Etbers in asthmatic dyspioea; Naphtha and hydrocyanic acid in dyspeptic vomiting; Narcotics in local pain; Chloroform in sus- pending sensation ; Belladonna and the Calabar Bean in certain diseases of the eye; Santonine in ascarides; Counter-irritants, in various kinds of local pain ; and small Bloodlettings in aneurisms, pulmonary conges- tions, and hypertrophied heart. To these may be added, certain essen- tial Oils, and Assafoetida, in flatulence — Sudorifics and Diuretics to meet peculiar indications — Nitrate oi Silver locally in ulcers, etc. etc. Such, then, are the chief articles of the materia medical am acquainted with that can be shown to be of direct therapeutical value — discovered during the last two or three thousand years by the medical practitioners of civilized nations. To some this result may appear to be insignificant, but by those who are capable of appreciating the difficulty of establish- ing the therapeutical value of medicines, it will be admitted that the use of these remedies has proved of incalculable benefit to mankind. In the second place, let us consider what is known of the action of the materia medica on the functions of the various tissues and organs of the body in a state of health. Action of Medicines on the Ultimate Elements of the Tissues. Molecular elements. — We have no drugs, properly so called, capable of influencing the activity of the molecular element of the body, unless we include cod-liver oil, which increases the molecular constituents of the chyle, but which, for reasons previously stated, we class among the dietetica. In one sense it is true it may with reason be maintained that all medicines operate on this element of structure. This, as a theory of the ultimate action of drugs, will be referred to subsequently. The cell elements. — Beyond what we are acquainted with, concern- ing the albuminous, fatty, and mineral elements, which enter into the PHYSIOLOGICAL ACTION OF REMEDIES. 337 structure of cells, we are ignorant of any medicinal substances known to affect them especially. The tubular elements. — The nerve tubes are differently affected by numerous substances, which we shall refer to under the head of nervous system — and the minute blood tubes are especially dilated by a new sub- stance — the nitrate of amyle — which Dr. Richardson has shown experi- mentally to have this property. Fibrous elements. — We have no knowledge of any especial agents which act upon the molecular, areolar, or elastic fibrous tissues. The muscular and probably other contractile fibres, generally are supposed capable of being influenced by a class of remedies called tonics. But when we investigate closely into what this tonic property consists, we find it to be anything which removes debility. Hence it has been ascribed to stimulants, nutrients, vegetable bitters, and mineral salts, and great discussion has arisen whether these operate through the nervous system or through the circulation — whether they stimulate appetite or impart directly restorative qualities to the blood — the truth is we know little or nothing on these topics of a positive character, and may rest assured that nutritive food and proper exercise are the real agents through which strength is imparted to the muscular system. Cartilaginous and osseous tissues. — These textures have the peculiar property of separating from the blood and fixing large quantities of mineral matter, which, of course, must enter the body in the tood and drink. Of any method of increasing or modifying this peculiar pro- perty we are profoundly ignorant. Therapeutists generally in their writings, although certainly not de- ficient in all sorts of theories as to the actions of medicines, have cultivated very little a knowledge of the ultimate composition or structure of those tissues or organs on which their remedies operate. This is one of the reasons why their views give such little satisfaction to the modern scientific inquirer. Action of Medicines on the Nervous System. Many articles of the materia medica produce decided effects upon dif- ferent parts of the nervous system, stimulating or perverting some, and destroying or suspending others. From the circumstance also that these effects have, to a great extent, been largely studied by physiologists, as the result of experimental investigation, our knowledge with regard to them is much more precise than it is with respect to many other drugs. They have been classified according to their stimulating, narcotic, or seda- tive properties, understanding by stimulant, what excites nervous func- tions, by narcotic., what first increases, then depresses it, and by sedative., what depresses it. I shall refer to them, however, according as their action principally affects the brain, spinal cord, or nerves. Cerebral f unctions. — These are influenced 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 exciters of the cerebral functions, and cause sleeplessness. Alco- 22 J38 GENERAL THERAPEUTICS. holic drinks^ ether^ 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 unscientifically denominated an- aesthetics. The fact is, they influence local sensibility, or the sense of touch very slightly if at all. Their action is cerebral, and in large doses spinal. Hence the danger which occasionally attends their action. Spinal functions. — Strxjchnine acts especially as an exciter of the motor filaments of the spinal cord, causing tonic muscular contractions, as in tetanus from spinal arachnitis, or from the irritation of a wound. Worari produces exactly an opposite effect, causing paralysis and reso- lution of the same parts. Conium paralyses the motor and sensitive spinal nerves, produciug paraplegia, commencing at the feet and creeping ’Upwards. (See case of Duncan Gow, p. 460.) Picrotoxine^ according to Dr. Mortimer Glover, causes the animal to stagger backwards, as in the experiments of Magendie on the Crura Cerebelli. Tobacco is a powerful sedative and depresses all the spinal functions. Cerehro- Spinal functions. — Ilxjdrocxjanic acid in poisonous doses, acts ^conjointly on the cerebrum and spinal cord. All the animals 1 have seen killed by this agent utter a scream, lose their consciousness, and are convulsed. These are the symptoms of epilepsy. Cold is at first an exciter of the spinal functions, and is a strong stimulant to diastaltic activity, but, if long continued, produces drowsiness and stupor. Neuro and Neuro-Spinal functions. — These are especially affected by the action of certain metallic poisons, such as mercury., which occasions irregular muscular action with weakness, and lead, which causes numb- ness and palsy, most common in the hands. On the other hand, caxi- tharides stimulates the contractions of the neck of the urinary bladder, and secale cornutum those of the pregnant uterus. Stramonium acts as a sedative to the nerves of the bronchi. Aconite operates powerfully in paralysing the action of the heart, through the cardiac nerves of the vagus, while antimony excites vomiting by acting on the gastric and other branches of the same nerve. Belladonna also has a peculiar local influence in causing dilatation of the pupil, while the Calalar lean has the opposite effect, producing its contraction. The secretion of the lachrymal gland is increased by the pungent emanations from onioxi, garlic, squill, and mustard. Organic Nerve Functions. — It is now some years since I put forth the idea that qxiinine, salieine, and the allied compounds, have a special influence over the sympathetic or ganglionic system of nerves, controlling and exciting their power, and thus influencing those periodical functions connected with nutrition, secretion, and growth. The experiments of Bernard, Brown-Sequard, and others, have now proved that these are in- timately connected with this part of the nervous system — irritation of these nerves causing cold and pallor, while section or destruction of them induces increased heat and redness, Pereira supposed that stimulants and sedatives especially acted upon this system of nerves, but, unques- tionably, they also act on the brain. Jt must be further observed that, although the primary action of PHYSIOLOGICAL ACTION OF REMEDIES. 339 these narcotic medicines is such as I have stated, that in large doses their influence is more extended, and their operation is more diffused over the nervous system. Thus, chloroform may not only act on the brain, but on the spinal cord. It is very probable also that most of the medicines which have an unequivocal action on special organs, do so by operating on the nerves distributed to them, through the medium of the blood. Action of Medicines on the Respiratory System. Diffusible stimulants, more especially the ethers, have an unques- tionable effect in checking or relieving dyspnoea, which is probably owing to their action on the heart and circulation generally, rather than on the lungs specially. Whether there is such a medicine as a true expectorant, that is, one capable of increasing the secretion from the bronchial mucous membrane, is, in my opinion, quite uncertain. Even Headland admits, that, on this point, no investigation has been made (p. 325). That antimony, ipecacuanha, squill, and other drugs possess this property, however, has been so generally assumed, that they are constantly em- ployed in all cases of cough, with or without expectoration, and lengthened discussions have occurred as to whether such remedies act on the glands of the mucous membrane, or upon the muscular fibres of the bronchial tube. In the meantime, the uncertainty of their action is admitted, and there are no series of observations extant, so far as I am aware, which prove that they act at all. The lungs have been made the vehicle for the introduction of medicines in a state of vapor from ancient times, and the discovery of the effects of ether in producing insensibility to pain has only served to extend the practice. Action of Medicines on the Circulatory System. Numerous remedies have been employed for the express purpose of diminishing and increasing the rapidity of the circulation and the force of the pulse, as well as the quantity and quality of the blood. This can be done directly by bloodletting and starvation on the one hand, and by stimulants and generous diet on the other. Certain drugs are supposed to have an especial action on the nerves of the heart, more especially aconite and digitalis. Veratrum viride has recently been extolled as being capable of diminishing the force of the pulse, which I have myself seen it do, by acting as a depressing acrid poison to the system generally. Other remedies are imagined to act on the capillary circulation when ruptured, and to be capable of arresting haemorrhage from them ; among these are acetate of lead and gallic acid- But how these drugs, intro- duced into the stomach, should produce this effect, has never been shown, and there are no series of observations which establish their alleged influence, although, as in the case of expectorants, the assump- tion is generally acted upon. The Blood. — All soluble remedies introduced into the economy are absorbed into the blood. They may act on the nerves or distinct parts through it, but there are some which act upon the blood itself, adding to or detracting from its constituents. The former are restoratives^ the 340 GENERAL THERAPEUTICS.' latter are named by Headland catalytics. Among the former we must never forget that aliment holds the first place, and that it is by restoring what is deficient, or detracting from what is in excess in the diet, that many medicines operate ; as when cod-liver oil is given in scrofula, or lemon-juice in scurvy. To exactly the same principle I would refer the operations of alkalies and acids, which, by forming new combinations in the blood, serve to restore or correct morbid conditions of that fluid. The same may be said of salines and of chalybeates. It should be ob- served, however, that several of these remedies can only be considered restorative, on being added to the blood in proportion somewhat similar to what exists in health ; but that, if introduced in excess, so far from being beneficial, they are absolutely destructive. In cholera, for instance, it was shown by Dr. Stevens that the saline constituents of the blood were greatly diminished. They were, in consequence, dissolved in water, and large quantities of the solution injected into the veins. The efi'ect appeared, at first, to be miraculous : persons on the point of death recovering in a wonderful manner. But as excess of water and saline matter dissolves the blood corpuscles, all these persons, after a few hours, again sank and died. In their attempts to introduce chemical remedies and form chemical combinations, therapeutists have too often overlooked the fact, that in order to act as restoratives, drugs must facilitate the addition of structural elements to the economy. Hitherto, however, very few of the writers on this subject have been histologists. Mercury has been supposed capable of dissolving the fibrin of the blood, and thereby of favoring absorption of coagulable lymph. For the same reason it has been considered antiphlogistic. These views are connected with the exploded theory of inflammation commencing in in- creased fibrinosis, and have been shown, by modern experience, to be altogether erroneous. The assumption that many diseases originate in the blood, has led to the employment of a variety of medicines called specifics, which, in the opinion of some neutralize in that fluid the particular agency producing the disease. There is no theory which the modern inquirer should dis- trust so much as this, or with regard to which he should demand more rigorous proof. The tendency of modern physiology and of modern ex- perience is to show the fallacy of the reasoning on which this doctrine has been supported. For example, iodine has been supposed to be spe- cific in scrofula, mercury in syphilis, antimony in inflammations, colchi- cum in gout, etc. etc. We now know that scrofula is to be removed best, not by giving a poison which acts as a specific or alterative, but by improving nutrition. We shall subsequently see that syphilis has been cured, in recent times, just in proportion as we have ceased to give mer- cury. Antimony, in contra-stimulant doses, is a fatal practice in acute inflammations. And if colchicum be useful in gout, it is not by acting as a catalytic or blood-destroyer. If by specific, again, be meant remedies operating in an unknown manner, it is only reasonable to believe that, as knowledge advances, and we obtain glimpses of how medicines operate physiologically, the idea of specifics should be banished from therapeutics. The Blood Glands . — We are unacquainted with any medicine which has an especial operation upon the lymphatic system of glands, more espe- PHYSIOLOGICAL ACTION OF REMEDIES. 341 cially as sanguiferous organs. Generous food, and cod-liver oil, increase the amount of chyle. Iodine is said to diminish the size of the thyroid, when hypertrophied in bronchocele; and, according to Piorry, quinine, in large doses, almost immediately decreases the enlarged spleen in in- termittent fever. Further observations, however, are required to estab- lish either supposition. Action of Medicines on (he Digestive System. In consequence of medicines being directly introduced into the digestive tube, we have to distinguish two kinds of operations, viz., such as act locally, and such as act secondarily on other parts of the body, through the medium of the blood. Salivary Glands . — These glands are always called into action during mastication, and may be excited by the aid of sialagogues. Here the in- fluence of mercury is unquestionable, profuse salivation being the leading symptom of its peculiar action on the economy. Chewing tobacco, pyre- thrum, betel, and some other irritating substances in the mouth, produce the same effect locally. The Pharynx and (Esophagus are said to be rendered dry, and to be spasmodically contracted by belladonna. Stomach . — The reflex action of vomiting may be excited in various ways — 1st, By giddiness and vertigo arising from the motion of a ship at sea, or of a swing. 2d, By a variety of cerebral diseases. 3d, By the mental feeling of disgust or of irritation. 4th, By certain peculiar irritations, as that of a gall-stone. 5th, From pregnancy. 6th, By the introduction of certain medicines called emetics, some of which act in this way whether taken into the stomach or whether injected into the blood, such as antimony. In all these cases, therefore, the action is owing to nervous irritation, and when produced by drugs, these apparently act through the blood on the vagi nerves. Other emetics, such as sulphate of zinc or oxide of arsenic, act through their topical irritant properties. The secretion of gastric juice may be increased by stimulants, and if in excess be neutralised by antacids, such as bismuth, magnesia, and alkalies. It is thought also that its digestible properties, which partly depend upon its acidity, may be increased by small doses of hydrochloric acid. (See General Pathology and Treatment of Dyspepsia.) Liver. — x\lthough mercury, taraxacum, and some other remedies, are generally supposed to have the property of increasing the secretion of this organ, it still remains to be proved whether this is the case or not. Indeed, I am acquainted with no series of observations which demon- strate that an increased flow of bile has been unequivocally produced by any known remedy. Pancreas . — We know of no remedy which influences the functions of this organ. Intestinal Glands . — All local irritations excite these glands to an increased action, and numerous purgatives, especially the more drastic ones, are supposed also to induce increased excretion from them. Others, such as elaterium, are imagined even to cause separation of serum largely from the blood-vessels. We now know that immediately below the intestinal mucous membrane, there is a rich layer of organic nerves, 342 GENERAL THERAPEUTICS. which not only supply the glands, hut the blood-vessels and muscular layers also, and so regulate secretion, excretion, and peristaltic motion. There is no difficulty, therefore, in supposing theoretically that the special action of many purgatives is through the blood on this portion of the nervous system, although we have still no proof of it derived from experiment. Intestinal Tube. — Numerous remedies excite the peristaltic action of the digestive canal. They are called purgatives, and are derived from the animal, vegetable, and mineral kingdoms. There can be no doubt that saliva, bile, the pancreatic juice, and other fluids secreted in the alimentary canal, are natural stimulants to its proper action ; and when any one of them is deficient, constipation is the common result. Excess of bile, purges, mechanical irritants, also excite intestinal action, as the undigested husks of vegetables, small seeds, powdered tin, and so on. Purgative drugs may act either locally or constitutionally, sometimes in both ways. The more acrid, such as gamboge, may act principally in the one way ; and the more bland, such as neutral salts, more par- ticularly in the other. It has been shown, however, that the true pur- gatives, like the emetics, when introduced into the circulation directly through a vein, produce their peculiar local action. It has been sup- posed that some of them, such as rhubarb, act more especially upon the upper part of the canal ; and others, such as aloes, operate more par- ticularly on the lower portion of it. Seeing that we have unquestionably drugs that operate on the stomach, and others on the bowels, it may easily be conceived that among the numerous purgatives which exist, several of them may act on distinct parts of so lengthy a tube. But this has by no means been clearly proved. Another class of remedies, known as astringents, have the opposite efibct to purgatives — some diminishing mechanical irritation, and others having a direct constringing effect on the muscles and blood-vessels. Among the former are demulcents, antacids, and opiates. Among the latter, catechu, kino, gallic acid, and others from the vegetable ; and sulphuric acid, alum, nitrate of silver, iron, and others from the mineral kingdom. Introduced into the alimentary canal, whether ’by the stomach or rectum, their action is local. That they ever operate on distant parts through the blood is doubtful. One of the most valuable astringents for the stomach is ice, and for the lower part of the bowel cold water, used as an injeetion. Medicines used to expel worms from the alimentary canal are called anthelmintics, and the influence of some of these is unquestionable. Some act mechanically, as powdered tin, and others by their purgative qualities ; while a third class appear to exercise a poisonous influence over the parasite. Of these last, the most powerful is the essential oil of the male shield-fern, which kills the taenia solium. Action of Medicines on the Genito- Urinary System. We have no proof of any direct aphrodisiac properties existing, in drugs. The same may be said with regard to emmenagogues, or medicines supposed capable of increasing the catamenial discharge. In cases of PHYSIOLOGICAL ACTION OF REMEDIES. 343 amenorrboea, clialybeates and other tonic remedies are usually prescribed, but too frequently with indifferent success. Ergot of rye stimulates tbe contractions of tbe uterus during labor. Tbe secretion of tbe mammary gland is said to be affected by drugs administered to tbe mother, especially by acrid vegetable purgatives, and by bitters, such as worm- wood, and that in this way they operate on tbe infant. Tbe existence of any true lactagogue lias yet to be proved. Medicines which increase tbe flow of urine are called Diuretics. Of these, tbe most powerful are certain alcoholic preparations, such as nitric ether and gin, a few vegetable substances, such as digitalis and squill, and some salts, such as tbe supertartrate and the acetate of potash. The effect of these remedies is unequivocal, and their curative influence, in certain cases of Bright’s disease, has frequently been demonstrated by me in tbe clinical wards (see Bright’s disease, case of Herdman). We know of no drug capable of checking the urinary secretion. It has been said that colcliicum has a special action in eliminating urea from the kidney (Maclagan), although this has been disputed (Grarrod). Can- tharides appears to influence more especially the urinary bladder, causing contractions in its neck and strangury. Camphor is said especially to allay vesical irritation, although I have never seen it produce that effect. Certain balsams, especially that of copaiba, and the essential oil of cubebs, have an unquestionable influence in diminishing purulent discharges from the urethra, an effect probably owing to their local action, as they pass over the mucous membrane, dissolved in the urine. Action of Medicines on the Integumentary System. Remedies that increase the watery secretion from the sudoriferous glands are called Diaphoretics. This effect is also occasioned by exer- cise, warmth, and especially heated air — indeed anything that increases the circulation of blood in the skin. It is also a symptom of exhaustion, however occasioned, and is therefore present in all diseases which rapidly depress the system, as acute inflammations, fevers, phthisis, etc. The stronger a man the less easily he sweats on exertion. All nauseat- ing and depressing remedies are diaphoretic, such as antimony, ipecacu- anha, as well as narcotics, which after excitement produce a sedative in- fluence. We are ignorant of any medicines which increase the sebaceous secretion from the skin. The skin may be made the vehicle for introducing medicines into the blood — 1st, By friction, as in rubbing with mercurial ointment, when salivation is occasioned ; 2d, by inoculation, as in tbe artificial produc- tion of cow or small pox; 3d, by abrasion, as when powdered opium or strychnine is sprinkled over a blistered surface ; and 4th, by injection, as when morphia in solution is injected into the subcutaneous cellular tissue with a syringe and a finely pointed steel canula ; 5th, by vapor. Artificial irritations of the skin, to produce internal or distant effects, are caused by what are denominated counter-irritants^ including stimu- lants, frictions, hot applications to parts, sinapisms, blisters, moxas, cauteries, etc. etc. These all operate through the nerves by reflex action : some, like warm fomentations, soothe irritation ; others, as blisters, create*' 344 GENERVL THERAPEUTICS. it locally, but remove it from where it was primarily seated. How this is accomplished constitutes one of the most vexed questions in thera- peutics. Where there is breach of surface in the skin, eruptions or ulcers, various applications are made to it, constituting special treatments in medical and surgical practice. In the short general account now given of the physiological action of medicines, my object has been not to make an enumeration of drugs, but to point out what influences can and cannot be exerted by them over the functions of the animal economy, according to the present state of our knowledge. Systematic writers on therapeutics are fond of grouping remedies together according to their presumed qualities, eithe.r as modi- fying function in health, or restoring health during disease, constituting what have been called the physiological and therapeutical arrangements of drugs. Great confusion has resulted from both systems, because, as we have seen from the previous inquiry, our positive knowledge of either is very limited. It follows that they deal largely in assumption and loose analogies. One drug is often made to play many parts, and often possesses the most contradictory qualities. WKat we require is exact knowledge with regard to them, and this can only be arrived at by de- termining in the first place their simplest uses. Even here, as we have seen, there is yet much to learn. Let us next inquire the mode in which they act on the animal economy. General Theory of the Action of Remedies. Drugs may act topically on the parts to which they are applied ; on distant parts by reflex action through the nerves, and by selective affinity between the tissues and the blood. Great discussion has taken place as to whether certain medicines operate directly on the nerves or through the blood. The fact that the entire circulation is accomplished in about half a minute (Hering, Blake) is quite sufficient to account for the rapidity of the most active drugs, even of poisonous doses of hydrocyanic acid ; whilst it has been proved that medicines which act strongly on the nerves, when they are taken into the stomach, such as worari, have no efi'ect when applied to the nerves themselves (Kolliker). Indeed, it has been shewn that some remedies when applied directly act on muscles, others on nerves, and a third class on both (Kiihne), In the living body, however, activity of the circulation is necessary for the operation of remedies, and we observe that whenever it is too languid from exhaustion they fail to operate. It is fur- ther to be observed that by whatever channel a drug with characteristic properties is introduced into the system — whether by the stomach or the rectum, by the skin or the lungs — the effect is exactly the same as if it was introduced into the blood itself. It follows that the active pro- perties of drugs are first absorbed into the blood (Magendie), and then act upon difi'erent tissues, exerting or diminishing their functions, in consequence of a property of attraction and selection exerted by the molecules of the tissues themselves. In this respect drugs act in the GENERAL THEORY OF THE ACTION OF REMEDIES 345 same way that articles of diet do. In virtue of vital powers, whereby one tissue attracts and selects from the blood fat, another albumen, and a third mineral matter — or one gland attracts the materials out of which it forms bile, while another attracts the substance which it forms into urea — so does this tissue attract and select from the blood the peculiar property of one drug, and another tissue that of a different one. This is the only explanation that can be offered of why ipecacuanha acts as an emetic and aloes as a purgative; why opium acts on the brain, causing sleep ; and strychnine on the spinal cord, causing spasm ; why mercury stimulates the salivary, and supertartrate of potash the renal glands. This theory accounts also for the degrees and varieties of disordered function pro- duced by different drugs of the same class. The existence of such properties in drugs, or, more strictly speaking, in the living tissues to which through the blood parts of these drugs are carried in solution, are ultimate facts in the science of therapeutics. At the same time it may be understood that in a few cases impressions made upon the extremities of sensitive nerves act according to the laws of reflex action, as when counter-irritants relieve internal pain, or when sternutatories induce sneezing. The study of these various facts must ever furnish the proof that all exact explanation and knowledge of the action of drugs must spring from physiological investigation. It has been very generally supposed that if one drug exalts action and another depresses it, the eflects produced by the first may be counteracted by the second. But this does not always follow. For example, strychnine evidently excites the motor nerves to action, and worari as certainly paralyses them. As medicines, however, the one has no counteracting effect to the influence of the other. Poison an animal first with strychnine and then with worari ; so far from health resulting, the death of the animal is rendered doubly certain. Experiment and experience are here both opposed to a theory which lies at the basis of much of our practice. I have given strychnine in numerous cases, and in all forms of paraplegia, and have yet to find a single instance in which any benefit resulted from its administration. Again, in delirium tremens there is great wakefulness; it might be supposed that giving opium, which causes somnolence, would cure the former symptom ; yet I have frequently satisfied myself that so far from doing so it exasperates and prolongs the malady. Exactly on the same principle strong coffee and tea have been given to cause wakefulness in cases of poisoning by opium, but in no one instance have they been shown ever to produce the desired effect. The reason of all this appears to be very obvious. Each drug has an af&nity for certain parts of the nervous texture. The ultimate tubes or especial centres acted upon by strychnine, are not those which are influenced by worari. Neither is the nervous matter affected by alcohol or opium that which is impressed by coffee or tea. Another very general idea prevails, viz., that a medicine decidedly curative, such as quinine in intermittent fever, is also prophylactic, and will keep off the disease. It is difficult to understand how this can be true in theory ; and in practice, though largely acted on, we are as yet destitute of any demonstrative facts in its support. It is now recognised that medicines derived from the organic world 346 GENERAL THERAPEUTICS. owe tlieir peculiar action to certain principles whicli they contain, and which the chemist can abstract from them. Thus from Peruvian bark is extracted quinine; from opium, morphia ; from nux vomica, strychnine ; from belladonna, atropine, and so on ; and experiment has demonstrated that the peculiar properties of the drugs are not only possessed by, but intensified and concentrated in these preparations. The art of phar- macy therefore has greatly advanced of late years, and placed in the hands of physicians medicines capable of acting with far greater power and certainty than formerly. The notion that disease is a something which, having got in, requires to be driven out of the system — is an enemy that we must attack, lay siege to, and conquer — is one that largely prevails in the works of thera- peutists. — “ The intestinal canal is, in the great majority of cases, the battlefield where the issue of the most important disorders is decided.” — (Hufeland.) “ We must introduce the only medicine of which we are thoroughly convinced that it possesses the power of efficiently striving with the enemy who, by subtle means, has now efiFected an entrance within our stronghold.” — (Headland.) “ The whole of life is a perpetual struggle with an enemy to whom we must at last succumb.” — (Stille.) These expressions, however metaphorical, indicate the kind of operation sought to be carried out in treating disease. The active practitioner, like the victorious general, is more intent on driving out the enemy, than in securing the safety of the fortress, which during the operations of both is too often greatly damaged, and not unfrequently levelled to the ground. But the truth is, in many cases what we call disease, instead of being an enemy is our best friend. It should be regarded as the natural and necessary result of those injuries to which the animal econ- omy is necessarily exposed. It is the effort made by nature to elimi- nate from, or reconcile the frame with, those noxious causes which have influenced it. If it cannot do this, the vital force is exhausted. Our great object, therefore, should be, not to suppress, but to favor the natural operations of diseases, and conduct them to a favorable termination. If a sword is thrust into the flesh, should we suppress the pain, heat, redness, and swelling which result? No; for they are the evidence of those healthful changes, which, properly managed, will heal the wound. If the lung be inflamed, should we seek to check the dyspnoea, arrest the fever, and weaken the pulse ? Again I say no. They are the proofs that the constitution is actively at work in re- pairing the injury, and preparing the way for recovery. Neither can it be correctly supposed that life is a constant struggle with death. On the contrary, death is the natural termination of life ; and so far from being an evil, can only be so considered, when it is induced by violent or unnatural means. Another circumstance should not be overlooked, and that is the correctness of the observation made at the commencement of this century by Bichat, viz. — that the science of therapeutics has not been, as is alleged, founded on rigid observation and experience, but on “ the pre- vailing theories in physic.” Thus it is that when the theory of inflam- mation regarded fulness of the blood-vessels as the essence of that disease, the practice which resulted was of course blood-letting. So TRUE FOUNDATIONS FOR MEDICAL PRACTICE. 347 long as a full and rapid pulse was imagined an injurious symptom, its reduction by antiplilogistics was thought to be a matter of necessity. . It is strange that the persons who delighted to call themselves practical men, never perceived that their practice was a most fatal one. Now the theory is changed, and the practice is changed with it ; and the proof that the last theory is superior to the former one, is that the mortality from cases of acute inflammations is greatly diminished. It follows that the true method of advancing our knowledge of how to treat disease for the future, is not blindly to go on repeating the routine practice of our forefathers, but to improve our theory of morbid processes, and then re-investigate, with all the aids of modem science, the effects of remedies. This leads me to the last general proposition we have to discuss. PHYSIOLOGY AND PATHOLOGY THE TRUE FOUNDA- TIONS FOR MEDICAL PRACTICE. When we investigate closely into what is actually known of our the- rapeutical means, divided into alimenta, hygienica, and materia medica, it will be seen that we have few exact details founded on scientific re- search. What we require is, that such details must be first arrived at, and then applied in accordance with pathological laws. These point out that all treatment must be general and special — general as regards the nature of the disease, special as regards its seat. The great problem in conducting any given case is to carry out both indications, .so that one does not interfere with the other. If, for example, the object be to favor the removal of inflammation or tubercle from the lung, the means requisite for that end must not be put aside or counteracted by a desire of alleviating pain, breathlessness, or expectoration. Indeed, one point of great importance, and which clinical observation has in recent times made manifest, is, that general and local symptoms fre- quently bear no relation whatever to the fatality of the lesion. Thus, an extensive acute inflammation of the lungs, a febricula, or an impacted gall-stone, may cause the most violent .symptoms and perturbation of the economy, and yet spontaneously terminate in recovery in a few days ; while a phthisis, a pleurisy with effusion, or even a pneumothorax, which may permanently destroy the action of a lung, may come on imperceptibly, and cause only trifling functional symptoms. To the pathologist, therefore, such symptoms are no longer the same guides to treatment as they used to be. They do not so much excite his regard as the structural or chemical lesions which produce them, for he knows that the former will disappear if the latter are removed. It need not, therefore, excite surprise that as our knowledge of pathology has advanced, and our means of diagnosis have improved, we direct our attention more to morbid alterations and less to the temporary effects. In this way it has gradually become manifest that so far from doing good by attempts to relieve symptoms, we too often do harm to the disease. If, for instance, impaired digestion cause headache and sleeplessness, the relief of these symptoms by morphia is anything but beneficial, inasmuch as it depresses the nervous system and diminishes 348 GENEEAL THERAPEUTICS. the appetite, and so increases the real disease. For the same reason, of what advantage can sedatives and cough mixtures he in phthisis ? The true indication for treatment is to strengthen the appetite, increase the nutrition, and invigorate the frame. Medicines which only tempo- rarily lull irritation, create nausea, destroy appetite, and favor diapho- resis, however they may relieve symptoms, can never arrest the disease. An observation of the mode in which the various sciences are evolved will show that their progress has been more or less influenced by that of collateral branches of knowledge, and especially by the invention of ingenious instruments, the use of which has led to the discovery of new facts. Let us consider for a moment how the rude art of navigation possessed by the ancients was improved by the invention of the mariner’s compass ; how astronomy is dependent on mathematics, and on the tele- scope ; how natural philosophy, by inventing steam-engines and electrical instruments, has added to all the comforts of life, and so on. It would be as absurd to reproach the ancients with ignorance of navigation, or of railways, because they were unacquainted with the mariner’s compass and with the power of steam, as it is to charge medical men with igno- rance of therapeutics, until physiology and pathology are so advanced, that diagnosis and the action of medicines are better understood. Now I am anxious to impress upon you that this is not to be done by the method hitherto pursued by the profession. Most young men on entering practice endeavor to impress upon their memory, by repeated trials, the methods and formulas of their predecessors. This has been done so often that little more can be expected from such a system. On the other hand, the more we consider the flood of light which has been poured upon our art by the physiological discoveries of Harvey, C. Bell, Magen- die, Marshall Hall, Schleiden, Schwann, and others, the more it must become apparent that the true way of cultivating medicine is by prose- cuting researches in physiology and pathology. This conclusion in no way invalidates the necessity of observing the effects of medicines at the bed-side. It only points out that the reason we have made so little progress in therapeutics of late years, is in consequence of the imperfect condition of the sciences necessary to its evolution. Some, it is true, may argue that many of our triumphs in practical medicine have no such scientific foundation. But of these I would remark, that although the mere remedy may have been acciden- tally applied in the first instance, still the cause, diagnosis, and course of the disease were pretty well known, and that from these the pathology could be correctly inferred. For example, in ague and scurvy, the diagnosis is easy. The causes — malaria in the one case, and imperfect diet in the other ; and the pathology — a morbid state of the blood — were known. The progress of these diseases was also recognised to go on from bad to worse so long as the cause continued. Then it was ascer- tained that Peruvian bark and lemon-juice removed these morbid condi- tions. Why the one should be removed by the first remedy, and the other by the second, has still to be discovered. All I contend for is, that therapeutical trials cannot be expected to be useful, unless they be preceded — 1st, by an accurate diagnosis of the disease ; 2d, by a know- TRUE FOUNDATIONS FOE MEDICAL PRACIICE. 349 ledge of its pathology ; and 3d, by an acquaintance with its natural progress. Not long ago a young American physician brought under my notice a tincture of the veratrum viride, which he maintained possessed the power of diminishing the force of the pulse, and said that on this account it was a most valuable medicine in fevers, inflammations, and other diseases where the pulse was excited. But pathology indicates that so far from lowering the pulse in these disorders, what is required is in truth to support it, for the reasons I have formerly mentioned. Indeed, I cannot conceive any circumstances in which such a remedy, even if it possessed the virtues ascribed to it, can be useful. But it so happens that several years ago Dr. Norwood, of Nashville, in the United States, was good enough to send me a bottle of the tincture, which I tried in several cases of fever in the inflrmary. In every instance the medicine caused violent vomiting, pain in the stomach, weak pulse, and symptoms of collapse, and had to be discontinued ; but in no one instance did it shorten the disease or improve the symptoms — quite the contrary. Yet this remedy is once more recommended to us on the ground of subduing, not a disease, but a symptom, although everything we know of pathology and the natural history of fevers and inflammations is entirely opposed to its employment. In the same manner hosts of new drugs, or new preparations of old ones, are constantly extolled and recommended on the most insufiScient data, few seeming to think it necessary to make experiments, careful observations, or deductions, but appealing only to a very limited expe- rience. But we have previously seen, even where experience has been universal and unanimous — as in the case of bloodletting in inflam- mations — what mischief and error have arisen from unacquaiutance with physiology and pathology. As another example, let us for a moment consider the contradictory opinions that prevail with regard to a medicine which, perhaps, has been more extensively tried than any other : I allude to mercury. I need not cite the extravagant praises which it has received from its partisans. It will suffice to say, that one of the most accomplished professors of materia medica in these times tells us that, physiologically, it is “ a cor- rosiv^e, irritant, errhine, cathartic, and astringent ; a stimulant, diuretic, diaphoretic, cholagogue, and emmenagogue ; and an excitor of that pecu- liar state of the constitution denominated mercurial action, of which salivation is one of the chief local signs. Therapeutically,” he says, “ it is antiphlogistic, alterative, sedative or contra-stimulant, deobstruent, antisyphilitic, and anthelmintic.” — (Christison.) A drug possessed of such wonderfully extensive and varied powers should certainly by this time have had its virtues universally recognised ; yet the fact is, that with the exception of its action as a sialagogue and a cathartic, there is scarcely one other of its supposed virtues that is not disputed. Is mercury a cholagogue ? We have no proof whatever that it increases the secretion of bile ; and the only experimental investigation with which I am acquainted — viz., that of Dr. Scott, who gave calomel to dogs, and then collected the bile through a fistulous opening made into the biliary duct — found it in three days to diminish the quantity of 350 GENERAL THERAPEUTICS. that fluid. ^ Is it an antisyphilitic ? In recent times it is admitted that syphilis has diminished in intensity just in proportion as the use of mer- cury has declined ; and the gigantic experiments made on entire garrison regiments in France, Germany, and Sweden, prove that the non-mercurial treatment of syphilis is far superior to the mercurial in every respect. Is it antiphlogistic ? All that we know of modern practice negatives the idea. Does it cause absorption of lymph or the coagulated exuda- tion ? The clinical observations of Professor John Taylor, of London, in pericarditis, and of Dr. Williams, of Boston, United States, in iritis, are opposed to such a supposition. Then as to its mode of administration what dififerences exist ! Some give it in large, others in small doses — some in acute, others in chronic diseases of the same kind. Some argue that it should precede, others follow venesection. Some combine calomel with blue-pill to intensify its action ; others with opium for the same reason. Its applications are so numerous and contradictory, that the question may well be, not for what diseases is it useful, but rather which has not been represented to be benefited by this drug ? In the meantime, it is admitted on all hands, that it arrests the appetite, checks nutrition, excites a peculiar fever and erethism, produces a coppery taste in the mouth, furred tongue, and sali- vation ; and the pathologist may well inquire how a poison operating in such a way can have any curative tendency whatever. Now, why all this uncertainty as to the ther^fpeutic action of drugs? My answer is — In consequence of our ignorance of an exact diagnosis and of a true pathology. Many persons think that the science of thera- peutics is to be advanced by trying the effects of drugs on animals, by testing them in healthy persons — by clinical observations, by records of cases, and so on ; but whatever amount of knowledge may be thus arrived at, it can never be advantageous for medical treatment, until, as I have endeavored to show, we are first capable of recognising with exactitude the disease we investigate, and secondly, know its nature and natural progress. These steps must be preliminary to all advance in therapeutics, and that they have not hitherto been made so, is at once the explanation of past failure, and the indication for future success. The true promoters of therapeutics, consequently, are not those men who pass their lives in treating patients as well as they can from the results of pre-existing or present knowledge ; they are not those who are constantly arranging the well-known opinions and assertions of former writers as to the efiects of past treatment ; but they are those who direct all their ener- gies to improving diagnosis, advancing physiology and pathology, and re-testing the action of doubtful remedies with all the advantage de- rived from our advanced knowledge. This conviction must force itself on the minds of all who seriously consider the subject, and, in truth, it is the one which renders every earnest and truthful student amongst us a physiological pathologist. The result is already obvious. We are gradually sweeping away the errors of empiricism, slowly clearing the ground for the erection of a more simple and solid temple of knowledge. This accomplished, we hope to accumulate, by laborious toil and research, * Beale’s Archives of Medicine, vol. i., p. 209. TRUE FOUNDATIONS FOR MEDICAL PRACTICE. 351 materials for its foundation, — a work to which I think we are gradually approaching, — in the hope that, by patience and perseverance, a day. will arrive when Medicine will be generally allowed to have approxi- mated towards, if it do not actually reach, the character of an exact science. The true principles, therefore, which should guide our efforts to advance therapeutics are — 1. That an empirical treatment derived from blind authority, and an expectant treatment originating in an equally blind faith in nature, are both wrong. 2. That a knowledge of physiology and pathology is the real found- ation and necessary introduction to a correct study of therapeutics. 3. That a true experience can only have for its proper aim the deter- mination of how far the laws evolved during the advance of these sciences (physiology and pathology) can be made available for the cure of disease. In concluding this part of our lectures, I have only to express my conviction that any uncertainties as to the future existence of a scien- tific Medicine can only be removed by working out in all its details the Molecular Theory of Organization. The histogenetic and histolytic trans- formations of the tissues, the various metamorphoses they undergo in the exercise of the nutritive and nervous functions, as well as the correla- tion and conservation of the dynamical, chemical, and vital forces of the economy, are the points now being determined by the physiologist. We are still waiting for the solution, by the organic chemist, of several inquiries necessary for our onward progress. But these accomplished, as it is hoped they soon will be, it must be recognised that all action and all function must be essentially dependent on the formation and existence of the molecular constituents of the frame. Then, also, it will be seen that the agents which operate upon it, either from without or within, must be capable of being so prepared as to act on these minute particles, and it will be made apparent that one law will blend into a harmonious whole the kindred sciences of physiology, pathology, and therapeutics. In the meantime it follows from all that has preceded, that many of the principles which have hitherto guided us in the treatment of disease must be considerably modified. That medical practice has undergone a great revolution during the last twenty years, is a fact already so well established, that it can be no longer denied. Firmly believing that many of the changes which have been effected are permanent improve- ments in our art, and may be traced to the advance in the sciences on which that art is based, it will be our especial object in the succeeding pages to point out in what way more perfect principles have led to a better practice. Amid the multiplicity of conflicting statements, and the clashing of opposing systems, it will be our honest desire to sepa- rate what is known from what is unknown, and lay down such rules for treatment as both science and experience may alike confirm. SECTION IV. DISEASES OF THE NEKVOUS SYSTEM. The diagnosis of nervous disorders is dependent on a kind of knowledge altogether different from that appertaining to the consideration of cutaneous, pulmonary, or cardiac affections. In these last, as we shall see, a direct appeal to the senses enables us to arrive at conclusions with tolerably accuracy. An arbitrary classification of skin diseases once established, with clear definitions, we have only to apply these to the appearances observed to ascertain the disorder. Once master the prac- tical difficulty of distinguishing with exactitude moist from dry rales — whether a murmur replace the first or second sound of the heart, and what is its position, and we possess a key which, with the aid of per- cussion, will frequently enable us to ai rive at the certain diagnosis of pulmonary and cardiac .affections. But with regard to nervous diseases, no such exactitude is attainable in the present state of the science or art of medicine. The encephalon is an aggregation of various parts, more or less connected together, the functions of which are by no means determined. In health these act in harmony, but in disease they are so irregularly disordered that while the action of one is excited, that of another may be perverted or annihilated. Then, again, we frequently observe that some of the most fatal nervous diseases, such as hydro- phobia, leave after death no lesion detectable by the most careful histological examination, whilst on other occasions tumors and extensive destruction of the cerebral mass may exist, without producing any symptoms whatever. And yet, notwithstanding the obvious difficulties which oppose themselves to exactitude of diagnosis of nervous diseases, careful observation, conjoined with a knowledge of physiology and patho- logy, will enable us to approximate closely towards, if not actually to reach, a correct opinion in the great majority of cases. The same circumstances render a pathological classification of nervous diseases impossible. Thus any one special lesion may produce the most remarkably different effects, according as it occurs rapidly or slowly ; as it is single or multiple ; as it is small or great in amount ; as its nature is simple or compound ; or as it affects different parts of the nervous mass. Thus the compound functional character of the brain alone, if disordered, may give rise to increase, perversion, or loss of three functions, viz., intelligence, sensation, and motion, each as different in its modes of manifestation and effects, as are the important functions of digestion, respiration, and secretion. Neither can we satisfactorily arrange nervous diseases in accordance with the symptoms which may be CEREBRAL AND SPINAL SOFTENINGS. 353 present, as these are so various and so complicated in different cases. This, however, is the method which has stamped its features on medical literature since the days of Hippocrates, and from which, ia consequence, without anything more certain to offer, it is in the present state of medical science impossible to escape. What we, however, strenuously contend for, is the inconsistency in our nomenclature of applying to morbid lesions the same names as have long been recognised in a different sense as indicating groups of symptoms. Apoplexy, for instance, is not necessarily hemorrhage into the brain, nor does every hemorrhage produce apoplexy. If, then, we use a mixed classification which seems to be the best now open to us, that is, one partly anatomi- cal, founded on altered structures, and partly physiological, founded on altered functions (that is, symptoms) — let us define accurately in all instances what we mean by the names employed. Thus we can use the terms congestion, softening, and suppuration of, or exudation, effusion, and hemorrhage into the brain and spinal cord, as we do when these lesions affect any other organs. But we should understand by apoplexy y, loss of consciousness and voluntary motion, beginning at the brain ; by epilepsy^ paroxysmal loss of consciousness with convulsion; by spa^rriy increased tonic ; and by convulsion, increased clonic contractions of the muscles; and \>j paralysis, loss of motor, or sensitive power of a part, etc. If we employ morbid lesions to designate the disease, we regard groups of symptoms as their effects. But if we use groups of symptoms to denominate the disease, then, however well we may observe these, we are often incapable of determining what are the structural changes on which they immediately depend. The key to the diagnosis of nervous diseases will be found in the general sketch we have given of the function of innervation (p. 137),, and especially in the pathological laws which regulate diseased action of the nervous system ; and to these we refer the reader (p. 148). The- morbid anatomy of the nervous system will be found treated of in various parts of the work."^ But there is one predominant lesion, which has lately had much light thro\Vn upon it histologically, and which is so important in a diagnostic point of view, that we propose allluding to it, before entering on the consideration of individual nervous diseases. ON THE PATHOLOGY OF CEREBRAL AND SPINAL SOFT- ENINGS, AND ON THE NECESSITY OF EMPLOYING THE MICROSCOPE TO ASCERTAIN THEIR NATURE. The nature of cerebral and spinal softening has been much disputed. Some attribute it entirely to chronic or acute inflammation ; others, while they acknowledge that softening is undoubtedly thus produced, are also of opinion that it may occasionally depend upon other causes. * Congestion of the cerebral vessels, pp. 148 to 151, Exudative softenings, pp. 16Y, 168. Albuminous degeneration, p. 248, Pigmentary degeneration, p. 263. Mineral degeneration, p. 271. 23 354 DISEASES OF THE NEEVOUS SYSTEM. Thus softening has been considered a lesion 8ui generis^ similar to what occurs in ataxic fever (Recaniier), to gangrena senilis (Rostan, Aber- comby), to obliteration of the arteries (Bright, Carswell), or to a dimi- nution of nutrition (Delaberge, Monneret). It has also been referred to post-mortem maceration (Carswell, Paterson of Leith), and is undoubt- edly often produced by mechanical violence after death. The difficulty hitherto has been how to distinguish with precision one kind of soften- ing from another. From a careful analysis of numerous cases of cerebral softenings, I have arrived at the conclusion that they may originate in six ways. 1st, From exudation which is infiltrated among the elementary nervous structures ; 2d, from a mechanical breaking up of these structures by hemorrhagic extravasations, whether in large masses or infiltrated in small isolated points ; 3d, from fatty degeneration of the nerve cells, independent of exudation ; 4th, from the mere imbibition of serum which loosens the connection between the nerve tubes and cells ; 5th, from mechanical violence in exposing the nervous centres ; and 6th, from putre- faction. 1st, Exudative or inflammatory softening always contains granules and granule cells, which are nume- rous according to the degree of soften- ing. The granules are for the most part seen coating the vessels (Figs. 148, 334, and 335), and the cells also may occasionally be seen there in various stages of development (Fig. 150). In the demonstrations that are made under the microscope, they the tubes (Fig. 401), which, accord- ing to the severity and extent of the lesion, are easily separated from one another, or broken up in a variety of ways. When recent, the serum are frequently seen diffused among which accompanies the exudation is infiltrated into the nervous substance. Fig. 401, Structure of inflammatory exudative softening of the lumbar portion of the spinal cord, showing granule cells infiltrated among the nerve-tubes in a para- plegic individual. — ( Wedl.) Fig. 402. Structure of a tubercular exudation in the cerebellum, composed of granules and tubercle corpuscles, with a few fragments of nerve-tubes. Fig. 403. 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. 260 diam. CEREBRAL AND SPINAL SOFTENINGS. 355 and may assist occasionally in producing softening, although for the. most part it is rapidly absorbed. In chronic cases this form of soften- ing may be regarded in one sense as a fatty degeneration, although, when speaking of this last lesion, I have stated my reasons for consider- ing it as a transformation of the exudation, and not of the nervous sub- stance. (See p. 257.) Simple, tubercular, and cancerous exudations, alike cause cerebral or spinal softenings, as shown by the presence of the characters peculiar to each. Tubercular masses in the brain are generally surrounded by a layer of cerebral substance exhibiting all the character.s of this form of softening (Fig. 403). Cancerous exudation into the brain is very rare (Fig. 302). 2f/, Re norrhajic softeninj . — 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 coloring matter, is infiltrated to a greater or less distance and absorbed. Under such circum- stances, the softened nervous tissue sur- rounding the clot presents fragments r- o o'" peculiar tendency to form circular, oval, or irregularly-formed globules, with double outlines, as iu Fig. 404. There are none of the granule cells so character isticof an inflammatory soften- ing, although they may appear later, as the result of exudation from the cere- Fig. 404. bral vessels surrounding the clot. In such cases the greatest variation in the appearance of the nerve-tubes is observable, from a slight dimi- nution in their natural firmness and consistence, which renders them easily separable, or causes varicosities or swellings in them to be readily produced on pressure, up to a condition when they exhibit nothing but fragments and separate globules, as in Fig. 404. The colored cerebral softenings which are subsequently produced as a result of hemorrhage are owdng to the transformations which go on in the coagulum itself. They assume a bright orange, brick red, yellow, fawn, or dirty brown color, 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 numer- ous shades of orange, red, brown, black, etc. etc. (See Pigmentary Degeneration, p. 262, et seq.) 3c?, True fatty softening . — This lesion, that is, a primary fatty Fig. 404. 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. 35G DISEASES OF THE NERVOUS SYSTEM. degeneration independent of exudation or hemorrhage, is one of the existence 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 necessarily with granular exudation, but the nerve-cells undergo the fatty degeneration primarily and are enlarged. The walls of many of them also are dissolved, leaving triangular or cres- centic-shaped granular masses between the nerve-tubes. This alteration is accompanied with diminution of the cerebral density, and the nerve-tubes are also easily separated and broken up, though not so readily, as in the last form of softening noticed. 4^/?, 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- borhood 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 ventricles. At other times this has occurred, and the softening so occasioned is found to be greatest near the central parts, and to diminish according to the distance from them. The causes which produce, and at others impede, post-mortem imbibition are unknown. 5/^7^, Mechanical softening . — I have frequently seen softenings occa- sioned in the brain, and more frequently still in the spinal cord, through crushing the nervous texture, after death, in various ways. Thus the saw or chisel may occasion mechanical softenings in the superficial parts of the brain, when the calvarium is being removed by inexperienced or unskilful operators. In France, where the hammer is used for this pur- pose, it is a frequent cause of superficial softenings. The spinal cord is especially liable to be injured, by slipping of the chisel or lever used in elevating the posterior spinous processes of the vertebra. Portions of soft nervous tissue, such as the corpus striatum, have frequently had their Fig. 405. Structure of the softened pons varolii, in a case where the basilar artery was obstructed, showing true fatty degeneration of the nerve-cells, among somewhat softened and broken up nerve-tubes. See Cerebral Hemorrhage, case of Alexander Walker. 50 diam. CEREBRAL AND SPINAL SOFTENINGS. 357 text are reduced to a pulpy consistence by mere handling, or by constant application of the finger simply to ascertain whether it be softened or no» I have seen softenings exactly resembling such as may be occasioned by disease, produced in all these ways, and thus give rise to most erroneous conclusions. They are only to be distinguished by a microscopical ex- amination, and by a careful consideration of the symptoms observed during life, and of the causes which probably may have produced them after-d3ath. G^A, Putrefactive softening . — This may occur in warm weather, from the body having been examined long after death, or from accidental causes. Hence the necessity of always stating the number of hours after death that the examination is made. Such softenings are always diffused through considerable masses of cerebral texture, and may be recognised by this cirGimstance combined with an absence of all the signs which distinguish the other forms. Of these SIX kinds of softening found in the body after death, only the first three occur in the living subject, and give rise to symptoms, and of these three, the pure fatty degeneration, though frequently associated with the others, has been so seldom noticed, that we are to a great extent unacquainted with its symptoms as a special lesion. As regards the last t’lree, they have been frequently confounded by morbid anatomists with the others, and all attributed to one cause. I diink we are now enabled to distiuguish accurately such as are the result of exudation from such as are not. From a careful analysis of 32 cases of softening of the nervous centres, which I published in 1842-43,* it was shown that different symptoms were connected with exudative or inflammatory, from those which occurred in non-inflamniatory softening. In 24 of these cases in which cerebral softening was observed, granular corpuscles were present in 18, whilst in G no traces of these bodies could be found. On analys- ing the symptoms of the 24 cases, a marked difference was found be- tween those resulting from the two lesions. Thus, in the cases where onlg inflammatory softening was present, well-marked symptoms invari- ably existed, such a loss of consciousness, preceded or followed by dul- uess of intellect, contraction and rigidity of the extremities, or paralysis. On the other hand, in the six cases of non-inflammatory softening, there was no paralysis or contraction, and no dulness or disturbance of the intellect. Again, in the four cases where l a lesions were present, symptoms were always observed in the side of the body opposite to the seat of the inflammatory softening, but none existed in the opposite side in the noninflammatory. An analysis of these 24 cases, therefore, leads me to the conclusion, that the two kinds of softening I have endeavored to establish are alike distinguishable, by their intimate structure, and by the sympto ns accompanying them during life. Now all practical men agree in considering it a matter of extreme difficulty to reconcile, with any certainty, the morbid appearances found in the brain, with the symptoms observed during life. The future microscopic examination of the softening may serve to prevent much of the error that has hitherto been committed. For instance, softening of * Edinburgh Medical and Surgical Journal, Nos. 163, 155, and 157. 358 DISEASES OF THE NERVOUS SYSTEM. the fornix, septum lucidum, and central parts of the brain, may exist in two cases. To the naked eye they may be in every respect identical, and yet the microscope enables us to determine that the one contains granular corpuscles, whilst, in the other, not one of these bodies is to be found. It becomes evident, then, that previous to this distinction having- been made, two different lesions were confounded together ; and that a different train of symptoms should, under such circumstances, be occa- sioned, is only to be expected. Again, it has frequently excited surprise that, notwithstanding the existence of well-marked symptoms of soften- ing, nothing was to be discovered after death. Now I have demonstrated in several instances that, although to the naked sight no morbid lesion was apparent, still portions of brain might contain the same granular- corpuscles as are to be seen in more apparent lesions ; and that by con- sidering such p-arts diseased, all the symptoms might be explained ac- cording to the pathological laws I have previously referred to (p. 148, et seq.) By excluding these sources of error, therefore, and by distin- guishing the lesion dependent on inflammation from others which simulate it, we shall be enabled to obtain more exact data for future investigations. From the observations recorded, however, the two following propositions may, I think, be established. 1st, That pathologists have often con- founded softening dependent on disease during life, with softening occa- sioned by post-mortem changes or mechanical violence. 2d, That not- withstanding the most anxious search, and the existence during life of the most decided symptoms of softening, the organic disease, though really present, has frequently escaped observation. Proposition 1. — That pathologists have often confounded softening dependent on disease during life^ with softening occasioned hy post' mortem changes^ or mechanical violence. With respect to this proposition it may be observed that, in many cases where no symptoms were present during life, extensive softening of the brain has been found after death. This is a well-known fact, and is one which tends in no small degree to throw confusion on the pathology of nervous diseases. Thus, in one case of a series I published in 1843,^ there was extensive softening of the central portion of the brain, corpora striata, and optic thalami, which, however, contained no granular corpuscles. The symptoms attending these lesions were sudden insensi- bility and convulsions, which evidently depended on a capillary apoplexy that was also present. No paralysis or contraction existed. Four other cases were recorded, with more or less softening of the brain, without head symptoms, and without granular corpuscles in the softened portions. Now in all these five cases there was an extensive softening, the nature of which it was impossible for any one to distinguish positively, by unaided sight. In none of them did granular corpuscles exist, and in none did those symptoms occur which are peculiar to softenings pro- duced during life. In addition to these five cases there were four others, where, conjoined * Pathological and Histological Researches on Inflammation of the Nervous Centres. By the Author. Edinburgh, 1843. CEKEBKAL AXD SPIXAL SOFTENINGS. 359 with an exudative softening producing particular symptoms, there was also a softening, occasioning no symptoms whatever, and containing no granule cells. The circumstances attendant on these nine cases, there- fore, must convince us that softenings produced mechanically, or by post-mortem changes, have frequently been mistaken for those occurring during life, and must necessarily he so^ so long as unaided sight is made the sole means of forming a judgment 'with respect to their nature. A perusal of these cases must satisfy any one that pathologists have hitherto been confounding two distinct lesions, viz., a softening dependent on \itil changes, and a softening dependent on mechanical or other causes. PnoPosiTioN 2, — That notwithstanding the most anxmis search., and the existence during life of the most decided symptoms of softening, the organic disease, though really present, has freguently escaped obser- vation. In the series of cases alluded to there are several which serve to establish tnis proposition, of which T may more especially refer to two. Case 1, a man had paralysis, with complete resolution of the limbs on the right side, and intense rigidity of those on the left. Death occurred in six hours. On dissection, a large coagulum of blood was discovered in the left hemisphere, thus explaining the paralysis on the right side. In the right hemisphere an old apoplectic cyst was found, and a number of small cavities, described by Dr. Sims as chronic softening undergoing a cure. Here, then, there was nothing acute, nothing to explain the intense rigidity. A microscopic examination demonstrated that these cavities contained numerous granular cor- puscles and granules, thus proving the existence of structural changes in the right lobe of the brain, and explaining the rigidity on the left side of the body. Case 2 was that of a man who entered the infirmary under Dr. Paterson, in 1842. All the symptoms of acute softening were present; paralysis of the left side, including rigidity and contraction of the left arm, dulness of intellect, and tonic spasms of the muscles of the mouth and neck. The right side was also affected in a slight degree. As the case excited considerable interest, great care was taken in examin- ing the brain after death. When the lateral ventricles were opened, it became a question whether the right corpus striatum was softened. Several persons applied their fingers and endeavored to ascertain the point. As the manual examination proceeded, the normal consistence of the part diminished, until at length it presented all the appearance of pultaceous softening. In this state it was shewn to Dr. Paterson, who naturally enough considered it to be the result of disease. I differed from him in opinion, first, because I had carefully observed the gradual increase of the softening in the manner alluded to ; and secoadly, because disease of the corpus striatum, in one side of the brain, could not have explained the well-marked symptoms which existed on both sides of the body. When the pons varolii was bisected, Dr. Peacock, who conducted the examination, conceived it to be 360 DISEASES OF THE NERVOUS SYSTEM. softened; others who examined it could perceive no difference in the texture; its color and consistence were unchanged. Keasoning from the symptoms, the lesion was very likely to exist. But how, it was argued, could a judgment he formed; we ought to reason from facts, not theories ? Here, then, was an evident lesion of the corpus striatum, which explained nothing, and a problematical lesion of the pons varolii, which, however, did it exist, would satisfactorily account for the symp- toms. In this state of uncertainty the microscope was sent for, and I demonstrated and made evident to Drs. Paterson, Peacock, and all the students present, that the corpus striatum contained no granular corpuscles, whilst in the pons varolii they were very abundant. I have endeavored to describe what took place on this occasion, from which it must be evident that had not the microscope been appealed to, the right corpus striatum would have been pronounced softened, whilst the real lesion in the pons varolii might have escaped observa- tion. Under such circumstances this case would have added another to the inexplicable observations with which the records of nervous diseases abound. Wliat renders these cases, and several others I could relate, so remarkable and satisfactory is, that they are not instances where the dissection was performed in a hurried manner, and by incompetent persons. On the contrary, from the particular symptoms connected with them during life, the post-mortem examination was in all con- ducted with extreme care. The physician who had charge of the case was present. The examinations were witnessed or conducted by my- self, in the presence of clerks and numerous students, and I may say that we were all in doubt until the microscope cleared up tlie difficulty. These cases, therefore, sufficiently demonstrate that the naked siyht is positively unable to detect lesions, even although they are directly indi- cated by the symptoms, and carefully looked for by experienced morbid anatomists. If, then, the two propositions formerly stated have been satisfac- torily proved, and it is agreed that pathologists have been confounding vital with post-mortem softening, and overlooking the former, although undoubtedly present, it must be evident that many of the contradic- tions which have apparently existed in connection with the pathology of nervous diseases may be accounted for. It must also be clear that no confidence can be placed in the analysis of cases, however nume- rous, when the sources of error now indicated have not been carefully excluded. ACUTE HYDBOCEPHALUS. Case 1."^ — Acute Hydrocephalus — Recovery, History, — Janet Reid, aet, 12 — admitted June 12th 1850. About three weeks ago she fell down and struck the back of her head violently, but soon recovered, and remained well until two days ago, when febrile symptoms, with headache, occurred. The following morning these continued, and vomiting came on, with great restless- ness, and crying at night. * Reported by Mr. E. S. Wason, Clinical Clerk. ACUTE HYDROCEPHALUS. 361 Symptoms on Admission, — On admission she is very drowsy, and starts occa- sionally in her sleep. When roused she is fretful and irritable, and complains of headache. The pupils are dilated, but contractile on exposure to a strong light ; pulse 104, of good strength ; skin hot ; tongue covered with a white fur, and dry ; no appetite ; great thirst ; bowels not open for two days. Urine, sp. gr. 1030, with phosphatic deposits. U Calomd^ gr. iij ; Fwlv. Scammon. gr. v., Fiant Fnlv. tales duo. Sumat tcmcm statiin., et alterumpost Koras tres. — Applicent. hinodines^ iv. capiti. Progress of the Case. — June IZth. — Leeches bled well. Took both powders, and had an injection, which brought away one stool of a dark greenish color. Still complains of pains in the head, and general uneasiness when moved. But tliere has been no more vomiting, and there is no intolerance of light. Pupils natural ; pulse 120, rather sharp ; skin still hot and dry ; continues drowsy, and fretful when moved ; tongue white and moist. — Sumat Ext. Senuce, 3 U, aqua., et repetatur post Koras quatuor si opus sit. June \ otK. — No headache and not so drowsy. June ‘I'ld. — Since last report has been gradually improving ; the febrile symptoms have ceased, and she was dismissed quite well. Case 2 .* — Acute Hydrocephalus in a Scrofulous Child — Recovery. History. — John MhUilay, aet. 9, son of a servant — admitted July 5, 1855. This boy is of a scrofulous constitution, and was admitted into the Surgical Hospital, June 22d, for a scrofulous sore on the left ankle. Three days afterwards he was attacked with scarlatina, which ran a mild course, and from which he was convalescent on the 29th, June 30^/q however, he complained of not having slept, vomited several times, and was very restless. July Is^, he refused to eat anything, and in the course of the day screamed violently several times. There was also cephalalgia, drowsiness, photophobia, and great irritation when roused. In this condition he remained until admitted into the Medical Clinical ward, the tendency to constipation having been counteracted by the administration of purgatives twice. Symptoms on Admission. — On admission, the face is pinched, and expressive of great irritability. He cries fretfully when touched or disturbed. The eyes are spasmodically closed, and he resists all attempts to open them ; but when this is done, both pupils are seen to be dilated, and not movable on exposure to the light. On being left quiet, he turns away from the light, and relapses into a doze, interrupted by occasional moanings. Pulse slow and feeble, difficult to count from resistance of the child ; skin and head of natural temperature. There is still a scrofulous ulcer on the left ankle, discharging pus of an offensive odor. Tongue furred ; refuses food ; bowels constipated ; has no cough or pulmonary symptoms, and has never had strabismus, grinding of teeth, convulsion, or paralysis. — To have beef tea., milk., and nutrients., witK § iij of sKerry wine daily. Pulv. Jalap, gr. v. ; Hydrarg. Chlorid. gr. ij ; ft. pulv. Kora somni sumendm. Progress op the Case. — July — At seven a.m. passed a copious, dark, offensive stool. Has been persuaded to take a little milk, but refuses other nourish- ment. Still fretful and irrritable, but the nurse says he did not scream or toss about so much during the night. Pulse 64, weak. Otherwise the same. July 1 1 tJi. — Since last report the general irritability has somewhat diminished, and last night he slept well. Has gradually been induced to take more nourishment. Does not scream now, but moans occasionally, and tosses about until exhaustion produces sleep. Now and then he puts his hand to the forehead, and says he feels pain there. His sight is occasionally dim, but at other times he sees well. Cannot sustain any train of thought or conversation long Still constipation, which is relieved every third day with the powder of calomel and jalap. July 20tK . — There has been gradual improvement on the whole, although much variation from day to day. Some nights are more restless than others, with occasional screaming. He still puts his hand to the head, which is sometimes, he says,' “ sore.” The pulse has varied from 60 to 80. The appetite has improved, and he takes more nourish- ment. Sight and memory more perfect. August 3c?. — Has been occasionally screaming a good deal at night, but is now much better, and walks about on crutches, the scrofulous sore on the ankle being no better. August SiK. — It having been stated that he was affected with worms, he has taken some doses of the etherial extract of the Male Shield Fern, followed by purgatives. These have produced * Reported by Mr. Robert Byers, Clinical Clerk. 362 DISEASES OF THE NERVOUS SYSTEM. several stools, but no worms. His appetite and general health have now been greatly restored. There is no pain in the head, or restlessness at night, and he was sent back to the surgical wards to have his ulcer treated. Commentary. — In the two preceding cases we have good examples of that congestive and irritative state of the brain, which occurring in children has been regarded as indicative of acute hydrocephalus. Whether in either of them the disease had proceeded to actual effusion, it is of course difficult to determine, although the pain in the head and restlessness passing into somnolence render this probable. In the first case, where the child was tolerably healthy, febrile phenomena with ex- citement were more pronounced than in the second scrofulous case, in which exhaustion was evident from the first. Hence why a few leeches and laxatives constituted the treatment in the girl Reid, although, it will be observed, that their employment produced no marked improvement in the symptoms, the pulse on the following day being 120, sharp, the skin hot and dry, with a continuance of the drowsiness. Notwithstand- ing, no further antiphlogistic remedies were persisted in, and two days subsequently the patient became convalescent. In the second case an opposite plan of treatment was practised from the first. Here the pulse was slow and feeble, the symptoms were indicative of exhaustion, and this child not only had a scrofulous sore, but had recently recovered from an attack of scarlatina. Nutrients with wine, therefore, were persever- ingly pressed upon the patient, notwithstanding the deficient appetite and nausea, with the effect of ultimately establishing a recovery. Case III .'^ — Acute Hydrocephalus — Phthisis Pulmonalis— Death — Effusion into the Lateral Ventricles — Eon-lnjlcmmatory sojtening of the central parts of the Brain — Meningitis at the base of Cra- nium — General Tuberculosis. History. — Mary Ann Flynn, set. 6 — admitted June 26, 1845. She is an intelli- gent child, of scrofulous and cachectic appearance, and greatly emaciated. From her own statement she had influenza a year ago, and has had a cough ever since. Her diet has always been very poor, chiefly consisting of potatoes without any milk or animal food. Latterly she has experienced pain in the head, has been feverish and restless at night, and yesterday she vomited several times. Symptoms on Admission. — On admission she complains of headache, pain in the back, great thirst, nausea, and cough. The pain in the head is felt over the fore- head, sometimes extending to the entire head ; is constant but not severe at present. She has also slight pains in the back, not increased on pressure. Her intellectual powers are for her age unusually good ; pupils and eyeballs natural ; never had fits or other derangement of the nervous system. She has no appetite, refuses all food, but constantly desires drink ; tongue covered with a whitish fur ; mouth dry. She has not vomited since admission, but complains of distressii g nausea; abdomen feels natural; had diarrhoea of light yellow fluid stools two da}s ago, which has now ceased ; has frequent prolonged cough, not accompanied by much expectoration. On percussing the chest, there is comparative dulness under the right clavicle, and on auscultation over this part, a loud moist rattle accom- panies the inspiration, extending down to the third rib. Here also there is broncl.o- phony. Similar signs exist on the right side posteriorly, at the apex of lung, and over the rest of the chest there is great harshness with inspiration, and prolonged expiration with occasional sibilation. Respirations are 26 in the minute ; pulse 150, small and somewhat hard; heart sounds rapid, but normal in character; skin hot, covered with perspiration ; head unusually warm. — Applicent. hirudines iv. temporihus — llaheat Vini Ipecac. ^ ss. Reported by Mr. D. P. Morris, Clinical Clerk. ACUTE HYDROCEPHALUS. 363 Progress of the Case. — June I'lth. — The emetic operated powerfully ; nausea removed ; headache diminished ; otherwise the same. July 2d. — Since the 28th there has been frequent vomiting, for which naphtha, hydrocyanic acid, and other- remedies, have been given without benefit. Little food has been taken. Loud gurgling audible under right clavicle ; constant cough, with purulent expectoration. The surface is pale, and she cannot be spoken to or touched without causing cries and moaning. Bowels open ; stools natural. There has been occasional diarrhoea, which has been checked by chalk mixture. Constant pains in the head, with great restlessness at night. Pupils slightly dilated ; pulse lUO, of good strength. Abradalur Capillitium et Applicet. Emp. Lyttm. Milk diet with beef tea and wine in small quantities. July 1th. — Has continued much the same since last report, the vomiting being considerably less frequent however. Last night it is reported she was comatose, and could not be roused, and that convergent strabismus of the left eye was undoubtedly present. To-day she is lying on the right side, the knees drawn up to the abdomen ; the face pale ; surface cool ; respiration easy. She does not answer questions or protrude her tongue when desired, although her eyes and look are intelligent. No paralysis. Metallic resonance when she speaks or cries under right clavicle. Pulse 104, of good strength. Habeat Calomel, gr. ij, tertid qudque hord. July \2th. — There has been alternate looseness and constipation of the bowels, the stools being of a spinach color. Sometimes better, at others com- plaining of great pain in the head. The expression of countenance is now worn and haggard, with evident anxiety ; eye and mind still peculiarly, and even painfully intelligent. No convulsion or paralysis, but great restlessness occasionally at night. At other times she sleeps well. Pulse is more frequent and weak, generally about 160 a minute. Omit. Pulv. Calomel. Habeat Vini, §ij, secundd qudque hord. July 15<;A.— Has been gradually sinking since last report. Pulse 180, feeble. Still intelligent, and answers questions. Died at five p.m., from exhaustion, without pre- vious coma, strabismus, convulsions, rigidity, or paralysis. Sectio Cadaveris. — Forty-three hours after death. Body greatly emaciated. Head. — On removing the dura mater from the superior surface of the hemi- spheres, the arachnoid covering them was found unusually dry, and the pia mater somewhat pale. On stripping the membranes from the convolutions, and holding them up before the light, they could be seen to be sprinkled at irregular distances with minute white hard points, having the appearance of tubercle, deposited in the sub-arachnoid tissue. The glandulte Pacchioni could easily be distinguished from them by their situation, softer consistence, and larger size. On removing slices from the hemispheres, fluctuation of fluid in the ventricles could readily be felt below. A puncture was cautiously made in the roof of the left lateral ventricle, and ^iiiss of colorless serum were removed with a pipette. On declining the head towards the left side, more fluid was removed, which had evidently passed from the right ventricle into the left through the foramen of Monro. This last portion was turbid, and contained small floating fragments of lymph. On opening the right ventricle it was collapsed. The foramen of Monro was the size of a large pea. The fornix, internal walls of the ventricle and cerebral portions in the neighbor- hood of the ventricles were of pulpy consistence, but of their normal color. On removing the brain from the cranium, the pons varolii, medulla oblongata, and corpora albicantia, were seen to be covered with a layer of pale gelatinous lymph, one-eighth of an inch in thickness. This layer only extended to the medulla oblongata inferiorly, where it passed through the foramen magnum, as was proved by careful examination of the spinal cord, which was healthy throughout. The third and fourth ventricles of the brain were enlarged, and distended with serum. The left lateral ventricle was also enlarged, especially its posterior and inferior cornua. The enlargement of the right lateral ventricle was confined principally to the anterior cornu. Chest. — Pleurae on right side sprinkled with miliary tubercle, situated below the serous surface. Both lungs studded throughout with hard miliary tubercle, of a grey color ; in some places, however, it was yellow and soft. The intervening pulmonary tissue was of a bright red color, engorged, but pervious to air. In the superior lobe of right lung the tubercles were closely aggregated together, and con- tained numerous anfractuous cavities varying in size. Some were lined by a distinct 364 DISEASES OF THE NEKVOUS SYSTEM. membrane, and all were filled with scrofulous pus. Heart and vessels healthy. The bronchial glands enlarged from infiltration of yellow cheesy tubercle, mixed with pigmentary deposit. Abdomen. — Liver of natural size. Gall-ducts and gall-bladder distended with fluid gx’cen bile. Kidneys healthy in size and general structure, but the cortical substance sprinkled over with minute grains of tubercle. Stomach healthy. The ilium was the seat of tubercular ulceration throughout, situated principally in the aggregate glands. Large intestines healthy. Mesenteric and lumbar glands for the most part enlai-ged in consequence of tubercular infiltration. Spleen throughout studded with yellow cheesy tubercle in granules varying in size from a pin’s head to that of a pea. Peritoneum here and there dotted over with hard miliary tubercle, deposited, however, below the serous membrane. Microscopic Examination.— The pale gelatinous lymph at the base of the brain was principally composed of molecular matter, in which a few granule cells might here and there be detected. The turbid fluid at the floor of the ventricles contained epithelium cells, some of which were undergoing the fatty degeneration. The white cerebral softening contained no granules nor granule cells. The hard grey and soft yellow tubercles in various parts of the body were carefully examined, and were found to present their usual characters (Figs. 157, 161). Commentary . — Tliis is a well-characterised case of acute hydrocephalus in a child also affected with general tuberculosis. From the first it was certain that it would be fatal, for in addition to the cerebral lesion we had to do with an advanced phthisical condition. The appearances after death are strictly in accordance with all the symptoms which were care- fully observed during life. Her mind throughout was unaffected, except when occasional drowsiness or coma prevailed, and the circumference of the hemisjThere was normal, while the lesions observed were confined to the ventricles and base of the cerebrum. Then there was no paralysis or convulsion, and the softening of the central parts was proved to be serous. The pain, irritation, stupor, and other symptoms, are readily explicable by the tubercular meningitis and gradual distension of the ventricles with fluid. Tlie treatment was nutritive, and in obedience to the prac- tice of twenty years ago, an emetic, a few leeches on the head, and small doses of calomel were given. They were of no benefit, and need never be employed. The nature of acute hydrocephalus has been keenly disputed, and, whether it be inflammatory or non-inflammatory, and should be treated with antiphlogistics or nutrients, will be found to be discussed at great length in systematic works and numerous monographs. The fact is, that the group of symptoms indicating the occurrence of water in the brain is altogether insufiicient to prove the existence of this morbid pro- duct in acute cases. What we observe are symptoms of excitement, gradually passing into those of depression, occasionally accompanied with paroxysms of pain, restlessness, and screaming, alternating with drowsi- ness, exhaustion, and coma. The sesymptoms are common to various lesions of the brain, and may be the result of mere congestion, or of this state terminating in effusion and frequently in exudation. Hence why sometimes after death we find no lesion whatever ; at others more or less distension of the ventricles with serum, and very commonly in addition exudation at the base of the cranium. In every case the symp- toms are referable not so much to the one or the other of these lesions, as to something which they all have in common, and this undoubtedly is * See the author’s article on Hydrocephalus, iu the Library of Medicine, vol. ii. London, 1840. ACUTE HYDROCEPHALUS. 365 more or less pressure on various portions of the brain, causing first irri- tation and then perversion of function, or so operating as to excite some parts and to depress others. In the great majority of cases the fluid dis- tending the ventricles is more allied to the dropsies than to the exuda- tions. Nay, even when lymph is thrown out at the base of the brain, the amount of serum in the ventricles is altogether disproportioned to the quantity of coagulated fibrin deposited. Hence I am disposed to think that, even when evidence of so-called inflammation does exist, as in Case ' III., still the fluid which distends the ventricles is owing to a mechanical obstruction of the vessels, causing dropsical effusion. As to the central white softening so commonly found in hydrocephalic cases, it is, in the vast majority of instances, a post-mortem appearance, caused by mechani- cal imbibition of the serum into the porous substance of the white tubular structure of the brain. I have seen this softening most extensive in cases where, immediately before death, the transmitting functions of the white central parts were perfect ; and the fact that no relation exists between the symptoms during life and such softening after death has been noticed by numerous observers. In a special work on this subject (London : 1843), Dr. Risdon Bennett, looking to the scrofulous character of the children usually affected with this disease, refers its nature to “ vital changes in the brain, chiefly in the central white parts, of the character probably of tubercular degeneration, — and that softening, effusion into the ventricles, and meningitis, are all consequences of antecedent alterations of nutri- tion ” — Pp. 148-49). This view, which contains the general truth, may, I think, now be more specifically stated as follows : — All circumstances, including scrofula, which weaken the general nutrition of the economy, tend to occasion languor and obstruction of the cerebral circulation. This defective nutrition is, in young children, especially liable to occasion congestions within the cranium, causing effusions and exudations, either simple or tubercular, and as a mechanical result of such effusion, those softenings so frequently found after death. Such appears to me the true pathology of acute hydrocephalus, including the “ hydrocephaloid dis- ease ” of Dr. Marshall Hall. In the treatment of this disease much stress has been laid by prac- titioners on the question, as to whether in any given case the symptoms are or are not dependent on inflammation, and if so, what may be the character, seat, and stage of the inflammation. If the disease be inflam- matory, blood-letting, with antiphlogistics and calomel, has been enjoined. • When, on the other hand, it arises from diarrhcea, or after exhaustive diseases, an opposite line of treatment has been the rule. The profession cannot be too grateful to Dr. Marshall Hall for clearly pointing out how all the symptoms of hydrocephalus frequently arise in children after long- continued diarrhoea, febrile eruptions, or other exhaustive causes, and how they may frequently be restored under such circumstances by nu- trients and stimulants. But it may now be asked whether, in fact, we possess the means of clearly distinguishing the inflammatory from the non-inflammatory forms, and whether, if we did, we are justified in treat- ing the former by antiphlogistic remedies ? In reply to these questions, I would observe, in the first place, that all authors are agreed as to the difficulty of separating acute hydrocephalus 366 DISEASES OF THE NERVOUS SYSTEM. from remittent fever, and no one, so far as I am aware, has ever pretended that he coiild point out with exactitude the symptoms which distinguish cases in which there are, and those in which there are not, exudations of lymph within the cranium. After the most careful examination of many cases, both during life and after death, I feel satisfied that, conjoined with exactly the same train of symptoms, we may sometimes find only effusion of serum in the ventricles, with white softening, and at others more or less meningitis of the base. Again, I also feel satisfied that this meningitis, as proved after death by the existence of layers of lymph, so far from indicating a so-called sthenic constitution in children, much more frequently occurs in scrofulous and weak children. Of this. Case III. is an example, where with phthisis and general tuberculosis, there was found conjoined with etfusion into the ventricles, inflammatory ex- udation at the base of the cranium. The distinctions, therefore, hitherto so much dwelt upon, of two distinct forms — an inflammatory and a non- inflammatory — as guides of treatment, have no real existence, and are opposed to all positive research, as well as to a large experience in the observation and treatment of individual cases. When, in addition, it is considered that all the symptoms of acute hydrocephalus are referable to more or less pressure on different parts of the brain ; that this pressure may be occasioned by congestion, effusion, or exudation ; and that we have no means of determining which or how much of each is present in any individual case, it must, I think, be certain that it is impossible in the vast majority of cases, and highly doubtful in all, to determine the existence of meningitis or cerebritis as a concomitant of acute hydro- cephalus. Lastly, the symptoms of the “ hydrocephaloid disease,” so well described by Dr. Marshall Hall, in which all the phenomena of hydrocephalus occur, and which are only distinguishable by the circum- stance that they originate from exhaustive causes, should alone make us pause before we have recourse to a lowering system of practice. But supposing we had the power to detect in any given case the occurrence of active exudation going on within the cranium, should we even then be justified in having recourse to blood-lettirg, general or local ? The considerations we have previously entered into (p. 268, et seq.) — first, as to the incompetency of this remedy (and of antiphlogistics generally ) to meet the end in view ; and, secondly, as to the fact that we can only reach the circulation within the cranium by influencing the force of the heart (p. 148,^^ seq .) — are sufficient answers to this question. It follows, then, that the uncertainty of diagnosis, as well as the evil ef- fects likely to result from a lowering practice in these cases which almost always occur in weak children, are not only opposed to it, but perhaps sufficiently explain the acknowledged great mortality of the disease. For the like reasons the use of calomel to cause absorption of matters, whose existence we have no means of detecting, appears equally unreasonable, even supposing it had been proved to possess an absorbing power, which it certainly has not. On the other hand, the two first eases we have recorded are examples of what may be done by an opposite plan of treatment in acute hydro- cephalus, and in the third case, we believe the practice followed to have been the only warrantable one in the desperate and necessary fatal cir- cumstances. It bore reference to improving the general constitution and CEREBRAL MENINGITIS. 367 nutritive powers of the patient, which in all cases connected with a scrofulous habit are the indications to be more or less energetically fol- lowed according to the severity and duration of the disease. The calo- mel given as an alterative utterly failed. CEREBRAL MENINGITIS. Case I Y.* General Acute Meningitis supervening on Pleuro- Pneumonia, History. — David Murray, set. 43, a coal-heaver — admitted January 18, 1854. He has been an intemperate man, and a week previous to admission was seen by one of the pupils to be atfected by delirium tremens. He now says, that on the 13th (which was the first day of thaw after frost and snow) he was much exposed to the weather while at work, but felt no ill efiects until the morning of the 15th at four o’clock, when he awoke very sick, and vomited several times. He kept his bed, feeling feverish, and in the afternoon began to cough. On the morning of the 16th he experienced a sharp pain in the right chest, about three inches below the nipple, which was increased by coughing and inspiring deeply, and prevented his lying on that side. Has had no rigor nor headache. Symptoms on Admission. — On admission, respiration is impeded by interrupted inspirations which give pain. Over the lower half of the right lung posteriorly, there is marked dulness on percussion, loud crepitation on insjiiration, and broncho- phony. The sputa are scanty, consisting of gelatinous matter, with rusty brown patches. No dyspnoea. Pulse 120, strong and full ; skin hot and dry ; tongue dry, furred, and fissured ; great thirst ; no appetite ; bowels open, lias no headache at present, but says he is restless at night, and sleeps badly. Other functions normal. To have one-third of a grain of tartrate of antimony in solution every two hours. Progress of the Case. — Tanuaru Tld. — Since /last report the pneumonia has followed its usual course. — (See Pneumonia.) On the 20th crepitation had dis- appeared, but has returned to-day. Yesterday evening was ordered a diuretic draught, containing Sp. AEdier. Nit. 3 j. The pulse 130, weak, and at the visit his replies to questions were a little confused. January 23(7. — Yesterday afternoon he was observed to mutter incoherently, but remained quiet until eight p.m., when he became violently delirious. He had a very wild and fierce expression of eye and countenance, insisted on getting up, would npt be controlled, and struggled violently with those who endeavored to restrain him. He spoke little, but made incoherent noises. The pupils were much dilated ; the pulse very rapid and weak. The head was shaved., and constant cold applied. Prostration, however, coming on, wine and stimulants were given freely. He continued now and then to struggle violently ; strabismus was apparent latterly. Died exhausted at five o’clock a.m. this morning. Sectio Cadaveris . — Thirty-one hours after death. Body greatly emaciated. Head. — On removing the skull-cap, the dura mater presented a uniform yellowish tint, dependent on a recent exudation below it. On removal, the subarachnoid tissue was infiltrated with a soft exudation, which covered the entire surfiice of both hemispheres, and of the cerebellum. It was as abundant at the base as on the supe- rior surface of the brain. On cutting into the cerebral substance, it was observed that the yellow exudation accompanied the inflexions of the pia mater between the convolutions. The lateral ventricles contained § iss of turbid serum. The lining walls of the ventricles were a little congested ; the choroid plexuses healthy. The septum lucidum rather soft, but the other portions of the brain normal. Thorax. — Three lower fourths of the right lung presented the characters of grey hepatization posteriorly. The anterior surfaces were healthy. The pleune covering this lung were partially adherent, with some shreds of recent lymph. Other thoracic organs healthy. Abdomen. — The liver enlarged, weighing 6 lbs. 4 oz., of pale color, and soft. The spleen also soft and pulpy. Other abdominal organs healthy. Microscopic Examination. — The exudation poured out in the subarachnoid * Reported by Mr. Robert Bird, Clinical Clerk. 368 DISEASES OF THE NERVOUS SYSTEM. cavity had everywhere undergone the transformation into pus. The turbid fluid in the lateral ventricles also contained some pus, with a few epithelial cells. The cerebral tissue was healthy. The liver cells contained an unusual amount of fatty granules. The pneumonic portion of the right lung was infiltrated with fluid mole- cular matter and pus corpuscles, most of which were more or less collapsed, and all of them very granular. The whole evidently in a state of disintegration. Commentary . — In this man, who was intemperate, and laboring under pneumonia, whicli was progressing favorably, there supervened at noon on the seventh day of the disease a little confusion in his ideas, which in the course of the afternoon passed into violent delirium, caus- ing strabismus and dilated pupils. At night he became comatose, and died at five o’clock next morning. At the commencement of the pneu- monia he had vomited, a symptom perhaps referable in him to cerebral irritation, a condition which the febrile state he was subsequently thrown into, however, did not appear to augment in any unusual degree. On examining the head after death, the subarachnoid cavity and involutions of the pia mater over the whole surface of the brain were loaded with purulent matter, and | iss of turbid serum was effused into the lateral ventricles. This, therefore, was an instance of very rapid death from meningitis, a result partly attributable to his previous intemperate habits, and partly to the circumstance that the disease appeared at a time when he was already much exhausted by the pneumonic attack. In this, as in Case III., it is observable that the occurrence of extensive exudation is in no way incompatible with depression of the bodily powers, a fact alto- gether opposed to tliG supposed connection between inflammation and a sthenic state of the constitution. In fact, the extent as well as the fatality of the cerebral disease is probably to be attributed to the ex- haustion of the vital powers at the time of its occurrence. The pneumonia went through its usual progress, and on the day when the meningitis commenced, the returning crepitation was audible. On examination after death, the whole pulmonary exudation was found softened and converted into pus, which was already undergoing rapid disintegration. (See Pneumonia.) Case V.* — Acute Meningitis at the Base of Brain — Serous Effusion into the Ventricles., with white softening of cerebral substance — Phthisis. History. — Helen Walker, ast. 21, a servant — admitted July 4, 1853. 8he has for some years been subject to cough and dyspnoea, but says she never had any serious illne.ss until eleven days ago. She then experienced rigor, pain in the head, thirst, and other febrile symptoms. The headache has been variable in intensity, being sometimes slight, at others very severe. Symptoms on Admission. — On admission, she appears to be very weak and languid. Complains of severe frontal headache which is increased towards night. The eyes are dull and heavy ; pupils unaffected. No muscae volitantes, tinnitus aurium, or vertigo. Is quite conscious, but has a tendency to stupor. The febrile symptoms have now for the most part disappeared. No thinst ; appetite impaired ; tongue furred ; pulse 84, .soft. On examination of the chest, all the signs of phthisis, with cavities in both lungs, were detected. The other functions are normal, ^he requested to have an emetic, which had previously relieved her, and one of ipecacu- anha and sul|)hate of zinc was given. Progress of the Case. — July oth. — The emetic has not produced the same * Reported by Mr. G. C. Pirrie, Clinical Clerk. CEREBRAL MENINGITIS. 3C9 relief as formerly. Headache continues. In other respects the same. Six leeches to he applied to the temples. July 6plications to he conistantly made. To have 3 ss of castor-oil in peppermint water. Progress of the Case. — July 21s^. — Was delirious during the night and became violent, raving incessantly, and trying to get out of bed, so that it was necessary to put on the strait-waistcoat. Bowels have not been relieved. Pulse 130, weak. To he cupped at the hack of the neck to § viij. To have a turpentine injection. July 22c?. Still delirious. During the night vomited several times. Will take no nourish- ment. The right arm is occasionally convulsed. Bowels have been freely opened. In other respects the same. A blister to be applied to the sinciput. Nourishment to he given in small quantities, frequently repeated with ^ iv of wine. July 2‘Sd . — Delirium not so violent during the night, consisting of low muttering. At present seems ex- hausted. Pulse 126, small and weak. Vomiting occurs now and then, but not so frequently. Blister has not risen. To continue nourishment with 3 vj wine. July 2^th. — Since last report the violent symptoms and vomiting have ceased, and she appears to suffer no pain, although the intellect remains confused. She was observed to move the right arm, as well as the other limbs occasionally, and took the beef tea, and other nutrients, with wine. On the night of the 26th coma came on, and on the following day she was evidently sinking. Died early on the morning of the 28th. Sectio Cadaver is. — Thirty-four hours after death. Body well formed, not emaciated. Head. — On removing the skull cap and dura mater, the arachnoid and pia mater covering the hemispheres are seen to be unusually congested. About the middle of the right hemisphere was a patch the size of a sixpence, of a dirty yellow color, which, on being cut into, was found to be the vault of an abscess, as large as a wal- nut, lined by a soft and vascular membrane, and containing one half ounce of dirty greenish pus. A similar abscess of nearly the same size Avas situated a little ante- riorly, and somewhat deeper, in the anterior lobe. A third abscess, the size of a hen’s egg, existed in the centre of the left hemisphere, above the corpus callosum, and about one quarter of an inch from the surface of the hemisphere. The walls of these abscesses were somewhat indurated, punctated with red spots, and lined with a fibrinous matter about a quarter of an inch thick, which apparently had not yet undergone the purulent transformation. Other portions of the brain healthy. Thorax. — In the bronchial glands, and at the apices of both lungs, wmre several cretaceous and calcareous tubercles, surrounded by indurated black pulmonary tissue. Other thoracic organs healthy. Abdomen. — The peritoneum covering the intestines presented here and there patches of highly vascular lymph, studded with opaque granular lymph about the size of millet seeds. The mesenteric glands were enlarged and infiltrated with old cheesy tubercles. The liver and spleen contained a few granular yellow deposits. The uterus was retroverted, the os, oedematous, and the cavity of fundus filled with a glairy opaque yellow mucus. Fallopian tubes obstructed by an atheromatous sub- stance, resembling broken down and viscid pus. Left ovary somewhat enlarged, and with its fellow covered with Graafian vesicles in different stages of development. Other abdominal organs healthy. Microscopic Examination. — The pus corpuscles in the cerebral abscesses more delicate and clear than usual, displaying their nuclei without re-agents. They were also mingled with, and surrounded by celloid albuminous deposits. The friable matter inside the lining membrane was composed of minute molecular filaments, and numerous molecules and granules. The membrane itself also had a fibrous basis, in- volving some nerve tubes, but no appearance of fibre-cells or nuclei. External to the membrane, the cerebral substance, to the depth of about a line, was composed of dis- integrated nerve-tubes and granule cells in great abundance. Case X. — Actde Cerehritis — Abscesses in the Brain — Pulmonary Tubercle — Abscess in Kidney. History. — John Dods, pet. 19, a butcher — entered the Clinical ward November 9, 1855. Has been in weak health for the last two years. A week ago he was seized ^ Reported by Mr. R. P. Ritchie, Clinical Clerk. 378 DISEASES OF THE NEEVOUS SYSTEM. with pain in the upper part of the head, not preceded by shivering, or occasioned by any obvious cause. Denies that he had been drinking. Since then he has felt hot and feverish, and says he has vomited frequently, generally about half an hour after eating. The pain has continued, accompanied with ringing in the ears, up to the present time. Symptoms on Admission. — On admission, he complains of racking pains in the upper part of the head. There is constant ringing in the ears ; the eyes are suffused • face flushed; speech confused, with difficulty in collecting his ideas. Appetite he declares to be good ; no great thirst ; tongue covered with a dirty yellow fur, white at the edges ; no pains in stomach ; bowels regular ; complains of cough, with’ slight mucous expectoration. Percussion everywhere normal. On auscultation, there is harsh murmur with inspiration and prolonged expiration at right pulmonary apex ; nowhere increase of vocal resonance ; pulse 04, feeble ; skin moderately warm ; body emaciated. Other functions normal. The head to he shaved and cold evaporating lotions to be constantly employed. Progress of the Case. — November llth. — Passed a restless night, but says the ce- phalalgia is diminished. Pulse still weak ; has taken no nourishment. To have beef tea., and 3 iij of wine. November 12^/i. — Last evening became very restless, and frequently cried out. This morning at two a. m. he screamed out violently, complained of pain in his head, and became incoherent, but when loudly spoken to, gave rational answers. Both pupils were of moderate size, the right slightly dilated more than the left, but con- tracting equally on exposure to light. At four a. m. he was seized with a general con- vulsion, preceded by a scream, in which it was observed that the left superior extremity was more rigidly contracted than the right. The right pupil now ^vas more dilated than the left, and both contracted only feebly on exposure to candle light. The convulsion lasted five minutes, and terminated in complete coma, which continued up to the hour of visit. He was then found to be perfectly unconscious, and could not be roused. There were occasional startings of the limbs. The left foot and leg are insensible to the action of irritants, which on the right side, however, occasion slight movements. Respiration stertorous ; right pupil more dilated than the left; pulse 120, full. To be cupped at the nape of the neck, and § viij of blood extracted. Continue the applica- tion of cold to the head. At eight p. M., having been cupped, the breathing became easier ; but the coma continued, and he died at three a. m. on the 13th. Sectio Cadaveris. — Eighty-one hours after death. Body emaciated. Head. — On removing the calvarium, two bulging abscesses were seen, one occupy- ing the anterior and middle third of the right, and the other the posterior third of the left cerebral hemisphere, immediately below the dura mater, which was of a greenish hue. On removing this membrane, the abscess on the right side was exposed, which was of roundish form, measuring three inches in diameter. On the left side the abscess was not quite so large, measuring two and a half inches in diameter. On cutting through these abscesses, they were seen to be embedded in the cerebral lobes, above the corpus callosum. They consisted of several excavations, varying in size from a pea to that of a hazel nut, all communicating with one another, and filled with greenish pus. Their margins presented a smooth, abrupt border, which was consid- erably indurated to the depth of one-eighth of an inch, with points of blood here and there scattered through it. The ventricles and all other parts of the brain were healthy. Thorax. — In the apex of right lung were about half a dozen miliary tubercles, and the pleura3 over these were firmly united by dense chronic adhesions. The ante- rior surface of the left lung slightly emphysematous. Abdomen. — Abdominal organs healthy, with the exception of an abscess the size of a hazel nut, in the cortical substance of the left kidney. Microscopic Examination. — The pus in the cerebral abscesses contained pus cells, with delicate walls, floating in a liquor puris crowded with molecules. The indurated margin of the abscesses was composed of a dense aggregation of minute molecules of a light brownish color, gradually diminishing towards the healthy portion of the cerebral texture, where they were seen to be infiltrated among the tubes. Commentary. — In these two cases, abscesses were found in both hemispheres, and it will be observed that the symptoms were of the same general character as those of meningitis formerly given. The only differences observable are the more decided convulsions and paralysis, CEREBRITIS. 379 and the less degree of delirium, somnolence, and stupor. Indeed, it may be said to be impossible to distinguish, with any thing like certainty, in individual cases, acute exudations poured into the substance of the brain, from those affecting the meninges or ventricles. The reason will be obvious when we reflect that the phenomena, in every instance, are in fact attributable to pressure on the encephalon, and that, if this be rapid ’and general, it can matter little whether it originate from the meninges or the centre of the cerebral lobe. In the latter case, however, as the disease progresses, there is more liability for the cranial ganglia, con- nected with motion, to become affected, and hence probably the greater amount of convulsion and paralysis. Lebert,"^ in an elaborate Memoir on Cerebral Abscesses, in which he has carefully analysed the histories of 80 cases, has come to the con- clusion, that what debilitates the individual, causes a predisposition to this affection. Such is also my own opinion, as most of the cases I have seen have been in scrofulous subjects, and more especially such as have labored under some form of otitis, connected with caries of the temporal bone. In the two cases recorded, effete tubercle was found in the lungs, and the general health was much deteriorated. Very little benefit can therefore be expected from depleting remedies. Hitherto, indeed, almost all these cases have been vaguely ascribed to meningitis or apoplexy. But as regards diagnosis, we are exactly in the same condition now in reference to meningitis and cerebritis, as medical men were in during the days of Cullen, as to pleuritis and pneumonitis; that is, we cannot sepa- rate them by the aid of their symptoms. Hence the following summary from Lebert’s memoir, as it comprises all that is known with regard to the symptoms in 80 cases, is deserving attention : — “ Sudden headache is the symptom which most frequently first excites attention ; it is generally accompanied by febrile symptoms, vomiting, difficult articulation, and convulsive attacks may supervene; the patients become heavy and morose, and show delirium, contraction of pupils, photophobia; numbness and formication may supervene, and apoplectic symptoms may occur ; but ail these symptoms vary much in different cases. The intellect suffers com- paratively little; sensibility suffers more frequently; the headache is more or less intense, generally diffuse at first, and subsequently unilateral. Coma occurs frequently, but often only temporarily. Paralytic states were observed in almost one half of the cases ; they were generally local, but showed themselves also in the form of general muscular debility. Diminished articulating power was observed in 10 cases. In regard to the special senses, only the affection of the ears presents any points of importance. No special symptoms are observed in reference to the vas- cular or respiratory system. Disturbance of the digestive organs showed itself in the form of vomiting in 20 cases ; involuntary defaecation occurred towards the fatal termination of 11 cases. The duration of the disease appears to fluctuate from two or three weeks to two months ; there is necessarily a difficulty in determining the point, as the commencement can only be approximately fixed It occurs at all ages; but the great- est frequency prevails between the sixteenth and thirtieth years.” f * Virchow’s Archiv. fur Patholog. Anat. Band x. f British and Foreign Med.-Chir. Review. April 1857. 380 DISEASES OF THE NERVOUS SYSTEM. Case XI .* — Chronic Cerehritis ; Ejnlejytiform Convulsions; Hemi- 'plegia of the Right Side ; Loss of Smell ; Blindness of the Left Eye ; Amyloid Bodies in the Brain. History.— John Bookless, set. 48, a plasterer, admitted January 7, 1855. He had enjoyed good health until two years ago, when he first complained of giddiness and gradual impairment of sight, and of smell. Twelve months ago he was attacked with “ fits,” three or four appearing in the course of the first night. They have occurred' occasionally, at considerable but irregular intervals, ever since. His general health had remained good, until the 3d instant, when, about 12 o’clock at night, a violent “fit” appeared, which was repeated from eighteen to twenty times before six o’clock on the following morning. On the 4th and 5th he was comparatively free from them ; but, on the Cth, during the night, they recurred more frequently. On the morning of the '7th, it was observed that the right arm and leg were paralysed, and he was sent into the Infirmary. Symptoms on Admission. — On admission, it was observed that the body was toler- ably robust ; that he was hemiplegic on the light side ; that the head was obstinately kept turned towards the right side ; that speech was slow and thick ; and that although conscious, he was some time in framing an answer to a question. To have § j of castor oil. Careful investigation on the following day elicited the following facts, viz., com- plete blindness of the left eye — sight in the right eye perfect — smell absent — cepha- lalgia — frequently applies his left hand to the left side of the head — other special senses normal — loss of voluntary motion over right side, with considerable impair- ment, but not absence of sensibility — left side normal — pulse 96, full — other functions healthy. Bowels have been freely open, from the action of the castor oil. Whilst I was examining the patient, he passed through two attacks of an epileptic character — there was no scream, only a slight groan — the muscles of all the limbs became rigid — the toes and fingers incurvated — the face flushed, and the head tetanically twisted towards the right side — the mouth was drawn somewhat to the left — the left arm and leg convulsed, the right arm and leg rigid and trembling — there was complete loss of consciousness. This state continued about one minute, when the face became pale, there was foaming at the mouth, the rigidity and convulsions subsided, and in another minute he was again conscious and fully restored to his former condition. To he cupped in the neck to the extent of ^ oz. — ice to he applied to the head. Progress of the Case. — From this period he lay, in the intervals of the attacks, tolerably tranquil ; the evacuations were passed involuntarily ; took nourishment with- out difficulty. The whole of the 12th he was free from convulsive attacks, but on the 13th they returned ; pulse 106, soft. A blister to the neck., and §iv of wine. On the 14th the epileptic attacks returned every ten minutes, until one o’clock in the morning of the 15th. From this time he remained free from them. At the visit he was still conscious, slowly answered questions, put out his tongue, etc. The respira- tions, however, were slightly labored, and gradually became more so, until he sank, at 9 P.M., on the 16th. Sectio Cadaveris. — Fifteen hours after death. Head. — On removing the calvarium, the subarachnoid cellular tissue was infil- trated with serum, which elevated the arachnoid in some places above the level of the convolutions. On slicing the brain from above downwards, its substance was healthy. Both lateral ventricles were distended with clear serum, which, on being carefully removed with a pipette, measured 1 oz. and '7 drachms. The ventricles were some- what enlarged, but their lining walls healthy. The foramen of Monro was the size of a fourpenny piece, its edges very thin. White substance of the fornix and central portion of the brain healthy. The left eorpus striatum atrophied and shrunk through- out, externally of a dull mahogany color, and, on section, composed of a diffluent fawn-colored substance, which flowed out, leaving an irregular cavity the size of a hazel nut Below the left corpus striatum, the optic thalamus presented, on section, a cribriform appearance, over a space the size of a shilling, dependent on chronic enlargement and thickening of small vessels, the open mouths of which, on being cut, were retracted into its substance. In the anterior portion of the right corpus striatum there was also a diffluent softening, occupying a space about the size of a pea. On removing the cerebral lobes from the cranium, a dense chronic adhesion, which it was * Keported by Mr. W. Gilfillan, Clinical Clerk. CEREBRITIS. 381 necessary to cut through, existed between the inferior surface of the left anterior lobe and the dura mater. It involved the optic and olfactory nerves of that side, and extended so far on the right side as to include also the right olfactory nerve. The portion of brain in immediate connection with this adhesion was unusually indurated to the feel throughout a portion of substance in the left lobe, about the size of a nut- meg ; but, in the right, confined to a thin layer of cerebral substance externally, about an eighth of an inch in thickness, and about the size of a shilling in its area. On cutting through the indurated substance on the left side, it felt like soft bees’-wax | under the knife, was of a very pale straw color, gradually disappearing, as did the induration into the healthy structure, without any obvious limit whatever. About another oz. of sanguineous serum was found collected in the depending portions of the cranial cavity after the brain was removed. The other portions of the brain were healthy. Thoracic and abdominal viscera healthy. Microscopic Examination. — The fawn-colored softenings in the corpora striata consisted of numerous molecules, granules, granular masses, and cells, mingled with vessels coated with granular exudation, and fragments of the tubes of the cerebral substance. In and around the cribriform alteration of the left optic thalamus, numerous round colorless transparent lioclies were observed which refracted light strotigly, and were apparently solid. They varied in size, from the 1-1 000th to the l-500th of an inch in diameter. Some contained an included globular body, around which faint concentric circles were dis- cernible. On the addition of diluted sulphuric acid and iodine, they did not give the reaction of starch or cellu- lose. They were unaffected by water, acetic and nitric rig. 406 . acids. Here and there they seemed to split up, not unlike starch bodies. The indurated portion of brain in the interior lobes presented an obscure amorphous appearance, consisting apparently of the normal elements, infil- trated with a brownish, exceedingly fine, molecular substance. The serum of the ventricles only contained a few epithelial cells, distended with water by endosmose. Commentary . — The symptoms observed during the life of this man were all clearly explained by the morbid cliange.s demonstrated after death. Before the post-mortem examination took place, I ventured to diagnose chronic softening of the left corpus striatum, with a tumor so situated below it as to press upon the left optic nerve, and both olfactory nerves. 8uch were the principal lesions discovered, as the indurated brain and dense adhesion may in one sense be looked upon as a tumor, producing the destruction of the special nerves, whilst the extensive lesion of the left corpus striatum sufficiently explained the hemiplegia on the right side of the body. Two other lesions, however, were dis- covered, viz., 1st, The limited disease in the right striated body; and 2dly, the effusion of serum into the lateral ventricles and subarachnoid cavity. To the first of these lesions may proabbly be ascribed the con- vulsions which more especially attacked the left side of the body, although alone this would be insufficient to account for its paroxysmal character — a phenomenon which, as I have elsewhere endeavored to explain, can only be referred to congestions within the cranium.^ As to the effusion of serum, I am inclined to consider it as having occurred during the last few hours of life; — 1st, Because he was conscious within twelve hours of his death, and was free from delirium and stupor ; 2dly, Because, after death, little imbibition of serum had taken place into the central ^ See Articles by the writer on Apoplexy, Epilcp.sy, etc., in the second volume of the Library of Medicine. Fig. 406. Amyloid bodies with fragments of nerve tubes, in the cribriform sub- stance of the optic thalamus. 250 diam. 382 DISEASES OF THE NERVOUS SYSTEM. white substance of the brain, and there was consequently no softening from maceration. Case XII.* — Chronic Meningo-Cerehritis — Sudden Convulsions Hemiplegia of Left Side — Softening of Anterior Lobe of Right Cerebral Hemisphere — Adhesioiis of Arachnoid. History. — William M’Donald, ast. 38, writer’s clerk — admitted November 22 1852, From the account given of him by his friends, it would seem that his habits have been of rather a dissipated nature for several years back. He was never known to have delirium tremens, but about ten months ago was seized with cephalalgia, unusual movements of the shoulders, and inability to speak or write, which symp- toms, it is said, soon disappeared. For the last six months also, he has been out of employment, and not eaten more than one meal in the day. On the morning of the 3 9th, he was seized with a fit, which was succeeded by profound sleep for some hours. The next day he was so far recovered as to be able to walk about, and in the evening he went to the theatre with one of his friends, who, on being interrogated, says that he did not consider him at that time in his right mind. On the 21st he had another fit, and on the 22d several others, which succeeded one another at intervals of ten minutes. Symptoms on Admission. — On admission, is still laboring under convulsive paroxysms, with loss of consciousness, and foaming at the mouth. These were always present with the exception of intervals, varying in duration from ten minutes to half an hour, during which the consciousness returns, and he answers questions cor- rectly. When a paroxysm begins, he generally utters a short groan ; the mouth becomes twisted, and pulled to the left side ; the eyeballs incline to the left side. During the fit the pupils are slightly dilated, and insensible to light ; the left arm is thrown into violent clonic convulsions ; the left foot is extended and rigid, and the right one firmly flexed. Towards the end of the paroxysm there is foaming at the mouth ; respiration is somewhat restrained, not stertorous ; there is no aj)pearance of suffocation, nor any marked lividity of the countenance. As the fit passes off, the respiration gradually becomes more free and natural ; during expiiation, the right cheek is puffed out like a flaccid bag. After recovering consciousness, he can move the right arm and leg voluntarily, but the extremities of the left side are quite powerless and insensible. Pulse 98, full, but not strong. Tongue is moist and clean, and the edges marked with indentations from the teeth. On being protruded, it is turned towards the left side ; no distortion of the face during the intervals ; urine during the fits is passed involuntarily ; bowels open. In all other respects the bodily functions are normal. Four leeches to he applied to each temple. The head to be shaved^ and cold constantly applied to the scalp. To take ten grains of Lover’' s powder at bed-time. Progress of the Case. November 23, 7 a.m. — During the night has had frequent convulsive paroxysms, such as have been previously described (66 were counted). The skin never is hot, but moist. Pulse 100, full and firm ; otherwise the same. To be cupped on the temples., and 12 oz. of blood abstracted. To have immediately after- tvards an opiate enema. At the visit the convulsions are almost continuous, with perhaps a minute of interval, and then another minute of violent struggles and clonic spasms. Pulse 120, strong and bounding, increasing in frequency and tensity during the attack. To be bled 15 oz. and the cold douche applied to the head. 3 p.m. — Is now unconscious during the intervals. Pulse 160, soft. The fits, which became less frequent after the bleeding, are now as numerous as at the visit. To apply liiq. Ammoniae, wdth a view of producing vesication, to the occiput. 2o have a table-spoon- ful of brandy every half hour. Sinapisms to be applied to the calves of legs. 7 o’clock P.M. — Consciousness returned after the first dose of the brandy. The ammonia has only caused redness of the integument. Pulse 120, small and weak. On ausculta- tion of chest a loud moist rale is heard over whole anterior surface of chest. Parox- ysms as frequent as before. Continue brandy at intervals of two hours, with beef-tea. November 24. — During the night the fits became less frequent, there being often intervals of a quarter of an hour. At 7 a.m. they ceased entirely, when the breath- ing became stertorous, and stupor came on, from which, however, he could be roused until half an hour preceding death, which occurred at 9 a. m. * Reported by Mr. Alex. T. M’ Arthur, Clinical Clerk. CEREBRITIS. 383 Sectio Cadaveris . — Twenty-seven hours after death. Body moderately robust, face and surface somewhat livid. Head and Spine. — Dura mater rather thicker than usual, especially so over both anterior hemispheres, but in texture healthy. There was a firm adhesion between the dura mater lining the frontal bone and the arachnoid covering the anterior lobe of right hemisphere, over a space f ths of an inch in diameter. The arachnoid membrane everywhere moist. Ventricles do not contain above 3 ss of serum. Pia mater and choroid plexuses healthy. The substance of the brain everywhere normal, except at the place in the anterior right lobe, immediately below the adhesion formerly noticed. Here the cerebral substance is softened to an extent about the size of a hen’s egg. The grey and white substance cannot be distinguished ; and, on section, the morbid portion is of a grey or dirty white color, of pultaceous consistence, readily disappear- ing under a fine stream of water. Frontal bone healthy. The spinal cord and its membranes healthy. The other organs could not be examined. Microscopic Examination. — Numerous fatty granules, granular masses and cells, both loose and accumulated round the blood-vessels of the cerebral softening, were visible. The tubular substance also was greatly disintegrated and broken up. Commentary . — When I first saw this man he appeared to me to be in an epileptic convulsion, but the history of the ease, and the short duration of the intervals of consciousness, during which he was composed and answered questions, pointed to an organic lesion of the brain. The pulse, though full, was not very strong. Hence eight leeches were applied to the temples, the head was shaved, and ice applied. This treatment in no way alleviated the symptoms. Next day the pulse was lOO, full and firm. He was now cupped over the temples, and 12 oz. of blood ex- tracted from the arm, followed by an opiate enema, but without benefit. Next day the pulse was 120, strong and bounding. Ho was now bled to 15 oz., and the cold douche applied to the head, with the result of making him much worse, for shortly afterwards he became insensible even during the intervals. In the evening, therefore, I at once changed the treatment, and gave brandy in table-spoonful doses, with the effect of causing immediate restoration of consciousness and a marked improve^ ment. Stimulants with nutrients were perseveringly continued, but in vain. Post-mortem examination demonstrated the existence of a chronic grey softening in the anterior lobe of the right cerebral hemisphere, with old dense adhesions of the membranes over it. The cephalalgia and ob- scure cerebral symptoms during a period of ten months, were evidently owing to these combined lesions advancing slowly or at intervals. The history informs us, that during the last six months he had been out of employment and insufficiently nourished, a condition highly favorable to the disintegrating process in the brain, which at length arrived at such a point as, probably combined with an unaccustomed congestion, to pro- duce violent irritation of the motor nerves, together with such disorgani- sation and pressure as to occasion hemiplegia. If this be the correct theory of the case, an antiphlogistic and lower- ing system of treatment could not be supposed very well adapted to remedy the mischief, to prolong life, or even to alleviate the symptoms. The indication generally laid down in practical works on this subject — viz., to bleed when the pulse is strong and full — was here carried out, and failed in the most signal maimer. Indeed, the most approved practice was actively followed, with the result of making the patient worse in every particular. When, however, at length antiphlogistics were aban- doned and stimulants administered, then, and then only, he rallied, and 384 DISEASES OF THE NERVOUS SYSTEM. showed for a little signs of amendment. In no case I ever met with have I been so impressed with the inutility of antiphlogistics, even when the symptoms seemed, from all our past notions, loudly to demand them. Nor, after the uselessness of these had been demonstrated, and the pa- tient reduced without benefit, could the value of an opposite practice have been better exhibited. We shall afterwards point out how unrea- sonable such lowering practice is in all organic diseases of the brain. — (See Cerebral Hemorrhage.) Case XIII.* — Chronic Cerebri tis of the Right Hemisphere — Cancerous Ulcer of the (Esophagus and neighboring Glands — Fatty Heart. History. — Robert Millar, aet. 72, married — saddler — admitted October 6, 1866. Patient states that, for the last month, he has suffered from pain in the epigastrium and from vomiting, for which he was in the habit of using Gregory’s powder. For a week past had vertigo, accompanied by a staggering gait. On the evening of the 5th, his feet were so cold, that he was obliged to use a hot brick in bed ; on the morning of the 6th, he found himself deprived of the use of his legs, and was accordingly brought to the hospital. According to the account of his wife, he has experienced considerable anxiety of late ; and she thinks that his mental faculties have been slightly impaired in consequence. Symptoms on Admission. — It is with great difficulty that the patient can be made to understand a simple question ; and his answers are often contradictory. He does what he is bid ; speech is slow ; there is slight confusion of memory, and want of con- catenation of ideas. Sensibility appears to be present in all parts of the body except in the inferior extremities, where the patient states that he feels numbness. He has no feeling of prickling or itching. Special sensation appears normal ; but he does not see so well as formerly. Complains of tenderness over the spines of the sacrum, on pressure and motion. Has not the power of moving the left inferior extremity ; and some difficulty in moving the right. The left arm is somewhat stiff, and he is unable to raise himself in bed. With the exception of an unusual jog with the impulse of the heart, it appears to be healthy. Pulse 60, of good strength. Tongue covered with a whitish-grey fur, but red at the edges. Protruded straight, but sometimes spasmodi- cally jerked to the sides. Passes his urine involuntarily; which is brown, opaque, with a flocculent white sediment ; alkaline. Habitually constipated. Face is thin and pinched ; skin dry, somewhat cool, especially at the feet. Patient states that he has observed himself becoming thinner during the last month. Other functions normal. Habeat Pit. Colocyrdh. Co. ij pro re nata. Progress of the Case. — October ^th. — Power of flexing the left leg has returned to a certain extent, but he is still quite unable to extend it. He can flex and extend the left forearm, but has no power of raising the upper arm on the same side. Bowels quite open; is only able to swallow fluids, and even these in very small quantities; it would appear that matters ingested pass only a certain extent down the oesophagus, and then regurgitate. October 2,bth. — Since last report has continued much the same. Vomiting still continues to such an extent, that everything swallowed is rejected immediately. There is tenderness on pressure in the epigastrium. An inch below, and to the right side of the umbilicus, a tumor of the size of a hen’s egg is now felt, which communicates to the hand an impulse synchronous with the arterial pulse ; it can, by careful manipulation, be moved to the middle line, or even to the left of it. I^ Bismuth. Alb. 3 j ; Pulv. Opii gr. iij ; Ext. Gentian Liq. q. s. ft. massa inpil. xxiv. dividenda. Two to be taken thrice a day. Habeat enema domesticum. November \%th. — After taking the pills the vomiting was much alleviated and has now ceased. Otherwise he has been in much the same condition as at last report. The bowels have required to be moved by means of enemata and purgatives. December 2d. — This morning he expresses himself as greatly relieved, and states that his appetite is much improved. He now answers questions slowly, and is occasionally subject to optical delusions. There is scarcely any perceptible difference between the left arm and the right ; the former being used almost as freely as the latter, and presenting little or no appearance of stiffness. He can also move all the joints of the left leg, but with difficulty ; stating that it is stiff, and that he has not so great command over * Reported by Mr. H. N. Maclaurin, Clinical Clerk. CEREBRITIS. 385 it as over the right. Feels a sensation of prickling, which he refers to the affected limb. Is occasionally subject to mental aberration. December Ath. — Has been very violent, and quite delirious all night. This morning there appears to be still some aberration of intellect, and occasional optical delusions. He understands, however, what is said to him, and answers intelligently, though slowly. Pupils very much contracted, and when a light is brought close to the eyes, they do not contract further. December ^th. — Again vomits his food usually shortly after taking it. Emaciation great; face pinched, with anxious expression and staring eyes. Repe- taniur P\L Bimmthi cum Opio^ Haheat Vini ^ iv indies. December 21.s^. — Has not vomited since taking the pills. The delirium and excitement subsided shortly after the last report. He again took food and rallied somewhat, and continued in the same state, with occasional attacks of excitement towards evening. During the last thi-ee days, however, his strength has been gradually diminishing ; there has been sopor, and latterly coma, and he died this morning at 7 a.m. S^ctio Cadaveris. — Fifty four hours after death. Head. — On removing the calvarium and dura mater, a considerable amount of clear serous fluid was seen to exist in the subarachnoid space, elevating the arachnoid above the level of the convolutions. On slicing the right cerebral hemisphere several small patches of softening were observed. These were met with chiefly in the white matter of the hemisphere, but one or two were seen in the grey matter of the convo- lutions. The softening was most distinct in the upper part of the hemisphere ; and disappeared towards the upper wall of the lateral ventricle. The softened portions were of a pulpy consistence, and of a white color, with here and there a slight tinge of red or yellow. No such condition existed in the left cerebral hemisphere. Each lateral ventricle was dilated, ansi contained about an ounce of clear serous fluid. The parts within the ventricles were natural, as well as the rest of the brain and the cere- bellum. The arteries at the base of the brain were generally opaque, and in some places rigid, from the presence of atheromatous and a little calcareous matter. Chest. — On removing the heart the coronary arteries appeared unusually promi- nent, and felt hard. The muscular substance was soft and of a fawn color. The aortic valves were competent, although a little calcareous matter was deposited at the base of two of them. There were one or two minute vegetations on the free margin of the mitral valve. The whole organ weighed 11 oz. The lungs were somewhat emphysematous superiorly and anteriorly, with one or two slight puckerings at both apices. On cutting into the pulmonary tissue, a little old tubercular matter and one or two minute cretaceous concretions were found. Abdomen. — The lower part of the oesophagus felt firm and thickened externally, and on passing the forefinger into its interior, a stricture was found to exist at the cardia, through which it could with difficulty be passed. On laying open the ceso^ phagus an ulcer was found occupying nearly the whole of the mucous surface imme- diately above the cardia. When spread out, this ulcer was seen to be of an almost regularly circular form, having a diameter of about an inch and a half. The face of the ulcer was depressed ; the margins prominent and hard. The base was on the whole smooth, except that from its centre projected a sort of ridge, about half an inch in length (running parallel to the length of the tube), of white glistening appear- ance, and of almost cartilaginous hardness. This ulcer was quite limited to the oeso- phagus ; and its surface was of a dirty greenish color. The external parts were fir.mly matted to the portion of the oesophagus corresponding to the ulceration. Two or three enlarged lymphatic glands were here met with. On section of the largest, which was about the size of a hazel-nut, it was found to be of firm consistency exter- nally ; while internally it consisted almost entirely of a glairy juice of a slightly reddish color. The mucous membrane of the stomach and intestinal canal was healthy. The other organs, with the exception of a slight degeneration of the kidneys, were healthv. Arterial System. — Many of the arteries had their coats loaded with atheroma- tous and calcareous matter. This was especially noted in the case of the cerebral and c ironary arteries ; and the right common iliac artery was swollen out into a saccular dilatation, more than an inch and a half long. Microscopic Examination. — The softened portion of the right cerebral hemi- sphere was composed of fragments of nerve-tubes, with innumerable granular cor- puscles. and granular masses coating the vessels. The muscular fasciculi of the heart presented various stages of fatty degeneration. The ulcers in the oesophagus 25 386 DISEASES OF THE NERVOUS SYSTEM. were composed externally of granular matter, in which a few cells in various stages of degeneration were observable. The nature of these was determined by those con- tained in the neighboring glands, which abounded in cancer corpuscles, in all stages of their development. The atheromatous matter in the arteries consisted of numer- ous fatty molecules and granules, associated with a few granule cells, numerous crys- tals of cholesteriue, and masses of earthly salts. Commentarif, — When I first saw this man he presented the usual symptoms of chronic softening of the brain, including failure of memory, confusion of ideas, and diminution of motor power on one side of the body, with rigidity. The leading symptoms, however, were constant vomiting, from an obstruction at the cardia, and consequent emaciation and weakness. At first, nourishment was carefully regulated and given in small quantities. Subsequently, pills of bismuth and opium seemed to alleviate tlie vomiting, which gradually ceased. He then rallied con- siderably, was enabled to take food more freely, and became much stronger. The paralysis and rigidity of the affected limbs disappeared, and he walked about the wards affirming that he was quite well. Indeed he several times desired to leave the house. His mental faculties, however, re- manicd confused, and he became garrulous, and was subject to optical delusions and intellectual aberration. In this state he continued about three weeks, when he began to wander at night, and became delirious ; then symptoms of effusion within the cranium manifested themselves, and the vomiting returned. Again the pills with wine caused him to rally a little, but his strength gradually diminished, and he sunk. On post-mortem examination, chronic softening of the right hemisphere was found, explaining the effects produced on the left side of the body. The old cancerous ulcer of the oesophagus was indurated, and evidently in the act of healing up by cicatrization, a fact which will be subsequently alluded to. — (See Stricture of the (Esophagus.) The subarachnoid cavity and ventricles were distended with serum, explaining the delirium and sopor which preceded death. The effects of treatment in this case offer a marked contrast to what was observed in the last one. It was (mite remarkable to observe Low there followed, on cessation of vomiting and improved nutrition, io marked an abatement in all his symptoms. Even the paralysed and rigid limbs recovered their tone, and he moved about, as if well. On the return of the vomiting, the prostration and nervous symptoms came back, and he again rallied on checking the vomiting and giving wine. No better argument could be furnished that delirium, or other evidence of supposed nervous excitement, is in fact a proof of weakness, and requires for its treatment nutrients and stimulants. Case XIV. — Paralysis of the Ahducens Occuli and Auditory Nerves — Nxophthalmia — Tumor at the Base of the Cranium — Partial Recovery, History. — John Wright, set. 30, typefounder — admitted November 26, 1860. States that four years ago he had a severe attack of rheumatism, soon after which he experienced considerable pain in the right side of the head. His right eyeball then became painful, and began to protrude. Hearing also on the same side was at first dull and then abolished. Ten months after the commencement of the headache, it abated on the right side, but became violent on the left, where it has continued ever since. He was treated with mercury and iodide of potassium. Tw'o years since, he * Reported by Mr. Cunningham, Clinical Clerk. CEREBRITIS. 387 wa 3 attacked with spasms and grinding of the jaws, and on two occasions, the con- vulsions were pretty general and attended with loss of consciousness. His vision was. quite perfec::, till about a fortnight ago, when he began to see double. He continued to work until the 28 J inst., wiien, owing to the imperfection of his sight, he was oblige 1 to desist. S'fMProMS o.\' Admission. — On admission, complains of cephalalgia, most severe on the left side. There is complete deafness on the right side. The right eyeball is very prominent ; can be turned inwards but not outwards. Vision is perfect in the two eyes, but from the axis of both not being alike, is double. He cannot lay hold of an object at once, an 1 in attempting to grasp it his hand is at first directed to one side. There is no other form of paralysis, and the other functions are healthy. PaooaESS of the Case. — Since admission, this man has presented considerable alterations in his symptoms, the headache being sometimes more severe than at others ; and on such occasions, there was considerable stupor, loss of memory, and confusion of ideas. Ii.a treatment consisted of the internal use of iodide of potassium and purgatives^ with coanter-irritants externally. On the Mh of February.^ it was noticed that the right eyeball was less prominent. On the 25^A it was ascertained, on careful examination, that he was not perfectly deaf on the right side, and that the right eyeball could be everted more than formerly. On the \st of March the pro- minence of the right eyeball was comparatively slight. He could abduct it fully, ani vision was then single. The pain in the head was unabated, but more erratic. By the 15^7?. of March., the cephalalgia had greatly abated. There was a marked im- provement in the general health. Movements of the right eyeball normal — deafness on the right side considerable. Blisters to the temples and neck, and a variety of reme- dies have been tried, to cause sleep, and diminish the pain ; of which M. xij of the Tr. of Cannabis Indica, appeared to be the most beneficial. With the exception of deafness, ha was dismissed May 22, quite w'ell. Commentary . — In this case, the doep-rooteJ eephnlalgia, the exoph- thaliiiia, the paralysis of the sixth and auditory nerves on the right side, clearly indicated the existence of a solid body pushing out the eye, and pressing on the affected nerves. At one period, also, irritation of the motor branch of the fifth pair was exhibited by spasms of the jaws, with other cerebral derangements. The tumor, however, latterly diminished much in size, as indicated by the following facts : — First, return of the eyeball within the orbit ; secondly, recovery of the functions of the right abducens occuli ; and lastly, improvement of hearing, with diminution, and then absence of the cephalalgia. The nature of the growth in this case cannot be stated with certainty, but as it was not likely to be a cancerous, and there was no evidence of its being a tubercular formation, so it was more probably a simple exudation. Acute cerebritis is distinguished pathologically by the exudation of liquor sanguinis into the substance of the brain, which, if it be poured out in quantity, is transformed into pus ; if slowly or to a limited extent, it usually passes into granules and granular cells, and becomes chronic. In the latter case it constitutes one of the forms of softening previously described as exudative softening (p. 35 1). I have already alluded to the opinion of those who Consider this to be a form of fatty degeneration, and have shown how this doctrine fails to explain the occurrence of new cell-formation in the white substance of the brain (p. 257). Besides, positive research has convinced me, that however fatty a true inflam- matory softening may ultimately become, this is only the result of a transformation of the exuded blood-plasma. Fig. 150 (p. 168) repre- sents this plasma on the exterior of a blood-vessel from the spinal cord, in which a formative process is going on, and I have seen other cases causing rapid death, Vf’here, on examination of the brain afterwards, the 388 DISEASES OF THE NERVOUS SYSTEM. coagulated liquor sanguinis has been observed in an earlier stage of formation. Thus, iu 1843, I recorded the case of a child, John Smith, aged three years, who on the 3d of February 1842 awoke from his sleep with a loud scream ; on the following day he vomited repeatedly, and on his admission into the Clinical ward under Dr. Traill, February 12th, presented as symptoms intense headache, constant rolling of the head, contracted pupils, quick and sharp pulse, considerable tremor of the limbs, great restlessness, especially at night, but without convulsion. He died the same night, and on examination there was no meningitis, no softening, nor serous elfusion into the ventricles. The blood- vessels, however, of the fornix and central medullary parts w^e coated with a fine molecular exu- dation (Figs. 407, 408), at many points two and even three times thicker than the vessel to which it was attached ; the exudation contained clear round granules, exactly similar to the nuclei of the cells figured p. 167. To argue that such matter is the result of a fatty degeneration of the vascular wall, appears to me opposed to all our positive Fig. 408. knowledge, whereas its being a recent coagulation of the exuded liquor sanguinis, and produced coin- cideiitly with the violent symptoms, is consistent with every known fact. In 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 w as observable. On the 6th of July 1848 he could not eat his breakfast; at 1 p.m. he vomited; at 4 p.m. febrile symptoms appeared; during the night there was great restlessness with occasional screaming ; on the niornii g of the 7th there were general convulsions, but principally on left side, and he died at half-past 6. The exa’niuation was performed by Mr. Goodsir. With the exception of 3 iss 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 Fig. 407. examination, this was seen to o consist of the same molecular matter surrounding the blood-vessels, as represented Fig. 407. 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 rapidly, 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 what may be called exudative softening. (See p. 354.) Fig. 407. A blood-vessel from the central substance of the brain, coated w ith a molecular exudation, and with nuclei forming in it. Fig. 408. Another blood-vessel, with masses of recently coagulated exudation attached to it. 260 diam. CEREBRITIS. 389 Chronic cerebr;ti.s so occasioned can only be distinguished with certainty by a microscopic examination. It may present various shades of color — white, grey, yellow, or fawn colored. I have seen white softenino-.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 f )rmation, 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 regarded by some as atrophic, I have shown by its structure to have originated in an exudation (Fig 40[)). The yellow and fawn- colored softenings generally owe their color to an admixture of blood to a greater or less extent, Fig 439. but are otherwise essentially the same. Hence, as previously stated, I regard the microscopic examination of such lesions to be absolutely necessary 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 soften- ing resulting from 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, hemorrhage is indicated by suddenness of attack, whilst uncomplicated chronic cerebritis gradually affects the mental and motor functions in various ways and degrees according to the portion of the brain affected. But it must not be overlooked, that an inflammatory, a hemorrhagic, and a primary fatty softening, may occur together in the same individual, as the conditions which occasion one are also favorable 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 place 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, Bechambre, 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 endeavored to dnnonstra^e the curability of a softening are not to be depended on. Durand-Fardel points to the softening resembling chalky milk as a proof Fig. 400. Structure of a chronic grey softening of the cerebral hemisphere, re- sembling chalky milk, entirely composed of exudation, transformed into granules and cells. 250 diam. 390 DISEASES OF THE NERVOUS SYSTEM. of the passage of the lesion into a state of cure, and Dr. Sims described fawn-colored cavities as evincing the same fact. Now I have seen cases where the grey milky softening was associated with hemiplegia of long standing, but which presented, on microscopic examination, the appear- ance represented Fig. 409, which although undoubtedly evincing great disintegration, cannot be said to show signs of healing. The fawn- colored cavities of Dr. Sims I have not only seen to be filled with granule-cells in all stages of formation, but associated with intense recent contraction, on the opposite side of the body. (See p. 359.) Neither of these lesions, therefore, appear to me to present anatomical proofs of 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 neighboring healthy cerebral substance. Whether the yellowish or fawn-colored 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 general diagnosis and treatment of chronic cerebritis will be considered under the head of Cerebral Hemorrhage, with which it is often associated. CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. Case XV.'^ — Faralysis rai)idhf lecoming general — Old Ajyojilectic Cgst in right Corpus Striatum — Softening of Fons Varolii — Clot obstructing Basilar Artery — Fneumonia of Left Lung. History. — Alexander Walker, set. 60, a pensioner, admitted December 3, 1855. According to the account of the patient’s brother, he has been long subject to vertigo, both v/hen at home and as a soldier in India. For this complaint he has been bled fifteen limes, 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 on 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 com- menced at the fingers. Shortly after, there occurred thickness of speech, which rapidly increased. During the night he became speechless, but could make signs, and appeared conscious. In the morning he was conveyed to the Infirmary. Symptoms on 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 a[)plication of stimuli, but the right leg, though some- what retracted, is partially paralysed. Left pupil somewhat more conti acted 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 witli snoring rales. Skin warm and dry. Bowels constipated ; bladder distended. To have a turpentine enema. The urine to be drawn off by a catheter. Iced-ivater to be constanilu applied to the scalp (the man’s head was bald), and the following bolus to be carefully plaud on the podcrior third of the dorsum of the tongue., so as to ensure deglutition. R Old t rotonis^ guti.j; Pulv. Jalap. Co. 3i; Confect. Sennee., q. s.fl. bolus. Progress of the Case. — December 4//i. — 30 oz. of healthy urine were drawn off yesterday by the catheter. This morning both faeces and urine were passed involun- * Reported by Mr. John Glen, Clinical Clerk. CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 391 tarily in bod. Both arms and legs are now completely paralysed, and do not movft on the application of strong stimuli. Respiration is more labored; pulse 120, weak; still conscious. To nourish the patient as much as possible b>j the mouthy and if neces- sary, per anum, with strong beef tea. December ^th. — Respirations still more labored, and the chest does not expand. The loud snoring with expiration masks the pulmo- nary sounds, and his position on the back cannot be changed to admit of examination of the lungs. In other respects is in the same state, but weaker ; pulse 120, weak. Is motionless, speechless, with the lips slightly separated. On attempting 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, with brandy, administered. He is still evidently conscious. December (Sth. — Since yesterday has been gradually sinking ; the 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 Cadaver is. — Twenty three hours after death. Head. — Surfaces of the arachnoid moist ; slight serous eafusion between the sulci of the cerebral convolutions. On slicing the hemispheres, their substance exhibits 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 cribriform appear- ance. In the posterior fourth of the substance of the left corpus striatum was a dif- fluent mass the size of a pea, which flowed out on section, having a small cavity with the walls of a fawn color. Both choroid plexuses contained simple cysts, the greater number on the left side. On cutting through the pons varolii, its centre was 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 whols course, was opaque, its coats loaded with calcareous and atheromatous matter, and obstructed by a colorless 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 color, and in the upper lobe two masses of pneumatic condensation about the size of walnuts. Mar- gins of both lungs emphysem itous. Heart healthy. All the other organs were healthy. Microscopic Examination. — The contents of the old apoplectic cyst in right corpus striatum had disappeared, but the indurated walls consisted of a dense aggregation of brownish opaque molecules, which gradually diminished in number externally, 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 encephalon. There were no granule-cells or granular 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. 405. 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 vessel. The hepatization of the left lung presented all the 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 vesi- cles filled with pus, and the surrounding mass indurated, exhibiting different stages of the transformation of an amorphous exudation into cells. (See Fig. 154, p. 174, which was drawn from a demonstration made from one of these masses.) Commentary . — After vertigo and other head symptoms for many years for which 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 392 DISEASES OF THE NERVOUS SYSTEM. pass urine or retain the faeces, and spasmodic closure of the jaws. These symptoms indicated a lesion of the central part 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 blood-vessels, 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 fatty degeneration commencing in the nerve cells. Of this lesion we shall be able to form a better idea after examining the facts of the following case : — Case XVI.* — Apoplexy — Hemiplegia of left side — Convulsive attacks— Cardiac and Renal Disease — Old Clot in the right Cerebral Hemisphere^ with surrounding softening. History. — Elizabeth Ross, set. 26, married, admitted May 23, 1853. States that about 4 -^ years ago she suffered from acute rheumatism, on recovering from which she frequently experienced palpitations, and during the last 18 months there has been occasional epistaxis, preceded by giddiness, dimness of vision, and muscie volitantes. Last January, when quietly sitting in a chair, she suddenly fell to the ground insen- sible, 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 oedematous 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. She had three similar fits during the succeeding ten days, which were preceded by a choking sensation in the throat, palpitation and uneasiness in the precordial region. Symptoms on Admission. — 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 completely 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 uneasiness in the precordial region. Action of heart strong, but rhythm regular. Apex beats between the 6th and 6th ribs, about half an inch to the outer side of the nipple. Transverse cardiac dulness 2^ 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 distinctly audible in both infra-clavicular spaces. Immediately above the right sterao-clavicular articulation considerable pulsation is visible to the eye, but no tumor can be defined upon manipulation. 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 difficult and indistinct. Respirations irregular and spasmodic, 20 per minute. No dyspnoea. Cough short: expectoration scanty. Chest resonant everywhere on percussion, and the only abnor- mal sound audible is a fine moist rattle with inspiration over the two lower thirds of left lung posteriorly. Tongue is red and dry ; appetite very bad, and dysphagia to such a degree that she can only take liquid food. Slight epigastric tenderness. Bowels costive. Micturition difficult, painful, and frequent. Urine of pale color, neutral reaction, sp. gr. 1010, with deposit of triple phosphate on cooling; quantity Reported by Mr. Joseph Johnston, Clinical Clerk. CEKEERAL DISEASE FROM OBSTRUCTION OF ARTERIES. 393 passed small, and deposits when heated a considerable coagulum. There is general ceJoina of the whole surface of the body, but especially of the inferior extremities. IJ Pd. Scillceet Digitalis, vj ; Siimat uiiam bis in die. Pil. Opii, gr. i. hora somni sumend. Haheat Elect. Laxans l\]\et repetatur post koras sex si opus sit. Progress of the Case. — May 2oih. — 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. Jane tsth . — Since last report has been gradually improving. She can use the extremities of left- side more freely, and the sensibility is more acute. Can rise and return to bed with- out 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 still considerable, though diminished. Digestive functions normal. Renal symptoms the same. His been taking half a grain of the proto-iodine of mercury every night, with mild diuretics and occasional laxatives. June ^th. — Yes- terday 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 uj)wards. She had no foaming at the mouth, but frepuently shut her jaws with great violence, so that her tongue could with great diificulty be kept from being injured. The attack lasted ten minutes. During the evening, she had four 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 we.e applied to the temples, anl 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 morn- ing, and a third last night. Paralysis not increased ; other symptoms the same. June 19th. — Since last report has been complaining of various wandering pains, more espe- C’ally in right hypocondrium. The gums on the 14th became slightly tender, when the proto-iodide of mercury was omitted. Since the 10th there has been diarrhoea, the bowels having 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 suddenly 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 foo i. 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 sfeertor during inspiration, and a puffing out of the cheeks during expiration. There was also foaming at the mouth. These phenomena soon subsided, and the patient was left in a comatose condition. Two hours thereafter these phenomena recurred twice, without the patient at intervals regaining the slightest degree of consciousness. The faeces and urine were passed involuntarily. During the last attack the inhalation of chloroform was tried, but the breathing becoming more stertorous and hurried, an 1 the pulse intermitting and almost imperceptible, it was instantly stopped. Abradatur Capillitium ; Applicetur Capiti Emp. Gantharid. (4 x 6.) June 29lh — Became con- scious last night about 8 o’clock, when she could answer questions directly, but slowly, and in an articulate 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. Haheat Vini § ij. June2\st. — No return of convulsions. Stools not passed involuntarily as formerly. No pain in head, and says she is free from suffering. Countenance dull and stupid ; pupils natural ; expres- sion of eye sluggish. Respiration slow and snoring. Over both sides of chest anteri- orly, loud moist rales are audible. Pulse 90, very weak. Other symptoms unaltered. Habeat Vini ^ 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 difficulty be roused to answer questions. Died at 1.30 a.m. Sectio Cadaveris. — Thirlyfive hours after death. Body pale, not emaciated ; lower extremities very oedematous. 394 DISEASES OF THE NEEYOUS SYSTE^H. Head. — The arachnoid membrane presents its natural degree of moisture. On sec- tion of the right hemisphere of the brain, a softened portion is situated above and to the outer side of the corpus striatum. It measured by 1 inch, and extends exter- nally close to the cerebral convolutions. In its centre there is a hard round nodule about tlie size of a small hazel nut, of a dark-red color, with a zone of bright yellow extending about a quarter of an inch into the softened cerebral suostance. This is of friable consistence, and of a yellowish hue in the centre, becoming of an ash-grey tint, and of almost diffluent consistence towards the circumference. Externally the diseased substance gradually passes into the healthy cerebral structure. Arteries healthy. Cjiest. — Pericardium distended, containing S^oz. of pale straw-colored fluid. Left ventricle firm, its cavity dilated. The mitral orifice admits the entrance of two fingers ; but the anterior segment of its valve has on its external surface a few scat- tered fibrinous granules, while its posterior-inferior angle is thickened and covered with small masses of fibrin, which extend along the shortened chordae tendineae, giving them a fringed appearance. The aortic valves are much thickened, hard and inelastic, especially at their free boi ders, upon which also a few aggregations of fibrinous gran- ulations are seen, similar to those on the mitral valve. They contain in their interior a small amount of atheroma, wdiich extends into the aorta for about three-quarters of an inch. They admit the passage of water through them rapidly, on its being poured upon them from above. The pleurae on both sides are partially adherent by long bands of chronic lymph. The right pleural cavity contains about six, and the left about three ounces of serum. The lungs are shghtly collapsed, flaccid, and im- perfectly crepitant. In several places are indurated masses, varying in size from a pea to a hazel nut, composed of infiltrated blood. Other portions 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 color daik, from venous congestion. Spleen of firm con- sistence, 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. No leucocythemia. Microscopic Examination. — The central portion of the diseased cerebral struc- ture is principally composed of fibre cells, distinctly nucleated, infiltrated, how'ever, with sanguineous coloring 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. Commentary . — In this young ■woman valvular disease of the heart had supervened upon acute rheumatism, and vegetations had formed upon the rurfaces of the mitral and aortic valves. These vegetations, as we shall subsequently see, are deposits of the fibrin in the blood which may become detached, and be carried by the circulation into more distant and smaller vessels. Four months previous to admission, when quietly sitting in her chair she became suddenly apoplectic; and on recovering her consciousness labored under hemiplegia of the left side and paralysis of speech. Five weeks subsequently symptoms of renal disease mani- fested themselves ; then there supervened another attack of apoplexy, followed by a long train of nervous phenomena, which exhausted her strength and caused death. I took charge of the case in the middle of June, b}' which time she was so reduced that wine and nutrients failed to rally her. On post-mortem examination the arteries of the brain were healthy, but evidence of an old hemorrhage existed, and the question that arises is, whether or not ihis had been caused by obstruction of the CEREBRAL DISEASE FROM OBSTRUCTION- OF ARTERIES. S95 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 — Two sudden attacks of Apoplexy — Hemiplegia — Cardiac Disease — Persistent Alhurninaria — Enlarged and diseased Spleen — Cerebral Softening- — Anasarca — Atheroma of Arteries — Obstruction of left middle Cerebral Artery. History. — James Balfour, sot. 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 twelve-month before admission, his wife had noticed that he was not looking as well as formerly, but he himself had no feeling of illness, 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 wdth 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 recovei ing from this state, he found he had lost the power of his right side, and that his features were drawn to the left. Ilis 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 suddenly 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 ho has recovered the power of his right side almost entirely, he has gradu- ally 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, wliich has increased considerably during the last ten days, but which causes no pain. Two weeks ago he was attacked with severe vomiting, the matters ejected being apparently bilious, and since then ho has suffered from pain in the splenic I'egion, especially when he stands or moves about. Symptoms on 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 unimpeared, tongue slightly protruded to the right side, while tlie 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 left. The grasp of the right hand is as firm as that of the left, and the patient walks with- out a limp, 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. lie cannot write now as well as formerly, being unable to form the letters ; but he can read writing and printing. On percussion, the transverse dulness of the heart is found to be 2^ inches, and for an inch external to this the note is flat. On auscultation at the apex, a blowing murmur ie. heard with the first sound, and the second is somewhat lengthened. At the base there is a blowing murmur with both first and second sounds. This double murmur is propagated along- the great vessels, and is heard most distinctly along the sternum and in tlie 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 color, and faecal odor. Hepatic dulness is not easily determined, but appears about 4^ inches vertically. In the splenic region there is a large area of dulness extending into the abdomen, where a tumor 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 * Reported by Mr. T. J. Walker, Clinical Clerk. 396 DISEASES OF THE NERVOUS SYSTEM. mucus, squamous epithelial scales and numerous tube casts, chiefly 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 astringent powder 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 exhibition of a terebinthinate followed by an opiate epithem. Astringents succeeded in arresting 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 'lUh April until May 6^/?, the physical signs and symptoms con- tinued much the same, but during this period the urine diminished, the anasarca in- creased, the aspect became more heavy, the weakness more marked, the articulation more embarrassed, and the ideas seemed to be i^ormed slowly although correctly. No leucocythemia. On May ^tth there was marked tenderness on pressure in both hypo- chondria. At the apex of the heart a long blowing murmur synchronous with both sounds still audible, and at the base a double blowing murmur. Great dyspnoea and prostration. Coma. He died the following morning. Sectio Cadaveris. — Seventy-five 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 color — 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 h.emp seed, occurred. On the inner surface of the lower part of the descending coinu 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 color. The choroid plexuses and other portions of the brain healthy. The middle cerebral artery on the right side, in the fissure of Sylvius, 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. Thorax. — 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 ventrical surface of the right and left semi-lunar valves, and on the margin of lacerations in their 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 nodular swellings projecting towards the auricles. The pleurae contained each two pints of clear, rather dark-colored serum ; the lungs were collapsed posteriorly, and a little . emphysematous anteriorly, but everywhere crepitant. Abdomen. — The peritoneum contained more than a quart of dark-colored dear 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. 1 oz., presented congestion of the hepatic veins, but in structure was normal. The spleen measured inches, weighed 21b. 2 oz., and on section presented one-third of its area normal in color, consistence, and minute structure ; but the other two-thirds were of a fawn yellow color, 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 color. The dark red color was due to the extravasation of a thin layer of blood. Microscopic Examination. — The serum in the ventricles contained a few epi- thelial cells. The superficial indurated patches on the surface of the corpora striata w'ere chiefly composed of numerous granules and molecules, containing many granule cells, closely aggregated together aud apparently in a state of disintegration. The CEREBKAL DISEASE FROM OBSTRUCTION OF ARTERIES. 397 gritty matter in the centre of the old apoplectic clot dissolved with effervescence 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, evidently 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 appearance of partial fatty degenera- tion of these organs. Commentary . — On the entrance of this man into the house, it was recognised that he labored under obstructive disease of both valves; and it is observable that the history says nothing of his having ever been affected with rheumatism. He had previously experienced two attacks of apoplexy, followed by hemiplegia on the leh side, and when he come 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 leucocythernia. On post-mortem examina- tion^ 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 and granule cells, and it may be asked whether they were the results of previous he- morrhagic 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 ven- tricle. 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 differeiit times. This, however, is a matter of opinion, and did not admit of demonstra- tion. It should also be noticed that the clot found in the artery of the Sylvian fissure on the right side did not appear to have occasioned any symptoms, or to have produced other structural alteration. These chronic cjrebral lesions seemed ultimately so to have affected the circulation within the cranium, as to have caused effusion, the two ventricles being greatly 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 distinctly 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 Virchow, Kirkes, Tufnell, and others. This obstruction may arise in two ways — 1st, From disease of an artery, causing coagulation of the blood, and obstruction immediately within the portion of the vessel affected. 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 smaller artery. An example of cerebral disease produced in the first way is ob- served in Case XY., and illustrations of the second mode are given in Cases XVI. and XVII. Gulliver was the first to demonstrate that the so-called ossification of 398 DISEASES OF THE NERVOUS SYSTEM. arteries, commonly observed in old persons, was in fact a fatty degenera- tion of the vessels, consisting of numerous oil granules and crystals of cholesterine, accumulated between their coats, and frequently associated with deposits of earthy salts. This disease of the arteries, however, is a true arteritis (Donders and Jansen), originating in an exudation betw^een their coats, from the vessels which supply them, which exudation sub- sequently undergoes the fatty degeneration. This lesion induces slight constriction of the vascular calibre, thickening of the arterial w'all, and occasional roughness of the internal surface — circumstances which favor coagulation of the blood at the part, and cause more or less obstruction. In chronic cases the vessel becomes brittle, and hence, on any unaccus- tomed exertion it gives way, and occasions heniorrliage. These obstruc- tions and ruptures of the vessels from chronic arteritis, are the most common causes of chronic cerebritis and hemorrhagic apoplexy. The case of Walker, however (Case XV.), demonstrates another mode in which SQftening may be occasioned. Here obstruction of the basilar artery had occurred, occasioned by a local arteritis, and subsequent mineral degene- ration of the clot. The result was a peculiar kind of softening, which, as the sole lesion ot the cerebral substance, I observed in this man for the first time. In the pons varolii the tubes and nerve cells w^ere loos- ened and easily broken down, without any exudation from the vessels, granules, or granule cells, such as are observed in chronic cerebritis. The nerve cells, however, were enlarged, and contained 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 fluid, but were easily recognised by their shape to have originally been formed in the interior of cells (Fig. 405). I have frequently seen this alteration associated with exudative and hemorrhagic softenings; but as constituting the sole lesion, and occasioning an ex- tensive 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 dege- neration of the nerve cells, and to depend upon altered nutrition of the part; a condition hypothetically put forth as a cause of softening by De- laberge and Monneret, but now for the first time demonstrated. 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 effect of pro- ducing fatal inflammations. Cases by Virchow, Kirkes, Tufuell, and others, have further shown the probability that the coagula and so called vegetations formed in the interior of the heart, may in like manner be occasionally 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 vegeta- tions in the heart, clots have been found in the arteries leading to im- portant organs, causing in the same individual cerebritis, pneumonia, ne- phritis, splenitis, etc. etc. But although it is certain that solid plugs may block up arteries and occasion serious results, it is by no means CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. 399 clear tliat 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 im- pulse of - the heart itself, arising from hypertrophy or fatty degeneration of its fasciculi, are equally powerful causes of cerebral disease, and that this in its turn very commonly occasions pneumonia by its paralysing 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-off looking appearance of its ends, its structure, etc. etc. It has been supposed that whilst spontaneous coa- gulations, or such as are induced by arteritis, are gradually converted into fibrous tissue, those coming from cnc place and impacted in a vessel at a distance, break down and undergo a disintegrating process. At- tempts 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 supposed to origi- nate. All I shall sa}’- with regard to such arguments is, that numerous investigations into the structure of coagula under a variety of circum- stances have convinced me that we possess no certain means of distin- guishing one clot from another, and that all such statements 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. Tims 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 and other symptoms, followed by exudations and hemorrhages, producing convulsions or paralysis. In the same manner, coagula formed 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 pulmonary artery, and was unusually firm and fibrous. It had apparently occurred during life, in an elderly gentleman, who was sud- denly 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 sudden 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 o.:e place to another, which, however, I am disposed to think has very rarely been demonstrated. 400 DISEASES OF THE NERVOUS SVSTEM. Virchow has sought to elevate this simple matter into pathological doc- trines, under the names of lltromhosis and Enibolismus. CEREBRAL HEMORRHAGE. Case XVIII.^ — Apoplexy^ followed by Hemiplegia of Left Side — Recovery. History. — Andrew Bryce, aet. '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 minutes, and when he again became conscious he found he could not walk. He was assisted home, and on the afternoon of the same day admitted into No. 10 of the Eoyal Infirmary. He was freely purged, and has been confineil 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 head- ache, 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 hand, but is unable to direct it steadily to a distant object ; neither can he place it on the top of his head. While in bed the left leg moves as steadily as the right, but he cannot stand upon it. The sensibility of he lett 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 slightly tovv^ards the right side. Sensibility of the face un- impaired. 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 color — sp. gr. 1023 — non-albuminous — a copious deposit 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 No. 10, from which he was dismissed with the power of the left side nearly restored, May 13, 1851. Case XIX.* — Apoplexy., followed by Hemiplegia of Right 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- Granton 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 perfectly unconscious of surround- ing objects, and as if in a deep sleep — the surface pale, the countenance calm, and respirations natural. The mouth was slighily drawn to the left side. The right arm, allowed to fall down after being raised, sunk 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 consider- able 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 containing 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 day 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 and para- lysed. Commentary . — 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 morbid lesions which may occasion these symptoms. By the followers * Reported by Mr. Cunningham, Clinical Clerk. CEREBRAL HEMORRHAGE. 401 of tliG French School of pathology the same word has been applied to an extravasation of blood into an organ; and hence the terms apoplexy of the lung, apoplexy of the spinal cord, apoplexy of the kidney, etc. Ecchymosis of the skin, the result 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 of consciousness and volition, coming on spontaneously, are called apoplexy. But should such cases prove fatal, and we are enabled 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. ete., according to circumstances. In the two cases before us there is great similitude — both were seized suddenly with apoplexy wdiile walking. In the first case, how- ever, the apoplectic state was of a few minutes’ duration; in the second, it continued 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 c mlition, or immediately afeer he emerged from it. In both there was perfect hemiplegia; but in the one case there has been complete recovery of sensation and partial recovery of motion, ai regards the affected 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 f But the patient shortly after exhibited signs of coming out of the apoplectic condition, and it was clear, there- fore, that the pressure on the brain was spontaneously diminishing, t!ie pulse was steady and of natural strength. How could a bleeding have benefited him ? 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. This I presu ne 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 which were adopted, and his recovery, though slow, was satisfactory. Case XX. ^ — Palsy — Plemiplegia of Left Side — Recovery. History. — Jessie Fleming, mt. 4.5, single, milliner — admitted Nov. 27, 1856. Since last May the mind of patient has been in an unsettled state ; previously she enjoyed good health. During last summer her digestion was much impaired, and she sutferel from severe cramps in the left leg, especially during the night. On Friday last, Nov. 21st, while engaged at her work, she suddenly fell down, and though retaining her senses, felt unable to rise without assistance ; shortly after she quite lo.st the use o.^ 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, soma leeches were applied to the temples, and on the 24th she was removed to the Infirmary. Symptoms on Admission. — Great pain is felt over the top of the head, which is 26 ^ Reported by Mr. M‘Arthur, Clinical Clerk. 402 DISEASES OF THE NERVOUS SYSTEM. constant, and prevents the patient from stooping. Speech thick and imperfect. The muscles of the left superior extremity are completely paralysed, and do not ad- mit of extension; the muscles of the head and face are not affected, nor is Ki .-ibility impaired. Cannot move the left leg, but on applying an irritant to the sole of the loot the limb is at once retracted. Pulse 120, of good strength; other symptoms noimal. The head to be shaved^ and ice to be applied to the scalp. To have a purgative lolvs. Progress of the Case. — On the following day the pain in the head was nmch relieved, 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 light inter- sca})ular region, and subsequently by an exanthematous eruption, acconq.anied by considerable fever. She was dismissed April 8th, when she could walk with the aid of slight assistance, and move the arm of the affected side without difficulty. Commentary. — In this case sudden hemiplegia occurred without loss of consciousness, when the individual was wide awake and performing her household duties, a fact which was established by frequent interro- gation and by the accounts of others. It may be presumed that a vessel had suddenly given way, causing hemorrhage into the right cerebral hemisphere. The clot must have been larger than in the last case, not only b‘-;cause 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, set. 40, married, a sempstress — admitted Novem- ber V, 1854. She states that on the 6th inst., at half-past 1 o’clock a.m., on waking from sleep, she found that she w^as unable to lift the left aim, 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 the head. Though habit- ually enjoying good health, she had occasionally had palpitations, with dizziness of the head, dimness of sight and tinnitus aurium, especially brought on by stooping. Seventeen months ago she had an attack of acute rheumatism. Symptoms on Admission. — Her speech is somewhat embarrassed, and her intelli- 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 lilt up the left aim, though she can m'ove it slightly by a strong effort of volition ; neither tan she grasp an object firmly with the left hand. Sensibility of the limb much diminished but not lost. The left leg 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. Slight pain in the loins. Urine slightly coagulable, sp. gr. 1014. Pulse 86, small and weak. Heart normal. Other systems healthy. A blister to be applied to the nape of the neck. To have 01. Ricini § ss. Quietude and rest enjoined. Progress of the Case. — November 14/A. — 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, which 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 ; sibilation audible on auscultation. November 28^A. — Since last report, has had an attack of pneumonia, involving two-thirds of the left lung, and characterised by all the signs and symptoms of that disease. (See Pneumonia.) To-day she has completely recovered, the pulmonary disease has passed througli its usual course, leaving her, however, weak and thin. The appetite is now good, the strength improving. The sensibility and power of motion in the left arm nearly restored. Dragging of the mouth nearly disappeared. December Wth. — Since last report all trace of tlie pulmonary disease has disappeared. A week ago, however, * Reported by Mr. 0. Beaugeard, Clinical Clerk. CEREBRAL HEMORRHAGE. 403 she experienced considerable pain in the lumbar region, and on examining the urine it was found tluit tlie albumen had greatly increased. To-day microscopic examina- tion demonstrates in addition numerous fatty and waxy casts of the tubes. Urine j)ale, passed in good quantity, sp. gr. 1010. She states that the ankles swell towards evening. JLibmt Fotaas. BUari. I j ter die. January Is^.— Has been gradually gain- in" stren"th ; all trace of the paralytic attack has now left the face and arm. Careful exTuninatTun of the left lung can detect no remains of the pneumonia. The urine is still coa"ulable on the addition of heat, but much less so tlian formerly. But it con- tains no^asts of the tubes, is passed in good quantity, and the oedema of the feet tias disappeared. Dismissed at her own request. Commentary. — The peculiarit}" in this case was the sudden occur- rence of palsy m 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 neiwes supplying those parts. Such hemorrhage was not likely to have been extensive, as we may assume that recovery followed on the gradual absorption of the clot. It is worthy of observation, that this woman had formerly suffired from an attack of acute rheumatism, and was liable to palpitations of the heart. On admission, no valvular lesion could be discovered, and yet there supervene 1 many of those phenomena supposed to result from coagnla in the blood, causing first, cerebral hemorrhage, then pneumonia on the left side, then renal disorder. The occurrence and gradual 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. 69 — admitted May 20th, 1855. She was brought to the Infirmary by some policemen, who had found her insensible in a common stair. Symptoms on Admission. — On admission she 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. Proorfss op the Case. — May 21a-U — C oma continues. The enema brought away some scybalous faeces, and she has since had several loose stools, which were passed in bed. There is now complete paralysis of the right side, and the mouth is sti ongly drawn to the left side. Head to be shaved, and cold constantly applied. May 23c?. Has continued insensible. She now breathes with difficulty, and with heaving of the chest. There is marked dulness over inferior two-thirds of right lung, but no mur- murs are audible there, in consequence of the stertor. May 24^A. — Slight occasional 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. Dyspnoea 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 convolutions considerably elevated above the sulci, in consequence of fluid in the subarachnoid cavity. The veins cover- ing 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 coagulated 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 color. 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 color, gradually dying away * Reported by Mr. D. Maegregor, Clinical Clerk. 404 DISEASES OF THE NERVOUS SYSTEM. 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 yellow 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 lew atheromatous patches on the lining membrane of aorta and of the mitral and aortic valves. The heart was healthy. The pleurge 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 puck- ered, of blackish color, and contained several cretaceous and calcareous concretions varying m size from a pin’s head to that of a small walnut. The rest of the lung was spongy, but at the base were two or three masses of chronic tubercle the size of fil- berts, surrounded by a dark ring of pneumonic condensation. Abdomen. — Abdominal organs healthy. Microscopic Examination.— The softened portion of cerebral substance sur- rounding the clot consisted of disintegrated nerve-tubes and blood globules, and con- tained 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 als*o numerous irregular masses of granules and mineral bodies, which, on the addition of nitric acid, were rendered very transparent, w hilst the larger ones presented a series of concentric rings surrounding a nucleus. They resembled the amyloid bodies so commonly found in the choroid plexus. (See Fig. 393.) Commentary. — This case is an example of death from primary 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 sequelse of severe lesion at the base of the brain. The woman was apparently in good health previous to the attack, which was induced by ascending a stair. Case XXIII. — Ajyoplexy — Hemiplegia of left side — Hemorrhage into right Cerebral Hemisphere — Diseased Heart — Pnevmonia. History. — Margaret Wales, mt. 65, married — admitted January 10, 1849. On the 1st instant patient and her husband left their home quite well, and walked about the str<^ets for about two hours, wdien, feeling cold, they enteied 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 aim and leg felt very cold, but were frequently moved. The left arm and leg of natural temperature, but completely paralysed. On the evening of the 4th she became delirions, mutteiing and roaring out. This continued until the '7th. Euiing this time she was seen fie- quently to move the right arm and leg, but not the left. On the 8th w as somewhat drowsy, but so far conscious as to speak w hen roused. On one occasion asked for a glass of w'hisky, but had some tea given her. In the evening of this day again be- came 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. Symptoms on Admission. — On admission the face, hands, and feet are cold, and of bluish aspect, not unlike that of cholera. The trunk moderately waim; eyelids closed ; pupils slightly contracted, and insensible to light. She is quite insensible, the strongest stimuli failing to rouse her. There is considerable dyspnoea (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, wdiere there is comparative dulness. Heart’s sounds are weak, and * Reported by Mr. James Struthers, Clinical Clerk. CEREBRAL HEMORRHAGE. 405 masked by bronchial rales. The right arm and leg, on being pinched, move slightly, but tiie left arm and leg are completely paralysed. The left side ot face also com- pletely paralysed, but no distortion ; slignt movement of facial muscles on the right side, wueu they are pricked with a pointed instrument. No injury of scalp or cra- nium can be detected. Olei crotonis gutt. ij ; Extr. colocyydh. comp. q. s. ft. piL. to bs taken, iiameliatelg. A large sinapism to be applied to each leg. head to be shaved,, and a blister applied to the occiput. Progress oe the Case. — January ll^A. — Continues in the same condition. Bo wels not open. To have a pill, with ol. crotonis gut. iv. A piece of lint H inches squTLre to be dipped in strong aqua atnmoniee, and ajjplied to the vertex. Jatiuary \'lth. — No improvemeut, though the bowels have been opened once copiously. Breathing is more rapid, with tracheal rale. Surface cold, and covered with a clammy sweat; pulse almost imperceptible. Died in the evening. Seclio Ca.daveris. — Twenty-three hours after death, Consilerable livor, with oedema of hands and feet. Integuments loaded with fat. Head. — On reflecting the scalp no wound or contusion wms 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 color. On opening the right lateral verntricle, 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 hues, which beyond the infiltrated portion was also softened to the extent of half an inch, the dark red gradually parsing through fawn-colored into white softening. The left ventricle was slightly distended with serum. The foramen of Monro enlarged so as to admit a goose quill. Cerebral arteries studded with patches of atheroma. Thorax. — Heart slightly hypertrophied, otherwise healthy. Aorta healthy. Both lungs much congeste 1, and the bronchi filled in many places with muco-purulcnt matter. The lower half of the inferior lobe on the right side hepatized. On section it presents a dusky red color, containing here and there circumscribed purulent- looking deposits about the size of a millet seed. Abdo.\ien. — Liver slightly enlarged, its right lobe adherent to the diaphragm by chronic adhesions. Gall bladder greatly distended; colon loaded with indurated faeces. Other viscera healthy. Microscopic Examination. — The white softening of the brain surrounding the clot externally consisted of the mechanical breaking up of the nerve tubes, as figured Fig. 401. The fawn-colored and reddish portions of the softening contained nume- rous granule cells, mi.xed with broken-down clots of blood, some of which were of a bright orange color, mingled with numerous crystals of hematoidine. (Fig. 349.) Commentary. — This case was very like the last, viz., chronic arteritis, followed by extensive heraoirhage 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 unfavorable sign. The importance of administering a purgative was here well demonstrated, the paralysis having affected 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 faeees. Case XXIV .* — Apoplexy — Hemorrhage at the base of the brain in a hoy aged. 14 years. History. Thomas Pitbladdo, ast. 14, a house-paiuter’s apprentice — admitted on the evening of June 6, 1856. His father states that he has generally been a healthy lad, but occasionally complained of pain in his head. This morning he got up as usual and went to his work. He ate his breakfast and dinner at the usual times, not so heaitil}/, it is said, as he was accustomed to do, but he made no complaint. Between 2 and 5 o’clock p.m., he was in the streets carrying errands for his master, durino- V. Inch time he purchased and ate several partially-decayed oranges. On returning tc * Reported by Dr. Wilson Fox, Resident Physician. 406 DISEASES OF THE NERVOUS SYSTEM. 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 hail past V p.m, his father was sent for, and Ibund him complaining of pain in the head and abdunen. Subsequently he was observed to grind his teeth. An emetic of ihccLcnanha was obtained from a neighboring druggist, which operated once, slightly. He was brought to the Infirmary at iO 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. Ko 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. Ihis, however, failed in consequence of the firm spasmodic contraction of the jaws, accom- panied by grinding of the teeth. Warm fomentations also weie aj plied to the abdomen. He now became completely comatose, and it was observed that there w'as strabismus inwards of the left eye with contracted pupil, the right one being fixed with dilated pupil. He lay motionless, with the exception of slight clonic spasms of the left hand and forearm. A purgative enema was given, winch returned un- changed. He was then placed in a w'arm bath. The spasmodic contraction of the jaws, however, continued, the respirations giadually became more laborious, and he expired about one a.m. on the '7th, without having had any convulsion. Sectio Cadaveris . — Tivelve 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 diy. Substance of hemi- sphere healthy. The lateral ventricles contained about § ij of sanguineous serum. At the base of the brain was a clot of blood, foiming a icund tumor the size of a walnut, situated below the arachnoid, and breaking up the cerebial substance sur- rounding the fifth and third ventricles, and the inferior portion of the optic thalami, between the pillars of the fornix, thereby communicating interiorly with the lateral ventricles. The sanguineous mass was about an inch in depth. Arteries everywhere healthy. Thorax and Abdomen. — Thoracic and abdominal organs healthy, with the ex- ception of an ecchymotic circular patch of a brick-red color, 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 outlines either isolated or attached to the tubes. The varicosities of the tubes also could readily be increased by pressure. (See Fig. 404, which was drawn from a demonstia- tion of the softening in this case.) Commentary — Cerebral liemorrliage is a rare idiopathic lesion in very young persons, and the causes leading to its occurrence in this 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 suj pose that the boy had eaten some poisonous substance, and the treatment was founded on this supposition. Pathologically, it is interesting to observe how the same lesion, which in an elderly person would Lave 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. Case XXV.^ — Apoplexy, followed hy Deliriwm, and proving fatal in eight hours — Hemorrhage into the Meninges of the Brain. TTtstopy. — Elizabeth Vicars, l throughout, its centre being occupied by a clot of blood the size of a hazel- nut, dark in the centre, of a brick-red color externally, surrounded by softened cerebral matter of a yellow fawn-color. 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 thill layer of blood between the pia mater and arachnoid membranes. The arteries at the base of the brain presented numerous opaque patches of athevonia. On cutting into the pons, an extravasation of blood had taken place into its substance, disinte- grating the whole of it ; it was of a dark red color, evidently recently poured out, and was Iluid in some places, and loosely coagulated in others. Chest — With the exception of a few atheromatous patches on the aorta and mitral valve, which latter in no way impeded efficiency, the thoracic organs were healthy. Abdomen. — Abdominal organs also healthy. Microscopic Examination. — The softening of left optic thalamus consisted of dis- integration of the tubes ; fatty granules accumulated in the ganglionic cells ; numer- ous granule cells, several tinted of an orange color, and others of a dusky red, were in the immediate neighborhood of this clot, mingled with several crystals of hematoid- ine, and masses of blood varying in tint. The centre of the clots presented a series of laminae of a brownish black color. The broken-up pons varolii was infiltrated with blood corpuscles, and the tubes were more or less disintegrated. Commentary . — In this case circumscribed hemorrhage into the right optic thalamus caused apoplexy and hemiplegia on the left side, from which she was gradually recovering, when an unusual exertion caused a secondary fatal hemorrhage into the pons varolii. Here the primary disease was chronic arteritis, causing brittleness of the vessels. In all such cases too much care cannot be taken to avoid sudden exertion, agitation of mind, and every other circumstance which is likely to pro- duce increased pressure on the blood-vessels. Case XXVIII .'^ — Five years before admission^ Ilemipleyia, followed ly Recovery — Four months before admission Apoplexy^ with convulsions and Partial Recovery — Pulmonary Pisease — Peath by Asp>hyxia — Chronic Softeniny of Riyht Corpus Striatum — More recent Hemorrhage into the Pons Varolii — Cardiac Hypertrophy^ with mitral constriction — Hemorrhage into the Lungs. History. — Mrs. Maepherson, act. 34, admitted December 22, 1850 — of intemperate habits. She has been troubled for the last four years more or less with cough. Five years ago she had an attack of paralysis affecting the left side of whole body. Her speech was thick. The left cheek appeared more prominent than natural ; there were twitchings also of the left arm. Leg not affected. Intellect unimpaired. She recovered perfectly in two or three months. She continued, however, her intem- perate habits, and was addicted to taking laudanum. Four months ago, after taking a drachm of laudanum, she was suddenly seized with violent convulsions, sprang a little distance, and fell on her face. She was quite unconscious at the time, a condi- tion from which she gradually emerged, but her mind has ever since been affected, and the power over the left side is mucli impaired. Since the second attack, she has been subject to violent and sudden fits of coughing, lasting for hours without inter- mission, which have latterly increased. Symptoms on Admission. — On admission, she leans to the right side when sitting. Countenance anxious, motions of chest rapid, with much elevation of thorax during inspiration. Dyspnoea urgent. Cough constant and paroxysmal. Expectoration copious. On percussion the anterior surface of the chest sounds resonant. There is dulness over the infra-scapular region of left side. On auscultation, the inspiration * Reported by Mr. Pearse, Clinical Clerk. CEREBRAL HEMORRHAGE. 413 is short, and the expiration much prolonged, and accompanied with sibilant and sonorous rales over the whole anterior surface of both sides ; loud crepitating and mucous rales over the inferior portion of left back, with distinct crepitation also inferiorly in right back. Vocal resonance is increased over left infra-clavicular region. Heart’s sounds normal, distant. Tongue of a brown color, moist. Appetite baJ. Bowels regular. Catamenia regular. Has no pain in head or any part of her boJy. Skin hot and moist. Prooress of the Case. — December 30^A. — She has been treated with various anodyne expectorant mixtures, sulphuric and nitric ether, ipecacuan wine, chloroform, morphia, etc., to relieve the cough and difficulty of breathing, but with little benefit. Is weaker to-day. Countenance sunk and anxious. Tossing about of arms. Breath- ing short and rapid. Cough almost ceased. Expectoration greatly diminished. Pulse weak, scarcely perceptible. Ordered two ounces of whisky and one pint of porter daily. January Is^. — Exhaustion still greater. With difficulty roused to answer questions ; incoherent in her conversation ; sleeps little ; breathing rapid, short, and labored ; paroxysmal cough. The rales formerly noticed still continue ; dulness over the left back more extensive and complete. Pulse small. Haheat Sph'it. commun. ^ iv. January 2d . — Since yesterday there have been coldness and lividity of face, with stupor gradually increasing. Dyspnoea very urgent. E.xpecto ration scanty. These symptoms increasing, she died at 3 a. m., January 3d. Sectio Cadaveris. — Nine hours after death. Head. — The dura mater and arachnoid membrane were healthy in structure, but the subarachnoid cavity contained superiorly a small quantity of serum between the sulci. Both lateral ventricles contained about a drachm of fluid, but that on the right side was opaque, of a greyish color like dirty milk, while that on the left side was colorless and clear. Three-fourths of the right corpus striatum posteriorly was reduced to a f iwn-colorel diffluent pulp, from which a turbid grey fluid flowed out on puncture, similar to what had tinged the serum in the ventricle. The white substance external to the corpus striatum was not alfected, the lesion being limited to a space about the size of an almond nut. On cutting through the softened texture, a few bright yellow patches were observable, about the size of a millet seed, closely resem- bling in appearance the reticulum often seen in soft cancer. On slicing the pons va- rolii, there was observed near its centre, a little to the right of the median line, a he- morrhagic extravasation the size of a small pea, the centre of a dark red, and the cir- cumference passing into a rusty brown. Other portions of the encephalon were healthy. Chest. — The left ventricle of the heart was somewhat hypertrophied, the apex rounded, the mitral orifice was smaller than usual — just admitting the thumb — but there was no thickening or disease of the lining membrane. Lining membrane of the heart and large vessels stained of a claret color — blood fluid. Both lungs anteriorly emphysematous. The lining membrane of the bronchi of dark mahogany color, and more or less filled with sanguinolent mucus. Inferior lobe of left lung greatly engor- ged, containing coagulated masses of extravasated blood, varying in size from a pea to a moderate-sized orange. Inferior lobe of right lung also engorged, with similar masses of blood, but not so numerous nor so large as on the opposite side. Abdomen. — Abdominal organs healthy. Microscopic Examination. — The turbid fluid in the right ventricle of the brain contained numerous floating granular cells and masses. The softened portion of the corpus striatum was infiltrated with them throughout, and the bright yellow masses were composed of an aggregation of the same cells and masses mingled with innumerable molecules and granules. The clot in the pons varolii contained seven'll round and oval celloid bodies, varying in size from the four to the six hundredth of an inch in diameter, crowded with blood corpuscles (Fig. 316). No granular cells were anywhere visible in its neighborhood. Commentary . — The history of what occurred to this woman previous to her admission, involving the account of the two paralytic seizures, was obtained after her death from the husband, who attended the post-mortem examination. During the period she was under treatment, the pulmonary symptoms were those that excited chief attention. The weakness stated to exist on the left side of the body was certainly very slight, as, in the frequent examinations which occurred, it was observed that she sat up 414 DISEASES OF THE NERVOUS SYSTEM. ■when desired to do so, presented either hand when bid to have the pulse felt, and frequently got out of bed without assistance. The crepitating and mucous rales, with the dulness of percussion and great prostration of the patient, however, left little hopes from the first of her recovery; and of these symptoms she alone complained, never speaking of a former or a present palsy. These facts in themselves are very curious, when com- pared with those narrated when the brain was examined, although here it must be confessed that the investigation of the nervous phenomena, from the dislike to interrogate closely a woman evidently dying, was not very minute. There can be little doubt that the first attack was owing to disease (perhaps a hemorrhage into the right corpus striatum) five years previously, and the second, four months before admission, to the limited hemorrhage into the pons varolii. Case XXIX . — Three attach of Apoplexy — The first dependent on He- morrhage into the right Corpus Striatum^ in May 1861 ; the second on Hemorrhage into the left Cerebral Lobe and right Optic Thalamus^ November 1831 ; and the third on Hemorrhage into the Arachnoid Cavity^ March 18C’J. Atheroma of the Blood-vessels — Hypertrophy of Heart — Chronie Disease of Lungs, Liver, and Kidneys. History. — John Gow, act. 56, hawker, was brought to the hospital March 12, 1802, by strangers who found him insensible on the road near Penicuick. His wife gives the following account: — Previous to the month of May 1861, he had been a strong and healthy man. At that time, when walking, he suddenly, without any cry, fell down insensible. He had no convulsions, but foamed slightly at the mouth. 371100 he recovered his consciousness he was able to walk, but the left leg was dis- tinctly dragged after him. His mind was at this time unimpaired, but his speech w'as altered and hesitating. From this period till November last he remained in much the same condition, w'hen he had another fit, again falling down quite insensible. He foamed at the mouth, and bled from the nostrils. He remained insensible for several hours. On becoming conscious, both legs and arms were paralysed. He was for six weeks confined to bed, during which time his mind has been impaired. The speech was rambling and not to be understood, either as regards sense or articulation. He asked for nothing, but was constantly muttering. Deglutition has been unimpaired, but it was necessary to feed him with a spoon. In May 1862 he was able to get up and walk about a little, but dragged both his legs, and the arms hung listlessly at his side. On March 10th, having previously confined his walks to about the door of his house, he contrived, unknown to his wife, to reach Penicuick, seven miles from Edinburgh. How she does not know. She heard nothing further about him till she discovered he w^as in the Infirmary. Symptoms ox Admission. — He is able to understand and answer questions in monosyllables. He is drowsy, and like a person in a state of collapse. He moves his anns and legs freely in bed, when asked. Sensibility is unimpaired. The muscles on the right side of the face are more contracted than on the left. The tongue is pro- truded straight. Appears depressed and exhausted. Whole surface cold. No oedema. His pupils are slightly contracted, but they obey the stimulus of light. Dis- tinct arcus senilis in both eyes. Considerable emaciation. Slight cough. No dyspiKca. No expectoration. Respirations, 12 per minute, not labored nor stertorous. Respiratory murmurs harsh. Percussion resonance over the chest less clear than natural posteriorly. Pulse 66, weak. The second sound of the heart is clear and ringing. Radial artery corded and tortuous. Tongue covered with a dirty white fur. Deglutition unimpaired. The urine dribbles away in bed. A catheter was passed, and about half an ounce of urine w^as obtained. It was albuminous and contained fatty and granular tube-casts. Habeat Pidv. Jalap. Co. statim 3 i ; et Haust. Sennee 3 ij, post fertias koras. To be dry-cupped over the loins. Half a pint of strong beef- tca to be given, and hot bottles applied to the extremities. * Reported by Mr. R. B. J. Cunynghame, Clinical Clerk. CEREBRAL HEMORRHAGE. 415 Progress of the Case. — Five p..\r. Surface still cold, pulse very feeble, 5G per minute. IZb have w>ne 3 i evert) houi\ vrilh strong heef-tea. In the evening, hrandg 3 ss every hour was administered, March V-V.h. — lias passed urine freely in bed and at stool since ; he was cupped yesterday. Bowels were moved this morning. \Varmth has returned to the surface. Just before visit to-day, he passed nine ounces of urine which was highly albuminous, and contained fatty and granular tube-casts, with urates and phosphates in excess ; pulse 5G, rather stronger ; takes food well. B d^otass. Biiart, 3 £S ter in die egatho aqiioe. Beef-tea and vnne to be continued. March \-^th . — In much the same condition. Got out of bed last night, and was able to stand leaning against a pillar. He fell in making the attempt a second time. Drowsiness continues. ]dmj)last. Lgttce michae appUcandurn. March\^th. — Appetite good. Pulse 72. Tongue hard and (Iry, covered with sordes. He is quiet, and sleeps well. Pupils immobile to light. Brandy dailg. March lHh. — Tongue very dry. There is great foetor of the breath. Pulse GO, very feeble, intermittent. Evacuations passed in bed. Urine free from albumen. March %)th. — He is very weak. Pulse 76, irregular, intermit- tent. He has not slept well. Appetite failing. From this date the patient gradually sank. He became insensible on the 23d, and died at 4 p.m. on tbe 24th. Sectio Cadaveris. — Twenty-one hours after death. Body emaciated, looks older than assigned age. Costal cartilages ossified. Head. — On removing the calvarium and dura mater, there was found on the right side a good deal of subarachnoid effusion, and the membrane was rather thicker and more opaque than natural. In the cavity of the arachnoid, over the left hemisphere, was a layer of blood of a brownish red color, and almost entirely fluid, which gravi- tated to the posterior part of the left hemisphere. The quantity amounted probably to about half an ounce. One small patch had coagulated, but was not at all decolor- ized, and was adherent to the surface of the hemisphere, rather anterior to its middle and very near the median fissure. On slicing the brain there were found more red spots than natural in the medullary portion, anl it was noticed that the vessels near the surface were unusually rigid, several of tiiem standing out and remaining open after being cut. The substance of the brain was somewhat cedematous. The lateral ventricles were much dilated. Each contained an ounce of clear serum. The foramen of Monro was the size of a sixpence. W hen the brain was removed, it was found that the hemorrhagic extravasation on the left side extended down to the base, where, in the middle and posterior fossae of the skull, it formed a layer about an eighth of an inch in thickness, and appeared rather inspissated than coagulated. In the anterior third of the left hemisphere, a portion of the grey matter of some of the convolutions, and the adjacent white matter was slightly softened, and of a faint yellowish olor. On slicing the brain an old apoplectic cavity vras opened into at this point. It was of an irregularly crescentic form, one and a quarter inches in length, by half an inch at its broadest part, very shallow, anl containing a soft matter of a russet brown color. It was situated on a level with the upper surface of the corpus cal- losum, and was close to the surface of the brain. The hemori’hage had evidently taken place from the vessels in the grey matter of the convolutions. The cavity was found to be lined by a thin but tough membrane. The lining membrane of the right lateral ventricle was thickened, anl a slight depression with a brownish yellow coloration of the margin existed at the posterior part of the optic thalamus. On cutting into this part, the cerebral matter did not appear to be affected, but the lining membrane of the ventricle was thickened there, and infiltrated into and below it was some yellowish matter. On cutting into the right corpus striatum there was found in its centre a small apoplectic cyst, about the size of a field bean, having a distinct lining membrane, an 1 containing a russet brown matter. Other parts of the brain were natural. There was considerable athero ma of the arteries at the base of the brain. This was especially the case with the branches in the fissure of Sylvius, many of which were of an opaque color, having quite lost their transparency. Their coats were thickene 1, but contained no calcareous matter. Thorax. — The heart was enlarged, weighing L 5 d ounces. The valves were natural, and the hypertrophy was entirely due to increased size of the left ventricle, the cavity of which was a little dilated, while its walls were much thickened. The right ventricle was of normal dimensions. The aorta was atheromatous and cal- careous just above the semilunar valves. The remainder of the vessel was but slightly affected. There were old adhesions at the apex of each lung corresponding to puckerings and cretaceous concretions in the pulmonary ti.ssue, and slight emphysema DISEASES OF THE IsEEVOirS SYSTEM. 41 G cf the anterior margins of the lungs. The bronchi contained mucopurulent matter, and the mucous membrane was much congested. Addomex. — The liver weighed 2 lbs. 8 oz., the capsule was slightly thickened, and harder than natural. The kidneys were very small, weighing together 3^ ounces. The capsule was removed with diihculty. The surface of the organs was tolerably smooth, but had a somewhat rough indurated feeling. The vascularity was pretty regular and normal. Tliere wei-e no opaque granulations, but two or three small cysts v/cre visible. On section much fat was found in the pelvis of each kidney. The cortical substance was atrophied, forming a thin line around the surface of the organ. Microscopic Examination. — The contents of the cavity in the left hemisphere were found to consist of granular matter, yellow granular pigment, and remarkably well-defined crystals of hasraatoidin. The lining membrane presented an obscurely fibrous and rather fibrillated appearance, having quite the structure of an old clot. Immediately external to the cavity was a patch of fawn-colored softening, of the size of an almond, in which very numerous granular corpuscles were found, as well as granular matter and some blood globules. The softening of the right optic thalamus presented exactly the same structure. The small cyst in the right corpus striatum contained nothing but purely molecular matter. In the kidneys the amount of fibrous tissue was everywhere increased. The capsules of the Malpighian bodies and the coats of the vessels were thickened. Very numerous cysts of all sizes were seen, in most of which the lining of epithelium was distinctly visible. The tubes were contracted and seemed fewer than natural. The tube-casts in the urine were small. The epithelium also was granular, but there was little fat. Commentary . — This is a very instructive case of cerebral hemorrhage occurring at three distinct intervals, causing characteristic symptoms on each occasion, and leaving decided proofs of their occurrence after death. Tiie first attack in May 18G1 was sudden, and he recovered with his mind unimpaired, but with dragging of the left leg. This was evidently dependent on circumscribed hemorrhage into the right corpus striatum, the remains of which after death exhibited the form of a small cyst, with a distinct lining membrane, containing a brownish molecular matter. That is, the small clot was transformed in the manner described in a period of ten months. The attack in the following November was more severe, and on his recovery both legs and arms were paralysed. H is mind also was gravely affected, and he could not articulate. On this occasion hemorrhage must have occurred into the optic thalamus and ventricle on the right side, and into the anterior cerebral lobe on the left side, thus accounting for the paralysis on both sides of the body, and the disturbance of mind. The microscopical examination also proves that both these hemorrhages were of the same date, for though on different sides of the brain, they each contained numerous granule cells and crys- tals of haematoidine. The third and fatal attack was evidently caused by the recent hemorrhage into the arachnoid cavity. Whether this was caused by a fall, cannot be stated wdth certainty, as no contusion could be found; but considering his state of weakness, and that the mental hallucination under which he labored, induced him to drag himself seven miles from his residence, it is by no means improbable. The atheromatous condition of the cerebral blood-vessels, and condition of the heart, lungs, liver, and kidneys, present a complication of diseases, all of which predispose to fatal apoplexy. The predisposing cause of cerebral hemorrhage is, in the vast majority of cases, previous disease and consequent brittleness of the arteries. It is true there are some rare instances in which it cannot be traced to this circumstance, and where its origin is obscure (Case XXIV.), or where m young persons, or those of middle age, it may originate from obstruction CEREBRAL HEMORRHAGE. 417 of the vessels by clots sent from a distance, as previously explained. Still, even in these, and in the great majority of individuals advanced in life, among whom apoplexy and sudden palsy are common, chronic cere- bral arteritis may be considered as the real disease, and hemorrhage as its result. Hence why all those circumstances which induce increased pressure on the internal surface of the arteries* are the proximate causes of apoplexy and sudden palsy, such as violent exertion, constipation, straining at stool, strong drinks, undue repletion at meals, mental emo- tions, etc. etc. The histolocrical facts ascertained in connection with the hemorrhao;ic clot are important. The colored blood corpuscles at first accumulate in groups, and some of them are subsequently surrounded by a colloid membrane. Under such circumstances they slowly disintegrate ; the red color is changed into a brown, which becomes darker and darker, and is ultimately converted into black. Not unfrequently crystals, supposed to be of hernatine, are scattered among the broken-up clots, and have been seen both of a deep-red and black color even within the membrane alluded to. That this membrane really does form in the manner described — that is, secondarily — around heaps of blood corpuscles, I am satisfied — my former assistant. Dr. Sanderson, having proved it by direct experiments in my presence. He thrust a needle through the cranium into the cere- bral lobes of four pigeons which were killed, and the brain inspected, successively on the third, fifth, and sixth days. There could be observed in one case, where a slight hemorrhagic streak marked the track of the pin, that the cerebral substance, seen under a magnifying power of 250 diameters linear, contained groups of from five to twelve oval blood cor- puscles, each surrounded by a delicate membrane. (See Fig. 317, p. 248.) When the clot is large, this process may go on through its entire sub- a b c Fig. 410. stance, in conjunction with the formation of compound granular cells. I examined a tumor the size of a small hen’s egg, brought to me by Dr. Peddie, in which the external layer presented numerous fibre cells and fibres, in various stages of development, whilst the interior was prin- cipally composed of numerous granules and compound granular cells. Here and there, however, were patches of red extravasation more or less Fig. 410. Section of the capsule and portion of the coagulum, size of an orange, f und in the brain in Dr. Kirkwood’s case. External portion of capsule, consisting of fibrinous laminae ; h, internal portion of capsule, rendered dark-red, purple, and opaque, from condensed blood corpuscles ; c, broken-down blood corpuscles in the in- terior, with crystals of cholesteriue. 260 diam. 27 418 DISEASES OF THE NEKVOUS SYSTEM. recent, containing large delicate vesicles filled with blood globules. (See Fig. 316, p. 248.) In another tumor sent me for examination by I)r. Kirkwood of Berwick, which was the size of a large oi'an^e, and im- bedded in the right cerebral hemisphere, I found it to consist of a firm resistant shell or capsule, about one-eighth of an inch thick, containing coagula of blood of a brick-dust color. The capsule, externally, was of a straw color, like that of coagulable lymph; but one-third of its thickness, internally, was dark red passing into black. A small portion of the ex- ternal layer of the capsule, examined under the power of 250 diameters linear, presented apparently a dense mesh-'work of fibres, running in waved bundles, which in fact were the edges of laminae. The thicker in- ternal layer was composed of simikar fibres, mingled with masses of blood corpuscles, in various stages of disintegration. The internal coagula were composed of numerous molecules and granules, and a mass of blood corpuscles, diminished in size, and variously altered in shape, but still presenting their normal yellow hue, mingled with numerous crystals of cholesterine. These and numerous other examinations have convinced me that when the hemorrhagic extravasation is small, it breaks down and disintegrates in a period varying from three to six months. Even then it may leave traces of its existence, especially in the form of a cyst, the internal membrane of which is of a bright orange, or brick-red color. On examining this membrane, or the colored softening in its immediate neighborhood, it may be seen to consist of numerous molecules and granules, sometimes associated with fragments of the nerve -tubes. There are also granular corpuscles and masses, variously tinted, of a bright orange, brick-red, reddish-brown, or dark brown. The former are evi- dently the celloid bodies formerly described and figured (Fig. 317), con- taining blood corpuscle in diferent stages of disintegration. There are also fre- quently present a greater or less number of crystals of hematoidine, of a deep red or ruby tint (Fig. 349). If the clot be large, the period required for absorption may extend to years, and then the ex- ternal portions of the clot are trans- formed into an external fibrous cyst, within which the blood is very slowly disintegrated and absorbed. Most com- Fig. 411. monly, however, in these cases, long be- fore absorption occurs, secondary changes take place in the surrounding nervous structure, or pressure is exercised on parts at the base of the cranium, whereby oonvulsions, paralysis, or other symptoms occur, and life is destroyed. The diagnosis of cerebral hemorrhage from the other lesions of the brain is not always easy, in consequence of the fact that a chronic cere- britis may proceed imperceptibly, and then induce apoplexy or sudden * Monthly Journal, March 1851. Fig. 411. Granular corpuscles and masses, of a bright orange and pale yellow color, some of them passing into brown, wdth crystals of hematoidine from an old apoplectic clot. 250 diam. CEREBKAL HEMORRHAGE. 419 palsy. It may generally be observed, however, that a true exudative c.-releral softening is preceded by more or less weakness of the intellect, and more especially by slowness in receiving mental impressions, or framing replies to (questions, frequently combined with more or less headache, confusion of ideas, and perversion of motion. Much will de- pend upon the seat of the lesion, the mind being disordered most in pro- portion to the extent and nearness of the disease to the hemispherical ganglion — while motion is the more influenced, according as the central and basic parts of the brain are afl’ected. Then it should not be forgot- ten that whilst a cerebral softening may occasionally lead to or be com- plicated with a hemorrhage, so a hemorrhage is one of the most common causes of a softening. The distinction between the two under such cir- cumstances becomes very difficult. Still there can be no question that suddenness of attack^ whether of apoplexy or of palsy, is (excluding ex- ternal injury) the characteristic symotom of cerebral hemorrhage. Occa- sionally, however, sudden paralysis mikes its appearance in cases of chronic softening, a result which Dr. Todd has attributed to the rupture or deliquescence of tubes which had been already softened, but not suffi- ciently to interrupt their power as conductors of the nervous force. Whether hemorrhage be consecutive on diseased arteries, or upon their calibres being obstructed by clots, must be determined from all the facts of the case ; the former being most likely in elderly, and the latter in younger persons with diseased hearts. Little, however, is as yet under- stood of this point diagnostically in the living subject. For what is known with regard to the seat of cerebral hemorrhage and softening, I must refer to page 152. The influence of cerebral softening and hemorrhage on the motor function has justly excited the attention of physicians. Whilst by some more or less contraction and rigidity of the limbs have been considered as highly characteristic of inflammatory softening, others have maintained that it is altogether incidental, that it often exists when no softening can be found, and that it is as often absent when softening is present. It has also been known to accompany hemorrhages, apparently unconnected with softening. The analysis of many cases in reference to this subject has led me to the conclusion, that on the whole muscular rigidity or con- traction is a valuable sign of softening when present^ but that, as the softening may be permanent, whilst the rigidity is only temporary and indicative of the irritating effects of the lesion, the absence of the one is no proof of the non-existence of the other. It should be remembered that much of this discussion took place formerly when no means were known of distinguishing histologically between inflammatory, hemorrhagic, and post-mortem softenings. Dr. Todd has especially drawn attention to the state of the muscles in palsied limbs from cerebral disease,* arranging the cases into three classes — 1st, Those in which the muscles of the paraly- tic limbs are completely relaxed; 2d, Those in which the paralysed muscles exhibit rigidity from the moment of, or soon after, the attack; 3d, Those in which rigidity comes on long after the paralysis. The first class of cases he considers usually results from hemorrhage, combined with preyious softening of the brain and rupture of the tubes, the clot of ^ Clinical Lectures on Paralysis, etc. 1854. 420 DISEASES OF THE XEEYOUS SYSTEM. blood being separated from healthy brain. The second class of cases depends on the clot of blood acting directly on sound brain at the point of implantation of the nerves of the affected muscles ; while the third class of cases are owing to a similar irritation from an attempt at cicatri- zation of the brain’s substance. These views of Dr. Todd, though in- genious, must as yet only be regarded as probable speculations. The true generalization appears to me to be, that complete paralysis indicates such pressure on or obstruction of cerebral tissues as to prevent all trans- mission of nervous influence, whilst rigidity, convulsion, and pain show that some tubes of that tissue are preternaturally excited. Both cond^i- tions may be occasioned by hemorrhage, exudation, effusion, tumors, or any lesion that affects the brain. The treatment of cerebral hemorrhage must refer to the attack, and to the subsequent management of the case. At the moment of attack, the steps to be pursued must always be a subject of anxious considera- tion. Formerly there was little difficulty — venesection to a large ex- tent being the established routine remedy. The advance of pathological knowledge, however, must have made it apparent, that the same pro- ceeding is not likely to be beneficial in ail cases where the nervous centres are similarly affected. We may have sudden loss of conscious- ness and volition from syncope, as well as from coma, the only supposed difference between the two being, that the same nervous phenomena commence in the heart, with a weak pulse, in the one case, whilst they originate in the brain, and have a strong pulse, in the other. But care- ful observation has sufficiently proved that there are many cases of even true hemorrhagic apoplexy which are closely allied to syncope, and which have recovered under the use of stimulants, rather than of deple- tions. It seems to me also very probable that many of those individuals who died under what Abercrombie called simple apoplexy, and in whom no trace of disease could be found in the brain after death, were really the victims of one form of fatty degeneration of the heart — an affection in his day altogether unknown. The best rule, therefore, I can give you, is to judge from all the circumstances of the case. Whenever the individual is of vigorous frame of body, if the face be flushed, the attack recent, and the pulse strong and full, a moderate bleeding may be bene- ficial. The extent must be influenced by its effect on the heart’s action ; for as we have seen, the object of this measure is not to draw blood from the brain, which is impossible, but to diminish the pressure on that organ, by lessening the force with which the heart propels the blood through the carotid and vertebral arteries. On the other hand, if the individual be of spare habit, the face pale, the pulse weak and irregular, and the usual symptoms of shock be present, wine, brandy, stimulants generally, and restoratives, are demanded. But it most frequently happens, that when you are called in, neither one nor the other indica- tion presents itself It will be most prudent, under such circumstances, simply to apply cold to the head, administer an active purgative, and above all enjoin quietude. At the same time the patient should bb placed in the horizontal position, with the head slightly elevated, whilst the cravat, stays, and all impediments to the respiratory and circulatory functions should be removed. CANCER OP THE BRAIN. 421 Should the individual recover from the attack, quietude, mental and boJily, and supporting the economy by good nourishment, constitute thj chief treatment. Thus long conversations, literary labor, business transactions, the sudden reception of joyful or distressing intelligence, etc., should be carefully avoided. Sudden exertions, rising from bed (see Case XXYII.), constipation, straining at stool, etc., must be guarded against. Of all these I believe the prevention of constipation to be the most important, as the straining at stool thereby occasioned is one of the most common causes of secondary attacks. If paralysis remain, considerable caution must be exercised before having recourse to local stimulants, such as frictions, galvanism, or exercise of the affected parts. These are remedies of undoubted utility, but never to be employed at the risk of causing general excitement, and always very gradually applied, and their increase well regulated. Exactly the same management is required in cases of chronic cerebritis, or where there is reason to suspect that coagula from the heart constitute the cause of the cerebral lesion. CANCER OF THE BRAIN. Case XXX.^ — Cancer of the Brain^ Spinal Cord, Liver, and Bones. History. — George Gall, aet. 29, a stoker on board a steam-vessel — admitted July 1, 1857. About the beginning of December 1856, he contracted a cold with cough and profuse expectoration, and has not since enjoyed good health. At the end of March 1857, he began to feel pain in the lumbar and sacral regions, extending also to the neck, affecting the shoulders, and spreading down to the joints and muscles of the arms. The knee-joints were also painful. They are reported to have been swollen, but only for a short time. At the commencement of last April, he seemed to labor under confusion of thought, with shortness of memory, and incapability of carrying on a train of ideas. During the next two months became gradually more weak and emaciated ; at length he was unable to walk or to rise unassisted ; passing his urine in fair quantity, but involuntarily during sleep. Symptoms ox Admission. — Has no headache; is very silent, but listens to ques- tions, and answers them after a slight pause intelligently. The questions, however, require only monosyllabic answers. He says little, and his thoughts are apparently few. Special senses normal. The pupils are unusually dilated, but contract on stimulus of light; are equal and parallel. No paralysis of the muscles of the face or tongue. Marked tenderness over dorsal, and still more over lumbar vertebrae. Never had tingling or numbness of the extremities. All attempts to walk cause great pain in the back, to such a degree that he cries out. Great atrophy of the muscles ; he moves very little ; lies often in a cramped position ; cannot rise up in bed without assistance. The tongue is clean ; the appetite is reported to be good ; but he fre* queutly vomits, sometimes immediately after a meal, sometimes an hour or two after- wards. No increase in hepatic or splenic dulness ; abdomen appears natural, except in being retracted and emaciated ; the bowels are habitually costive. He has at pre- sent no cough, sputum, nor dyspnoea. The respiratory murmurs appear healthy ; the cardiac sounds are natural. Pulse 82, small and weak. The urine is passed involun- tarily during sleep, but voluntarily during the day. It is of a light straw color, sp. gr. 1005 ; contains no albumen but abundant chlorides. Is ordered nutritive food, with laxative pills, and, if necessary, eaemata. Progress of the Case. — July Uh. — Is growing weaker; pulse 96, small and wiry ; has a headache, chiefly over the occipital region. July %th. — The pain in his liead continuing, the hair is shaved ; cold cloths are applied to the scalp, and a blister Vi put over the nape of the neck. July \0th . — Pulse 104, very weak; hot skin; g^'eit thirst; little appetite, and frequent vomiting, usually some time after taking food. Is ordered a saline mixture, and four ounces of port wine daily. July 12//i. — * Reported by Mr. John R. Murray, Clinical Clerk. 422 DISEASES OF THE NERVOUS SYSTEM. On re-examination, besides the atrophy common to both lower cxtrcn itics, there appears to be almost total want of sensibility and motion in the right kg; the left leg being, for one so emaciated, quite normal. Pupils continue widely dilated ; there is no headache at present. July lAth. — Is able to move the right leg slightly, and feels irritants applied to the sole of the foot, but not to the limb generally. Again complains of pain ditfused over the whole occiput; pulse 112, weak. July Complains of his vision becoming impaired; can recognise objects, and name their number. Had an evacuation yesterday morning, and for two days has not vomited so much as formerly. Has headache, but it does not seem severe ; the application of cold has been continued. July \Uh. — Pulse 148, small, weak, and hard. Respira' tion 22 per minute. Ordered two additional ounces of wine ; continue oiutrienis. July ‘list. — Vomiting recurred yesterday, after being nearly absent for a week; is observed to recur when the bowels have been much confined, and to disappear after copious evacuation. Ordered two pills, and, if necessary, an injection. Jtdy 29^/n — \ omited less after operation of the laxatives ; is extremely weak, but little change can be noticed from day to day. July 30/A. — This miOrning he ivas found more ex- hausted ; a cold sweat over the whole surface ; the respirations short and hurried ; the pulse extremely feeble, cardiac impulse at apex increased. Wine was freely given, but he sank, and finally expired at 2.30 p.m. Sectio Cadaveris. — Forty-eight hours after death. Body moderately emaciated. Head. — On removing the dura mater, the surfaces of the hemispheres were unusually smooth, from flattening of the convolutions. The vascularity of the membranes was normal. On slicing the brain it was seen to be studded throughout with nodules varying in size from a hemp-seed to that of a large hazel-nut. They were of a grey, pinkish color — the smaller of pulpy consistency, ihe larger more firm, amd all capable of being easily enucleated from the surrounding brain substance. None of them projected from the surface, but they were irregularly distributed, some in the grey, but most in the white matter. Here and there was slight softening round some of the masses, but there was no extravasation of blood. In the right hemisphere, projecting a little through the roof of the ventricle, was a mass the size of an ordinary marble. In the roof of the left ventricle was another of similar dimen- sions. The left corpus striatum contained two of these bodies, one the size of a small cherry, situated anteriorly ; another that of a pea, somewhat more posteriorly. Around these was no softening. The optic thalami were normal. Similar bodies were scattered through the cerebellum, but there were none in the pons varolii and medulla oblongata. Each lateral ventricle contained almost a drachm and a half of clear fluid. On removing any of these bodies, there could readily be squeezed from them a creamy matter, leaving behind an apparently membranous substance evidently very vascular. Spinal Column. — The four upper dorsal, and two or three of the lower dorsal, and the first lumbar vertebrae, were soft and spongy, the osseous substance yielding on pres- sure a copious, thick, greyish juice. The membranes of the cord were healthy. On bi- secting the cord, a mass the size of a pea, exactly similar to those observed in the brain, was found in its right half, opposite the junction of the second and third dorsal vertebrae. Chest. — About the centre of the sternum was a slight bulging, of reddish color and soft consistence, yielding a dirty yellow colored cancerous juice on pressure. Similar soft enlargements were found in the anterior portions of the third and fourth left ribs. The lower lobe of right lung contained an infiltrated indurated mass, about the size of the fist, in some places of a yellow brown, and in others of a dirty grey color. Some bronchial glands cancerous. Other thoracic organs healthy. Abdomen. — Liver contained small, rounded, dirty white masses, principally at its circumference, varying in size from a small pea to that of a horse bean, and not pro- jecting from its surface. Some of the gastro-colic glands were enlarged and cancerous. Other abdominal organs healthy. Muscular System, wherever examined, and especially in the inferior extremities, was atrophied, but presented its normal color. Microscopic Examination. — The various encephaloid masses scattered through- out the brain, consisted of a vascular stroma, and a thick creamy juice. A drop of the latter contained numerous cancer cells in all stages of development, as repre- sented Fig. 277, p. 215. The stroma of the small masses consisted of a plexus of vessels of various sizes, crossing and inosculating with one another, many forming loops which were enlarged and crowded with blood corpuscles as in Fig. 151. In the CANCEK OE THE BRAIN. 423 larger masses the vessels had undergone development, by pushing out from their sides prolongations, which, subsequently uniting, formed a plexus (as seen in Fig. • 302). During this process, however, another change had occurred, viz., an in- vestment of these prolongations, which often assumed the form of acini in a gland, with a distinct membrane, in the interior of which was a vascular loop. It re- sulted that whilst some part of these masses contained a vascular plexus, with numerous cancer cells in a mesh- work, in others it exhibited a structure, now . Fig. 412. Fig. 413. villous, and now approaching towards that of a gland (Figs. 392, 893). This was evidently the “ Cancer Stromata,” so well described by Rokitanski, in some forms of encephaloma. The small cancerous nodule in the spinal cord presented the same structure as those in the brain. For the most part the nervous substance surround- ing these masses was quite healthy ; but here and there, in their immediate neighbor- hood, it contained a few granule cells. The cancer of the lungs and bones presented the usual structure of encephaloma in those organs. Commentary . — The occurrence of cancer in the brain is exceedingly rare ; and the form of it above described was seen by me for the first time, and examined with the greatest care. Its structure histologically was very interesting, and contrasted in some remarkable particulars with another well-observed case recorded by Dr. Redfern of Aberdeen,^ in which the stroma consisted wholly of shreds of cell membranes and granules. Before death, there were manifested both a cerebral and spinal disease. The former occasioned a peculiar perversion of the mind, consisting of a certain confusion of thought and incapability of carrying on ideas, whilst he answered questions readily and appeared perfectly conscious. Theoretically this is readily explained by the numerous circumscribed cancerous masses which may easily be supposed to have disturbed that continuity of transmission along the tubes so essential to vigor of mind. The spinal disease was indicated by local pain and incapability of supporting himself erect, symptoms attributable * Monthly Journal of Medical Science, December 1850. Fig. 412. Peculiar vascular stroma with villi in the larger cancerous masses of the brain, acetic acid being added. The interstices were crowded with cancer cells. Fig. 413. Gland-hke expansions of stroma in other portions of the same mass. 80 di. 424 DISEASES OF THE NEKVOUS SYSTEM. to the osseous disease and weakness. The paralysis of the right lower extremity may be owing to the nodule of cancer in the spinal cord opposite the dorsal vertebrae; but this is by no means certain. There was some difficulty in determining whether the indisposition to walk and powerlessness was owing to a^^rophy of the limbs or to a true paralysis. I am disposed to think that both causes co-operated. DROPSY OF THE BRAIN. Case XXXI.'^ — Chronic Hydrocephalus — Paracentesis Capitis — No Benefit. History. — Esther Little, ret. 17 months, was admitted June 27, 1857. Her birth was natural, and nothing peculiar in the size or shape of her head was then ob- served. For two months her health was perfect; she then had convulsions, vomit- ing, and strabismus ; her appetite diminished ; her abdomen swelled, and there were frequent green slimy stools. She was under medical treatment for nine weeks, when she began to improve, and from that time her mother has noticed no deficiency ill her appetite. When five months old a swelling appeared on left side of neck ; it was lanced, and soon afterwards healed. But about this time also — twelve months c-go — the size of the head attracted the attention of her parents ; and from that day, up to admission, it has been gradually increasing. The child is thought by her parents to feel no pain in her head, but only inconvenience from its weight. She lias not suffered from dentition, and has now cut ten teeth. She has not yet been weaned. ^ Symptoms on Admission. — The child is not emaciated, the arms, legs, and body being well nourished; it often smiles, but the smile is readily converted into a querulous cry. It is fretful on the slightest change in the position of its head, which is too heavy for it to support. The head is of an irregularly square shape, the left side appearing to bulge posteriorly a little more than the right. The anterior fontanelle, 4 inches broad, and 9 inches at its greatest length, gives a distinct sense of fluctuation, being at the same time tense. The veins are seen with unusual distinctness coursing over the head. There are laminated scabs of chronic eczema over the scalp. The forehead is projecting. The eyes appear to Fig. 414. Fig. 415. Fig. 416. protrude against the inferior eyelids, which cover the greater part of their sur- face. The upper lids are retracted slightly, and leave the sclerotic exposed. The lids are somewhat red. There is no strabismus ; there is intolerance of strong * Reported by Mr. W. Guy, Clinical Clerk. Figs. 414 to 416. Lateral, vertical, and front views of the head of Esther Little. In consequence of the well-nourished face and limbs, the drawing does not convey to others an idea of the comparative size of the head so well as usually occurs in these cases. DROPSY OF THE BRAIN. 425 light. The features of the face are well-proportioned, and the cheeks bear a good deal of color. The measurements of the head were found to be 24 inches at the greatest circumference (the girth on the left side being 12^), 15 inches across the head from ear to ear, and 16 inches from the frontal sinus to the occipital pro- tuberance. On examination, the cardiac sounds are healthy, and the respiratory murmurs are natural. The tongue is moist and clean. The appetite is reported good. The child is not yet weaned, and is often at the breast; it, however, also gets milk, beef-tea, and bread. Its bowels are reported to be regular. The urine is passed in good quantity, but none has been obtained for examination. The mother has five living healthy children. Progress op the Case. — The hair being clipped close, the tincture of iodine had been painted over the scalp. July Uh. — To-day, about 1 p.m., tapping was performed by Mr. Syme. A small trochar being introduced to the depth of about one inch behind the posterior edge of the right os frontis, one inch to the right of the mesial line, five ounces of fluid were withdrawn. A compress was then applied over the puncture and secured by strapping. Slips of diachylon plaster were also applied from side to side and obliquely, to effect gentle compression, and support was further given by a bandage passed round and across the head. There was very little crying on the part of the child. The fluid was clear as water ; alkaline ; sp. gr. 1009 ; depositing slowly, after being heated and acidified, a slight amount of albumen, and giving also (under action of sol. sulph. cupri, aqua potassae and heat) a trace of grape sugar. July IWi . — Since the operation there have been no symp- toms of nervous excitement or derangement. On measurement of head to-day, was found to be the same size as on admission. July IMh. — Yesterday, on again measuring the head, the same results were obtained. To-day, Mr. Syme again per- formed paracentesis, removing twelve ounces, the puncture being made on the left side at a point corresponding to the previous one on the right; the fluid exactly resembled that formerly drawn, but did not give the grape-sugar re-action. The head was gently compressed while the fluid was flowing through the tube, and until, by means of strapping and bandage, equable pressure was applied to the cranium. The scalp was collapsed and puckered after the operation, and the bony margins of the fontanelle had considerably approached one another. July lUh . — Child has been more fretful ; has passed less water : ordered ten drops of sp. ether nitrici thrice a day. July Vith . — The urine has increased in amount. The child has recovered its usual health. July 21s^. — To-day, the seventh since the operation, the bandages were removed ; the coronal region felt full, and on measurement, the same numbers were obtained. July 24^A. — Paracentesis was again performed ; twelve ounces were removed, the fluid being faintly yellow; 1008 sp. gr., and otherwise identical in character with the fluid formerly withdrawn. At close of the opera- tion rigors occurred, and the child looked pallid and faint. It was revived by wine and warmth; it partially vomited the wine; it was then kept at the breast, and by the evening it had regained its usual aspect. July 2^th . — The urine again scanty; slept well last night; is exceedingly fretful, and does not incline to the breast. July 2&th . — The fontanelle is again tense ; urine still scanty ; did not sleep well last night. July 'ijth . — Slept better; urine slightly increased, but none can be obtained for examination. Judy 2>%th . — Again slept better ; appetite is returning ; the child is very fretful; but otherwise has no unusual symptom. The mother is anxious to return home, and a fourth paracentesis is not deemed advisable. The head was again measured, and found to be of the very same size as on admissiom Discharged, July 28^/i, 1857. Chemical Examination by Mr, Turner of the fluid removed. The fluid was especially examined with reference to the question whether it pos- sessed the power of deoxidising the blue hydrated oxide of copper like grape-sugar. This property was possessed by the first specimen, the reduction to the state of sub- oxide taking place after boiling for a few minutes. No such re-action could, however, be obtained from the second portion, although the experiment was tried several times, both with the fluid as received, and also with it after it had been considerably concentrated by evaporation. The third specimen, however, exhibited the re action in a more decided manner than the first. All three specimens contained albumen in small quantity. Heat and nitric acid causing it to fall down as a white flocculent precipitate. The following inorganic constituents were also found in the fluid in minute quantities : — Chloride of sodium, phosphoric acid, lime and magnesia. 426 DISEASES OF THE NERVOUS SYSTEM. Commentary . — The history of this case indicates that, two months after birth, the child had probably an attack of acute meningitis at the base, from which she recovered. From this period dates the commence- ment of the hydrocephalus, a circumstance which induced me to suppose that the chronic exudation had in some manner compressed the blood- vessels, and caused dropsy. I have previously pointed out that such is the pathology of effusion following acute meningitis (p. 372), and there is every reason to suppose, that such is the explanation of the slow accumulation of fluid in the present case. With the exception of the cerebral disease, there was no other malady. So far as 1 could discover, there was especially no tubercular complication, which is generally so much to be dreaded in these cases, and all the functions were performed naturally. On the other hand, the mother assured me that the head was daily enlarging, and it was clear that, under no circumstances, if left to nature, would the child’s existence be an enviable one. Under these circumstances I determined to try the effect of cautiously removing the fluid, and seeing whether the cause producing the effusion might not have ceased to operate, when assisted by diminished pressure. The first five ounces of fluid removed, produced no disturbance in the child what- ever, and, encouraged by this circumstance, on the next occasion twelve ounces were taken away. On this occasion the head was greatly diminished, and the scalp considerably corrugated immediately after the operation. The head subsequently was carefully covered with strips of adhesive plaster in the manner recommended by Mr. Barnard, and the whole supported by bandaging. For a few days afterwards, the child exhibited somewhat more restlessness, soon followed by a little unusual stupor. This I attributed to a re-accumulation of the fluid. On re- moving the bandages the head was found to be of the same size as on admission. Subsequently the scalp became very tense, and another twelve ounces were removed, followed by bandaging. On this occasion, however, the operation was followed by a rigor, but the child speedily recovered. The mother next day informed me that on this, as on the preceding occasion, the urine was diminished, although I had endeav- ored to meet the possibility of this occurrence by the exhibition of nitric ether. This circumstance, therefore, convinced me that no benefit was to be anticipated from continuing the tappings, and the mother and child consequently returned home. I have since heard from Dr. Anderson of Selkirk, that, a few days after returning to that town, the child died, but as he was unfortunately absent at the time, he did not see her, and she was buried before his return. From an account fur- nished by the parents of the symptoms which preceded death, it appears that there was no vomiting, unusual restlessness, strabismus, convulsions, paralysis, nor coma. But there was great pallor, disinclination to take food, and exhaustion. Had she remained in the Infirmary, these symp- toins, and the fatal results, might have been delayed by the judicious administration of nutrients and stimulants. The most satisfactory proof of the occasional benefit of tapping the head in cases of chronic hydrocephalus, is to be found in the paper of Dr. Conquest,^' who at that time had operated in nineteen cases, and in ten of these successfully. He tells us that ‘‘ all the operations were * Lancet, vol. i. 1837-38, p. 890. STEUCTUR.UL DISEASES OF THE SPINAL CORD. 427 performed in the presence of many medical gentlemen, and most of them before large bodies of students at St. Bartholomew’s Hospital.” One of these cases, that of Catherine Seager, in its general details was very like the one now under observation. Two pints of fluid were removed by the operation, followed by a convulsion. Yet she was seen by Dr. Conquest, two years and a half afterwards, perfectly well, and in complete possession of all her intellectual faculties. With such facts before us, it is clear that the operation is warrantable when, from an absence of complication, there is a reasonable hope of success, as existed in the present case. Should another case present itself to me, I would allow a longer time to elapse between the tappings. With this exception, I do not know, on a retrospective view of all the circumstances, that there was any point in its treatment that required modification. It would be a matter of great practical importance to determine, whether, as a rule, evacuations of the fluid are as useful in advancing as in stationary cases of chronic hydrocephalus. It is probable that the good effects described by Dr. Conquest were obtained in the latter kind of cases. 8TRUCTUIIAL DISEASES OF THE SPINAL COBD. Case XXXII. — Otorrhcea — ISudden Lumhar and Cervical Pams— Convul- sions — Spinal Meningitis. History. — Martha Bell, aet. 19, servant — admitted on the evening of May 29th, 1863. She has since childhood suffered from otorrhcea and occasional pains in the right ear, but in all other respects has been healthy. After her last menstruation, which terminated on the 21st, the ear became more painful than usual, and there was an increased discharge from it. The symptoms were followed by languor and disinclination for work. On the morning of the 24th there was nausea, and in the evening vomiting. During the next two days the vomiting returned frequently at irregular intervals, the matters rendered being tinged with bile. On the 27th she experienced severe pains in the neck and in the lumbar region, and in the evening there was a rigor followed by febrile symptoms, which have continued since. Symptoms. — May ZOth. — There is no headache, but she complains of severe pain in the back of the neck and across the lumbar region, which is not increased on pres- sure. Intelligence, sensation, and motion normal ; the tongue is slightly furred ; no pain or swelling ; no appetite, great thirst ; severe nausea , slight abdominal tenderness ; constipation, the bowels not having been relieved since the 24th ; pulse 120, of mode- rate strength ; respiration hurried ; urine loaded with urates ; a purulent fluid flows from the right ear, unaccompanied by pain even on pressure ; skin hot and dry ; a warm poultice to he applied to the right ear and a domestic enema to he administered. May 31s^. — Passed a restless night. There has been no recurrence of vomiting although she has taken food tolerably well. There is still, however, nausea, with frequent ex- pectoration of saliva; pulse 120, weak, ; bowels not relieved ; great pains and rigidity in the muscles of the neck. To have §j of 01. Ricini. June Is^. — Last night her agony was so great that a draught was ordered containing M. xv. of Sol. Mur. Morph, and of Chlorodyne. At midnight, though quite sensible, she became very restless, frequently endeavoring to get out of bed. During the previous afternoon the pain in the side and back had considerably increased. During the night the bowels were opened twice but without giving her relief. On both occasions she rose from bed to go to stool. Towards morning the patient became more quiet, but took her breakfast readily. At the visit she was found insensible, lying on the back, head resting on left side, both arms twitching convulsively, with slight interrupted moaning. Skin hot and covered with perspiration. Pulse 160, small and weak. No rigidity of muscles of neck. About half past one p.m. a louil mucous rattle was heard in the throat Dyspnoea came on, and she died at half past two p.m. Sectio Cadaveris. — Twenty-four hours after death. The body was well nourished. 428 DISEASES OF THE NERVOUS SYSTEM. Head and Spinal Cord. — The cerebral membranes were congested. Their surface was somewhat dry. At the base of the cranium there was an abundant foimation of pus between the arachnoid and pia mater, reaching as far forwards as the optic nerves and backwards over the pons and medulla oblongata. It extended to the lower end of the cord, but existed only posteriorly as far down as the third dorsal vertebra. Below that point it surrounded the whole organ, and was more dense. There was no change to be observed in the substance of the brain or the cord. Other organs normal. Commentary. — This was a characteristic case of acute spiral meniu- gitis, in which both the cranial and vertebral portions of the cord were alfected. It will be observed, that with fever there was no hcacache, but considerable nausea and vomiting, pain and stiffness in the neck, which extended to the back. The pain in the latter situation became intolerable, without paralysis or any symptom of mj^elitis. Lastly, con- vulsions and death. The fatality of this formidable affection is in pro- portion to the amount of the cord involved. Its treatment should consist in rest, supporting the strength to enable the pus to be absorbed, and applying local warmth to relieve pain. In the early stage, local cold or the application of ice may be supposed to be effective, but then the symp- toms so closely resemble those of acute rheumatism, that the disease is seldom detected. Case XXXIII.* — Acute Myelitis in the Cervical portion of the Cord — General pains resemhliny those of Rheumatism — Fugitive Paralysis in the arms and legs — Engorgement of the Lungs — Peath. History. — Duncan M’Lean, mt. 27, a laborer, married — admitted November 1st, 1858. Patient states that on the 19th October he was driving cattle, and got wet through. Having been engaged all that night, he did not change his wet clothes, but drunk a good deal of whisky. On the following day he went into a laihvay carriage while perspiring profusely, fell asleep, and felt cold and stiff when he aw eke. Ee went home, changed his clothes, and remained well until the morning of the 26lh, when he experienced pain in the calves of the legs as he walked to his work. This became more severe during the week, and extended upwards to the muscles of the thigh, and thence to the intercostals, and to the muscles of the shoulder, arm, and k w er jaw. When he sat or stood at rest, the pain was scarcely felt, but it was exciucialirg duiing motion or when firm pressure was made on the affected muscles. On the £ 0 th October, when standing in the street — the evening being cold — the pain became exceedingly severe, so as to compel him to return home. He had at that time also a sensaticn cf stiffness over the body. He remained in this state till November 1 st, when as he was coming down stairs on his way to the Infirmary, his strength failed him, and he had to be conveyed in a cab. Symptoms on Admission. — Pulse 70, of good strength. Eespiraticnnoimal. Eas a slight cough. Complains of pain in almost all the muscles of the body, and this is greatly aggravated by pressure or movement. Bending the joints only causes ] ain in the muscles. He cannot put his tongue far out on account of the pain on epenirg his jaw. It is slightly furred, dark in the centre, and trembles constantly. Con plains of great pain at the back of his throat in the act of deglutition. Appetite almost gone; considerable thirst ; bowels costive. Urine strongly acid — otheiw ise non al. 'J’he skin feels rather warmer than natural, and he sweats much at night. Le vos ordered half drachm doses of bicarbonate of potash thrice daily, dissolved in j ovr ovnas of water. Progress of the Case. — November Ath. — The pains still continue as severe as ever. Otherwise much in the same state as w^hen he entered the house. 1^ Spt. Aih. A 'Arid 3 ij ; Aq. Acet. Ammon. 3 ij ; Aqnce ad 3 iv, ft. mist. A tablespoonful to be ioten every four hours. Nov. &th. — He speaks thick, as if his tongue were paialvscd. Eas scarcely slept since he came into the hospital. Unable to move his hands or feet. He cannot shut his eyes fully, the left being uncovered when he tries to do so, to the ^ Reported by Mr. T. S. Clouston, Clinical Clerk. STEUCTURAL DISEASES OF THE SPINAL CORD. 429 extent of one-eighth of an inch, and the eyes are suffused and lachrymating. He has great thirst, and chewing and swallowing are performed with difficulty. Has had reten- tion of urine for two days, and required the use of a catheter. Retention has now ceased. He passed his stools in bed to-day when in a dozing state. November ^th — Counte- nance anxious and depressed ; eyes suffused ; pulse 120. Cannot move right arm or either leg. He has the sensation of pricking with pins and needles in the feet, but no pain in any part of the spine, except at the back of the neck. Great pain in tlie temporal region. Ordered to he cupped to the extent of five ounces over the hack of the neck^ the glasses to he applied along the middle line. Tinct. Hgoscyam. m. x. Aqica 5 j ; //. haustus, hora somni swnendus. Nov. 8lh. — Passed a restless night. Three glasses were applied, but only half an ounce of blood extracted. He is not in the least relieved. Complains to-day of a constriction round his chest, a little below the level of the nipples. Eyes no longer suffused, and he can move his right arm readily, but not his legs. Tongue coated with a dirty fur, pulse 110, Sweats a great deal and the perspiration has a peculiar mousy odor. Bowels freely moved by cas- tor oil. Ordered again to be cupped over nape of neck to five ounces. Nov. 9^/t. — The amount of blood ordered was drawn by cupping without producing any relief. Com- plains of great pain in his hands and feet, which had kept him awake during the night. The right arm is again paralysed, and he cannot lift it from his chest. The left arm is now in the same condition. B P'-dv. Ipecac. Comp. gr. x. To be taken at bedtime., and that failing to induce sleep, to have 25 minims of Sol. Mur. Morph. Nov. \0th . — No change. He slept for two hours after getting the morphia. Ijf ^P- -TEth. Nitrici 3 ij ; Potass. Curb. 3 ij ; Tinct. Gent. Co. § vi ; Infus. Gent. Co. 3 v ; ft. Mist. Two table-spoonfuls to be taken thrice daily. Nov. Wth . — Feels the sense of constriction as if tied with a cord round the chest. He has a cough, but cannot expectorate easily on account of the constriction. Nov. \"lth. — Cannot cough up the rather viscid ex- pectoration, which produces a gurgling in his throat. There is some harshness of inspiration. He can move his arms better than yesterday, and the left more than the right. The sensibility of the soles of his feet is much diminished, but is more acute in the right than in the left. Skin, is hot ; perspiration copious. Urine is alkaline to-day, and throws down a copious deposit of phosphates. Ordered three ounces of wine daily and 3 ss 0 / Sol. Mur. Morph, at night. Nov. \oih . — Slept very little on account of the pain in his legs, toes, and heels. Pulse 130, rather weak. Feeling of constriction not quite so troublesome to-day as yesterday. Appetite quite gone. Hot fomentations to he applied to the feet and lower part of the leg, which failing to give relief, they are to be painted over with the tinct. of aconite. Nov. id/A. — He became much worse last night, and to-day his face is pale and expressive of great suffering; eyes sunk, and he can scarcely speak. Respiration very quick and diffi- cult, and he is constantly pointing to his breast as the seat of pain. Loud mucous rattle m the throat ; marked dulness all over right side anteriorly ; feeble respiration and mucous rattle all over this side. Harsh respiration and very coarse mucous rattle all over left side. He expectorates pure pus. He can move his arms more freely than yesterday, and now also his legs to a limited extent. H tablespoonfid of wine every two hours. Vespere. — Skin covered with an exceedingly profuse perspira- tion ; respiration still more difficult than during the day ; pulse quick and feeble ; almost imperceptible. Abdomen very much distended with gas, impeding still more the labored respiration. Ordered a foetid enema. Nov. loth . — Has ralhed consider- ably to-day. Respiration much easier; abdomen less distended; pulse 126, and much stronger ; expectoration purulent and copious. His power of moving the legs is greater than yesterday, but still very limited. Crack-pot sound, and a great in- crease of vocal resonance over the whole chest anteriorly. On account of the pain the attempt gave him, and his weakness, his lungs Could not be examined posteriorly. Urine has again an acid reaction; chlorides much diminished. Nov. IQth. Yester- day evening he vomited about three ounces of a thin yellowish-green fluid. Sense of constriction of chest still remains, and the same mucous rales, etc., as formerly mentioned. Pulse 120, irregular. Complains of a burning in his throat ; iongue covered with a dirty-greyish fur, and livid at the tip ; feels slight nausea ; can take no solid food, but only wine and beef-tea. Sleep is very much disturbf'd by pain and a sensation of pricking in his heels and ankle-joints, and this is but little relieved by the warm opiate fomentations applied over those parts. Nov. \lth. — Pain in his heels not relieved by aconite or warm fomentations with opium. It distresses him exceed- ingly. Nov. \%th. Voluntary motion in his arms is now almost as perfect as in a healthy individual, but is limited in the legs. Pulse 130, small ; sputum very copious 430 DISEASES OF THE NERVOUS SYSTEM. and purulent. Nov. \9th . — He has a depressed and pallid look, and is very restless. Lips and tongue livid; pulse 1‘26, weaker than yesterday. Mucous rattle heard all over the chest anteriorly ; respiration heaving and quick ; expectoration diminished. Died at half-past 3 p.m. Sectio Cadaveris. — Forty-seven hours after death. Head. — Membranes of brain rather drier than usual, but nothing abnormal could be detected in the brain or its nerves. Spinal Cord. — Membranes healthy, but on slitting up the cord, its substance was found to be slightly softened in a space about an inch in length, at the level of the third and fourth dorsal vertebrte. The diseased portion of the cord presented its healthy appearance to the naked eye, but the softening, though apparent to the touch, was rendered evident by the flocculent surface produced on subjecting the section to a slender stream of water. Thorax. — The right lung was found to be strongly adherent to the thoracic wall, and there were many puckerings at its apex. The anterior edges of both lungs were emphysematous, and on section, were found to be of a prune juice color, congested and dense in patches, the parts between being still crepitant. This condition was most marked at the base of both lungs, especially that of the right. The bronchi contained a large quantity of pus, the mucous membrane being congested, and of a mahogany color. On squeezing a portion of the lung-substance, bloody and purulent matter was pressed out. All the other organs were healthy. Microscopic Examination. — The softened portion of the cord contained some granular exudation with a few granule cells. Several demonstrations were made from other parts of the cord, but nothing abnormal was found in them. Commentary . — Cases of acute myelitis are rare, and are almost uniformly fatal. In the present instance the symptoms commenced with the usual signs of fever and of general muscular rheumatism, followed by retention of urine and difficulty of deglutition. The insomnolence and haggard expression of countenance led us to fear that the brain might be implicated; but the total absence of mental confusion, the local pain and the appearance of paralysis in the arms, at once indicated the cervical portion of the cord as the seat of the disease. The fugitive character of the paralysis was remarkable, at first appearing in the right arm and leg; on the following day disappearing in the arms, then once more returning, and again towards the close of the case, altogether disappearing from the limbs. This must have been dependent on the congestion, which was more intense at one time than another, and which preceded the exudation. The sense of constriction round the chest was harassing, and latterly the lungs became engorged, one of the most common complications preceding death in cases of myelitis at the upper part of the cord. The treatment was on his admission directed to combat the supposed rheumatism, at first with alkaline salts, and secondly with Dover’s powders. As soon as the spinal character of the disease was manifested, anodynes were freely given with cupping over the seat of pain in the neck as a palliative. But it is to be ob- served that none of these remedies, whether internal or external, gave him the slightest relief. The disease took its relentless course, and life was only prolonged by assiduous efforts to support the system by nutri- ents and by wine. Case XXXIV.* — Slight Paraplegia. — Recovery. History. — William Maepherson, ast. 33, a blacksmith, a very muscular and appa- rently strong man — admitted June 1, 1853. For two months past he has suffered from pain between the shoulders, in the legs, and over the body generally, and (jluring tae last three weeks he has been very weak, frequently feeling as if the arms and legs * Reported by Mr. William Calder, Clinical Clerk. STEUCTUEAL DISEASES OF THE SPINAL COED. 431 were benumbed. He has been an intemperate man, but never had delirium tremens, paralysis, or other disease of the nervous system. Symptoms on Admission. — There is no tenderness on percussion along the spinal column, and he only complains of pain between the scapulee, shooting into both shoulders, increased by coughing and by motion. He says that both arms are very weak and benumbed, and that they often tingle, especially when he coughs. _ The arms are muscular, but the grasp he takes of an object is feeble, wdiile the sensibility of the skin is decidedly diminished. Both arms are similarly affected. The legs also are very weak, more especially the left one, which “ shakes ” when he walks, especially if going down a hill. During progre.ssioii the gate is unsteady, the left leg beino- jerked outwards in a semi-circle. He cannot turn round rapidly, and has slight difficulty in standing with the eyes shut. The sensibility of the skin over the inferior extremities as well as over the abdomen and thorax, is diminished to the same degree as in^ his arms. Occasionally there are involuntary startings of the legs and arms, especially at night, which sometimes prevent his sleeping. In all other respects the functions are normal. Appetite excellent. No constipation. ^ 01. Olivar. 3 ss ; 01 Crotonipears to be, the necessity of increasing the strength and nutrition of the body by all practicable means. Such, indeed, has been the general practice — the mineral tonics, and more especially chaly- beates, being the chief remedies administered in such cases, conjoined with the various preparations of quinine, bark, and the vegetable bit- ters. 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 bleedings, espe- cially 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 economy, and that for the former a lowering, and for the latter a supporting plan of treatment would be necessary. Experience, how- ever, has satisfied me, that if the former cause ever operates at all, it is extremely seldom, and that nervous disorder is almost always a symptom of exhaustion. The relief of pain, more especially in cephalalgia and spinal irritation, 454 DISEASES OF THE NERVOUS SYSTEil. 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 they can have diminished the congestion. How, for instance in cases of head- ache, 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 way ? 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 efiectual as wet cupping. The influence of heat and cold is most important in relieving all kinds of nervous pain, and has been previously referred to. (See p. 327.) As a true anaesthetic, or destroyer of local sensibility, congelation has been shown by Dr. James Arnott to be a most successful and manageable 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 pro- ceeding can be employed. Why remove the consciousness of an indi- vidual by 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 con- gestive nervous disorders, and not unfrequently produces a cure. Tliis is well observed in certain cases of spinal irritation, in which 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 vertebrae, in a young lady, who had long suffered from dyspnoea, cough, and supposed phthisis. Next 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 derange- ment, 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, pecu- liar habits and occupations, etc. etc., on the removal of which the cure depends. The ready metliod of applying numerous remedies for the cure of morbid states or particular symptoms is dictated by our knowledge of excito-niotory actions, and owes all its importance to the labors of Dr. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEil. 455 Marshall Hall. Thus dashing cold water on the face and general sur- face in syncope, or in the suspended animation of the new-born ; the irritation of the fauces to excite vomiting; the avoidance of this irrita- tion, 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. In 1856, 1 observed in a young woman with strong epileptic attacks, that on passing a galvanic shock through the larynx, the paroxysms ceased immediately. I have repeated this practice frequently since, but have only found it to succeed in hysterical women. Such is its marked effect, however, in this class of cases, that I have no hesitation in recommending it as highly useful, at once arresting the convulsion or spasm, preventing exhaustion, and thereby more rapidly causing recovery. This result, however, is by no means invariable; and in one case where it failed, the spasms (complete opisthotonos) were immediately stopped by dashing cold water freely over the face and chest. Whichever stimulant be applied, there can be no question that, whenever the con- vulsion can be controlled, its employment is highly conducive to recovery. 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 : — Case XLII .^ — Delirium Tremem— Recovery. History. — Peter Fraser, eet. 56, an engraver — admitted September 22, 1851. He has generally enjoyed good health. For some time his habits have been very intem- perate, and he has had much domestic annoyance. A year ago he had an attack of delirium tremens. During the last few weeks he has been drinking considerably, although he says not to excess. Fourteen days ago he began to feel very restless and uneasy while at work, and his sleep during the night became disturbed, but he has had no tremors or spectral illusions of any kind. Symptoms on Admission. — He now complains of severe pain in the head, referred principally to the frontal region. No pains in any other part of the body. His hands when put out have a trembling fidgety 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. 8ol. Mur. Morph. Dij; Vin. Antimon. 3j; Tinct. Aurantii^ 3 j ; Aquce 3 j- Ft. haustus hora somni sumendus. Progress op the Case. — September 23. — Notwithstanding the draught, passed a restless night. Bowels not open since admission. Pulse 90, of moderate strength. Pidv. Rhei. Co. Dj ; Aq. Menthce. Pip. § j ; Ft. haustus statim sumendus. Sep- tember 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 XLIII.f — Delirium Tremens with Ocular Spectra— Recovery. History. — Elizabeth Banks, aet. 34, married — admitted April 7, 1851. She states that a fortnight ago she was suddenly seized with pain in the head, trembling and dizziness, so that she was obliged to be supported. She ascribes the attack to the receipt of unpleasant intelligence. There have been several of these attacks * Keported by Mr. Scott Sanderson, Clinical Clerk, f Reported by Mr. W. H. Pearce, Clinical Clerk. 456 DISEASES OF THE NERVOUS SYSTEM. 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 illness she has enjoyed good health. Symptoms on 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 nor- mal. ^ Elaterii gr. ss. ; Pidv. Gamb. gr. ij ; Potass. Bitart. gr. x ; Ft. pulvis statim sumendus. Sol. Mar. Morphies 3 j ; Aquos 3 vij ; Ft. haustus hora somni sumendus. Progress of the Case. — April 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 gradu- ally recovered, and was discharged quite well on the 24th. Case XLIV ."^ — Delirium Tremens with Convulsion and Coma — Recovery. History. — David Seaton, set. 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 figure gives evidence of great strength. He is now comatose, breathes stertorously ; pulse 60, full and strong. The head to he shaved, 12 leeches to he applied, a drop of croton oil to he placed on the hack of the tongue with sugar, so as to ensure deglutition, and to he repeated in an hour if necessary. Progress of the Case. — September 11. — During the night he several times par- tially recovered his senses, and again relapsed. To-day is much better, and can answer questions in a confused way. Four drops of croton oil have been given, and operated once. To have one drachm of sol. of muriate of morphia at niglu. Sep- tember 12. — Violent delirium during the night, with insomnolence. It became neces- sary to employ the strait waistcoat. Pulse quick and feeble. Ice-water to be applied to the head. One drachm of sol. of muriate of morphia to he repeated at night. To have a turpentine enema. September 13 and 14. — No improvement. September 15. — Is somewhat sensible ; pulse rapid and feeble. To discontinue the morphia. To have of whisky every two hours. September 16. — Slept a little last night. To-day talks sensibly. Pulse 80, stronger. Bowels opened by means of an injection. From this time he gradually recovered, and was dismissed well, September 27. Case XLV.f — Coma and Death from Excessive Drinking — Opacity of Arachnoid — Subarachnoid Effusion — Fluid Blood. History. — James Dick, set. 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. All efforts at re-animation were of no avail ; he was dead. * Reported by Mr. Alexander Christison, Clinical Clerk, f Reported by Mr. Sanderson, Clinical Clerk. FUNCTIOJ^’AL DISORDERS OF THE NERVOUS SYSTEM. 457 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 subarachnoid tissue was seen to be in- filtrated with fluid, raising the arachnoid to the level of the convolutions. The sinuses were distended with fluid blood. The cerebral arachnoid presented considerable opacity all over the hemisphere, in some places diffused, in others exhibiting minute points closely aggregated together. The ventricles contained a small amount ^of fluid, and several simple cysts in the choroid plexuses. Cerebral arteries and other portions of the brain perfectly healthy. Chest. — Both pleur® contained several ounces of serum, and were slightly adherent at the apices. Both lungs were healthy, with the exception of unusual engorgement, posteriorly and inferiorly. A cretaceous concretion, the size of a barley-corn, in apex of right lung. Bronchi contained a moderate quantity of frothy mucus, which was more abundant in trachea and larynx. Pericardium contained one drachm of serum. Heart healthy. The blood in the cavities and large vessels remarkably fluid. Abdomen. — The liver pale in color, and very soft, weighed 3 lbs. 14 oz. A few serous cysts in the kidney. Other abdominal organs healthy. Microscopic Examination. — 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 . — Various opinions as to the nature of delirium tre- mens have been held by medical men, who have successively placed it among the neuroses, the phlegmasiae, and the pyrexim. Until recently, it was held that whilst drinking was its predisposing cause, the sudden abstraction of the accustomed stimulus brought on the attack. This theory was 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 habitually 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 deno- minated intoxication, delirium tremens, etc. Formerly the treatment used to consist of supplying the accustomed stimulus; but theoretically it is clear that this is tantamount to adding coals to fire, and practically it has been shown that patients more rapidly recover under the use of nutrients. In the vast majority of cases of delirium tremens, the poison Decomes eliminated from the system in a certain time; whether anti- mony, in half or quarter grain doses, assists this process, as was at one time supposed, is very doubtful. 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 its supposed beneficial action is generally coincident with the muscular fatigue, exhaustion, and tendency to repose which accompany the elimination of the alcoholic poison. I have been so struck with the increase, rather than the dimi- nution of the symptoms, by all attempts at medication, in the early stage of the disorder — a circumstance observable in the cases recorded — that for the last ten years I have given little but nutrients, and every case has recovered. During the summer of 1864 I strongly pointed this out; and every case admitted during May, June, and July of that year was carefully recorded. They all recovered as follows : — * Monthly Journal of Med. Science, June, 1864. 458 DISEASES OF THE XERVOUS SYSTEM. I No. Name. Sex. Age. Admitted. Symptoms. Treatment, 1 Dismissed. 1 T. Eadie M. 49 5th May. Mild. Good diet— rest. 12th Mav. 2 J. Bortliwick. M. 49 19th May. Well marked— 4th attack. Do. do. 24th May. 3 F. llastie. M. 44 19th May. Mild. Do. do. 24th May. 4 J. C alder. M. 7 24th M:iy. Mild. Do. do. 27th May. 5 G. Gillis. M. 33 25th May. Violent. Tied down in bed— beef tea and nutrients. 31st May. 6 J. Adair. M. 40 28th May. Mild— 3d attack. Beef tea and nutrients. 1st June. 7 W. Gordon. M. 47 29th May. Mild— 2d attack. Do. do. 1st June. 8 R. H. Whitten. M. 54 9th June. Well marked— had other attacks. Tied in bed— good diet. 16th June. 9 Thos. Robb. M. 55 11th June. Well marked. Do. do. 16th June. 10 T. Dickson. M. 48 12tli June. Mild. Good diet— rest. 15th June. 11 W. M'Donald. M. 43 17th June. Comatose on ad- mission. Emetic first— good diet. 20lh June, 12 B. M'Giiitie. M. 50 19th June. Mild. Good diet — rest. 28th June. 13 W. Simpson. M. 44 20th June. Severe. Emetic first — good diet. 1st July. 14 M. Bell. F. 24 21st June. Severe. Tied in bed — emetic — good diet — rest. 5th July, 15 M. Coverdale. F. 40 3d July. Mild. Good diet — rest. 13th July. 16 D. Davies. M. 44 4th July. Mild. Tied in bed — rest— good diet. 12th July. 17 D. Wallace. M. 47 6th July. Severe. Do. do. do. 12th July. 18 M. A. Smith. F. 34 ISth Ju'ly. Severe, Do. do. do. 28th July. 19 P. Forrest. M. 30 20th July. Mild. Good diet — rest. 22d July. 20 J. Bi’own. M. 52 21st July. jMild. Do. do. 30th July. 1 1 hold, therefore, that delirium tremens is one of those diseases that only requires a dietetic treatment, and that the sooner nutrients can be taken, the more rapid is the recovery. 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 as much as possible. Case XLVI.^ — Poisoning by Opium — Recovery. History. — Helen M'Dermott or Cuthbertson, set. 33, but looking ten years older, residing in the Cowgate as the wife of a cooper, was admitted at 3 p.m. May 25, 1857. She has not unfrequently been drunk, and had a quarrel lately with her husband. On the preceding day she had gone out and purchased two ounces of laudanum, namely, one ounce at two different druggists’ shops, and bad swallowed them (it is said) half an hour before admission. Symptoms ox Admission. — On admission, contracted pupils, great drowsiness, re- laxation 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 smelled 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 fall avsleep unless pushed or pricked. The galvanic battery was then applied to the popliteal spaces, and to the hands, breast, and neck — (Kemp’s battery being the instrument employed). Meanwhile, as patient was in bed, warmth was maintained by clothes and hot bottles. Under stimulus of the battery, patient was also induced to swallow some coffee. At 6.30 p.m. she was so easily 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 profound. At 8 P.M. a drachm of brandy, and half a drachm of Sp. Ammon. Aromat. were admini- stered, to be repeated every hour. During the first three administriitions of this stimulant vomiting occurred, the vomited matter consisting of the coffee that had previously been swallowed. At ten, eleven, and twelve, she was seen dozing slightly, but was easily roused. Next morning complained of sickness, and of not having been * Reported by Dr. John Glen, Resident Pliysician. FUNCTIONAL DISOKDERS OF THE NERVOUS STSTEil. 459 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 2'7th, having fully recovered, she was discharged. Case XLVII .'^ — Poisoning by Opium — Recovery. History. — Robert Cooper, aet. 47, admitted June 24th, 1864, a laborer, in the habit of drinking to excess. After leaving off work on the evening of the 20th, he commenced drinking, and continued to do so until the evening of the 24th, when he was brought to the Infirmary by some men, one of whom said he had seen him go into three druggists’ shops. Two hours before admission he was found fast asleep in the street, and as he could not be awakened, was brought to the Infirmary. In his pockets were two bottles, one capable of holding 5 j, the other § vi, both strongly smelling of laudanum. Symptoms ox Admission. — Pupils contracted to the sixteenth of an inch in diameter, insensible to light. There is profound coma, face pale, pulse weak. A stomach-pump was immediately procured, and the stomach emptied of its contents, which smelt of laudanum. It was filled four times with water, and again emptied. Then a strong infusion of coffee was administered. Three-quarters of an hour after- wards he appeared to be slightly conscious, and answered questions indistinctly. On the following morning the surface was bathed in perspiration, pupils still contracted, but slightly sensitive to light. Answers questions, but is oblivious of everything that happened since the 22d. Easily relapses into drowsiness and sleep. To have beef tea and nutrients. From this time slowly recovered, and was dismissed on the 28th. The matter pumped out from the stomach, on being analysed by Dr. Duckworth, was found to contain muriate of morphia in large quantity. Commentary . — The symptoms of poisoning by opium are first cere- bral, and secondly spinal, the danger to be apprehended being great depression of the vital powers. Our first efforts should be directed to removing as rapidly as possible the poison from the stomach, and to this end the pump should be employed, in preference to emetics. Indeed, in most cases, coma renders deglutition difficult. After this it was formerly the habit of trying to rouse the patient by walking him about, shaking him, or administering galvanic shocks. All these processes, as they tend to produce exhaustion of the vital powers, cannot be regarded as judi- cious. Our object ought to be to support the strength and. action of the heart as long as possible, with a view of permitting the poison to be eliminated. Accordingly, it will be observed that the second case recov- ered rapidly, without having recourse to any such expedients. Another idea is that some antidote should be administered, supposed to be capa- ble of rousing the brain. Thus, in both cases recorded, a strong infu’ sion of coffee was administered. In 1859, my then resident physician, Dr. Carter, now of Leamington, injected a solution of atropine into the cellular tissue, as a supposed corrective to the effects of opium. Coffee or tea can do no harm, but it is much to be doubted whether theoreti- cally their employment can be defended (see p. 345) as being useful. Experience and careful experiments up to this time have failed to give us any positive information on the subject. Case XLVIII.f — Poisoning by Hemlock — Death. History. — On Monday, April 21st, 1845, about seven o’clock in the evening, a man, called Duncan Govv, was brought into the Infirmary by two policemen. It was * Reported by Mr. D. Thomas, Clinical Clerk. \ Published by me in the Edin. Med. and Surg. Journal, No. 164. 1845. 460 DISEASES OF THE NERVOUS SYSTEM. Stated that he had been found Ijdng 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 by trade, was in such reduced circumstances that he had not eaten anything on Mon- da}q until he took the substance which caused his death. Two of his children, a boy and a 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 building), and knowing that their father was very fond of this, as well as of other green vegeta- bles, 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 westwards, the Comum 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 ascer- tained, for he ate nearly all that was brought. On finishing his meal, he rose, saying he would endeavor 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 a 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 nar- row, he faltered in his gait, and afterwards sat down hastily. He stayed ten minutes, during which time he conversed readily, drove a hard bargain, and obtained fourpence for what he sold. He did not complain of pain or uneasiness, was not excited in man- ner or speech, and his face was pale and wan. On rising from his chair, he was ob- served by Wright’s boy to fall back again, as if he had some difficulty in idsing. On making a second effort he got up, and was seen by Wright’s wife to stagger out of the house and down the steps. This was a little after four o’clock. On leaving Wright’s house, he was next seen standing with his back against the corner of the street, by Andrew Me’ All, a meal-dealer in the Grassmarket, about 200 yards from Wright’s house. Me’ 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 Me’ All’s shop, and sat down at the opening of the common stair next to it. Me’ All’s words are, “ He could not walk rightly, and was staggering as a man in liquor.” His mode of pro- gression 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 Mitcliell, 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 willingness to walk forwards, until the policeman could obtain the assistance of his comrade in the Cowgate. He was then raised up and supported by one arm, 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, which he was incapable of swallowing, and left him to get a barrow. On his return he found him surrounded by women, who were pouring cold water on his head, and sprinkliug his forehead. With the assistance of another policeman (James Hastie, No. Ill), he was then placed on a barrow. One of the women, Mrs. Anderson, on his being raised, saw that he made no attempt to walk, but that, as he was pulled away by the policeman, 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 endeavored to say something, but could not artic-ulate. 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. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 461 Dr. Tait, surgeon to the police force was now sent for, and saw him about quartet past six. In reply to a note which I addressed to him on the 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 toward 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 Avhen his arm pits were tickled, he seemed to manifest a little sensibility, but could make no exertion to rid himself of the annoyance. There were occasional movements of the left leg, but they appeared rather to be spasmodic than voluntary. Several efforts were made to vomit, but these were ineffectual. His pulse and breathing were 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 coun- tenance had a cadaveric expression ; pupils fixed. He was then sent to the Infirmary.” He was conveyed to tlie Infirmary by Hastie and another policeman, MTherson. After being put on the stretcher, Hastie saw him draw the legs gently upwards, as if to prevent their hanging over the iron at its extremity. This was the last movement he was seen to make. On being carried into the waiting-room of the Infirmary, he was visited by the house-clerk on duty, who found him pulseless, and declared him, as previously stated, to be dead. This was shortly after seven o’clock p.m. Seciio 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 longitudinal 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 pleurae on both sides superiorly. The apices of both lungs were strongly puckered. On the right side below the puck- ering were two cretaceous concretions, the size of peas, surrounded by chronic pneu- monia and pigmentary deposit. On the left side only induration, with hard, black, gritty particles, existed below the puckering. The structure of the lungs otherwise was healthy, although they were throughout intensely engorged with dark-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, readily breaking down under the fingers. The kidneys were of a brownish-red color 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 slightly spirituous odor. The mucous coat was much congested, especially at its cardiac extremity. Here there were numerous extravasa- tions 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 color and fluid, even in the heart and large vessels. Commentary . — From the absence of structural lesion, and the general fluidity of the blood, I was induced to suspect that the vegetable matter found in the stomach was of a poisonous nature. On examining this more minutely, it was seen to be composed chiefly of fragments of green leaves and leaf-stalks. Although much was reduced to a pulp, a con- siderable quantity of both had escaped the action of the teeth. The same afternoon, I carried as perfect a specimen of the fragments as could be found to Dr. Christison, who pointed out that they could scarcely be 462 DISEASES OF THE HEEYOUS SYSTEM. anything else than the lacinice of the Conium maculatum^ or common hemlock. Next day I bruised some of the leaves in a mortar, with a solution of potash, when the peculiar mousy odor 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 maculatum from 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 effects 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 effects 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 in- sensibility, 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 Kcovecov, or state poison of the Athenians, great pains were taken to obtain a perfect history of the case. In preparing it I endeav- ored to insure accuracy, by carefully interrogating all who saw him from the time of his eating the hemlock until the period when he was brought into the Infirmary. Fortunately, he was seen by many persons, and their several accounts are, on the whole, consistent, and render the case tolerably perfect. The time of day mentioned by the different narrators shows that the poison, shortly after it was taken, produced want of power in the inferior extremities, without causing any pain. This is proved by what took place ill Wright’s house. His gait, which at that time was faltering afterwards became vacillating ; he staggered as one drunk — at length his limbs refused to support him, and he fell. On being raised, his legs dragged after him ; and lastly, when the arms were lifted, they fell like inert masses and remained immovable. Perfect paralysis of the inferior extremities was ascertained to exist one hour and a half after the poison was taken, and that of the arms half an hour later. As regards the existence of sensibility, we have only the evidence afforded by tickling the arm-pits, which, according to Dr. Tait, seemed to excite it a little. The amaurosis, however, is a proof that one nerve of sensibility, at all events, was paralysed. This seems to have happened when perfect paralysis of the inferior extremities was manifested. The excito-motory functions seemed also paralysed. Tickling the arm-pits failed in producing movements. He lost the power of degluti- tion. Dr. Tait says his efibrts to vomit were ineffectual. There were no convulsions, only slight occasional movements of the left leg ; and lastly, both inferior extremities were slowly drawn upwards, when placed * Treatise on Poisons, p. 885 1846. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 463 over the iron of the stretcher. Three hours after taking the poison, the respiratory 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 hemlock, wdien brought into the police-office, although he could not swallow, he gave his address ; and a quarter of an hour afterwards, when seen by Dr. Tait, though he could not speak, he appeared sensible, and tried to turn his face toward him. Death took place about three hours and a quarter after eating the poison, and was evidently occasioned by gradual asphyxia from paralysis of the muscles of respiration. The appearances observed in the mucous membrane of the stomach were most probably caused by the unusual fluidity of the blood, and this, in its turn, by the gradual asphyxia. The phenomena, therefore, observed in this case, fully corroborate the physiological action of hemlock, as described by Dr. Christison, from his experiments on animals.* It evidently acts upon the spinal cord, pro- ducing directly opposite effects to those occasioned by strychnia. Para- lysis of the voluntary muscles, creeping from below upwards, is the characteristic symptom, unaccompanied b^y pains or derangement of the intellectual faculties. Some authors have described delirium and frenzy, and others giddiness and convulsions, to have been occasioned. But such symptoms were not observed in the case of Grow, nor in the experi- ments on the lower animals by Dr. Christison. Indeed, the symptoms described by Plato in the case of Socrates, resemble as nearly as possible those which appeared in Gow. We are told that Socrates was directed by the executioner to walk about after swallowing the poison, until his limbs should grow heavy. He did so, and then lay down. On his feet and legs being squeezed, they were found insensible ; they were also pointed out by the executioner to be cold and stiff. When paralysis had proceeded upwards to the abdomen, Socrates made a request to Crito, proving that his intellect was then unaffected. In a short time after, he became convulsed, his eyes were fixed, and he died. Whether stiff- ness 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 Kwvetov given by Nicander, 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 eyes roll. But staggering on their footsteps and tripping on the streets, they creep on their hands. Mortal stifling seizes the upper part of the neck, and obstructs the narrow passage of the throat. The '* Transactions of the Royal Society of Edinburgh, vol. xiii. 484 DISEASES OF THE NERVOUS SYSTEM. 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 degluti- tion, and place the loss of the intellectual faculties last, this account of Nicander agrees very well with what was observed in Gow. A difference of opinion exists as to whether the Conium maculatum of modern botanists be the Kwveiov of the ancient Greeks. Into the botanical controversy I do not feel myself qualified to enter. But, if the symptoms ascertained to have existed in the case I have related be compared with the accounts of Plato and Nicander, I cannot help think- ing that it will be found to favor the opinion of those who believe in their identity. Case XLIX.* — Poisoning with Lead — Painter's Colic — Lead Paralysis — Partial Recovery. History. — Peter Taylor, set, 60, 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 mouths ago had a severe attack of Colica Pictonum, from which he slowly recovered under medical treatment, and then resumed his work, being always subject, however, to transient twinges of pain in the bowels, as well as in the joints, which latter he attributed to rheumatism. Six weeks ago he first experienced debility and want of power in both hands, which has gradually increased since. His speech also has become slightly affected. Symptoms on Admission. — He has at present no pain anywhere, and only com- plains of want of power in both wi’ist joints. Both hands drop down from the arms, especially the right, which forms a riglit 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 of the paralysed parts is normal. Bowels still somewhat constipated, but were opened freely yesterday. Speaks with unusual slow- ness, which lie thinks has increased lately. All the other functions are healthy. Progress of the Case. — October 1st. — Since admission the bowels have been kept open daily by small doses of the sulphate of magnesia. The arms have been put up in splints., keeping the wrist and hand extended straight out. Galvanism has been applied twice daily for several minutes in the course of the extensors., and frictions over them arc occasionally employed in the interval by means of flannel cloths. October 16^/i. — He was ordered b' Potass. Hydriod. 3 ss ; AqucB Cinnam. ; Aqiice font, aa § iij. M. Sumat § j ter indies. To-day the splint was semoved from the left arm, which still droops, but is more readily extended. October SOth. — 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 Angers a little better. November 10^/i. — There is decided improvement in the power of motion in both wrist joints, especially the left. Extract. Nucis Vomicae, gr. vj ; Confect. Rosar. q. s. utfiant pil. vj. Sumat unam ter indies. November 21s<. — 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 ivrists in pumping water. Commentary. — Lead, as a poison, appears to act first on the peri- pheral nerves of the body, and subsequently on the nervous centres, its chief manifestations being in the nerves of the intestines, causing colic, Reported by Mr. Scott Sanderson, Clinical Clerk. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 4i)5 and those of the arms producing paralysis. Why this substance should especially alfect 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 G-endrin, 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, without being first rendered soluble, and therefore poisonous? On the other hand, some physicians in France who have tried the chemical treatment exten- sively, and among others Andral, Sandras, Piorry, and Grisolle, assert that it has no influence whatever, and that patients abandoned to them- selves get well just as soon. I believe this to be the correct view; most of the primary and slighter cases getting well of themselves in hospital, in about six weeks. 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 powers. The latter was employed in the above case, but with no great success. Dr. Christison informs me, that “ long ago, when there was a white lead manufactory in Portobello, I used constantly to have in the Infir- mary a case or two of lead colic or lead palsy and neuralgia. Every case of colic I saw got speedily well by the alternate use of opium and aperients, and every case of paralysis by generous living, stomachic ton- ics, warm baths, and especially support and regulated exercise of the arms. One man I well remember, who was three times under my care, in consequence of his always returning to the factory — had colic, palsy, and also neuralgia; but he got well in no long time by attention to the above means.” M. Duchenne has pointed out the great advantage of applying gal- vanism not generally to the arm, but more especially to the muscles affected, which in these cases are most commonly the extensores digi- torum, and not the lumbricales nor enterossei — hence why the first phalanges only cannot be extended, whilst when these are supported, the second and third phalanges can be voluntarily raised without difficulty.* * For a case of Poisoning by Aconite, see Aneurism, case of Henry Smith. 30 SECTION V DISEASES OF THE DIGESTIVE SYSTEM. Under this head I include derangements of all those parts which are concerned in the primary digestion — that is, not only the different portions of the alimentary canal strictly so called, but the liver, pan- creas, and peritoneum. The lesions of the spleen I shall consider in the section devoted to diseases of the blood, as there can be little doubt that this, with the mesenteric and other ductless glands, is not only concerned in the formation ot blood, but is most commonly disordered during its unhealthy states. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. Case L.^ — Tonsillitis. History. — Christina Slater, aet. 22, a well-nourished servant girl — admitted May 6th, 1857. Three weeks ago, after exposure to cold, during the family washing, she experienced rigors, headache, and thirst, with a sense of dryness and swelling in the throat, especially on the right side; could with difficulty swallow either solids or fluids, the latter occasionally regurgitating through the nostrils. These symptoms continued to increase till the night before admission, when she felt something give way in her throat. She spat up some matter, and thereafter felt general relief. Symptoms on Admission. — Pulse of moilerate strength and frequency ; no cardiac hypertrophy nor abnormal murmurs. Eespirations easy and not hurried. The voice is soft and natural, but articulation is indistinct and hissing. The jaws are so im- movable 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 color. Can now swallow fluids ; appetite returning ; bowels regular. The urine is non-albuminous, slightly hyperphos- phatic, with a mucous sediment. The other functions are normal. Progress of the Case. — Poultices were applied from time to time; on May \\t\ 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 21s^, 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 8^A, to Mr. Syme, who excised one half of the gland. June 10th. — Was dismissed cured. Gommentary . — Hypertrophy of the tonsils is so common in young children as scarcely to demand notice, unless suspicions of croup are Reported by Mr. W. Guy, Clinical Clerk. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 46'? entertained, when they should invariably be examined. I have fre- quently seen the fauces almost closed from the contact of enlarged tonsils, so as to cause croup-like breathing, and give rise to great alarm. Painting them with the tincture of iodine is the best remedy, and in- cision may be practised if much permanent inconvenience be occasioned. In the above case, all the three lesions which affect the tonsils were produced — namely abscess, ulceration, and enlargement. The former burst, the two latter were treated successfully by local applications of the solid nitrate of silver, and subsequently half the gland was excised. Case LI.^ — Follicular Pharyngitis. History. T-Peter M‘Donald, get. 42, a hammerman in an engine foundry — admitted December 1, 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 dryness in the chroat, 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 color ; no ulcers visible ; no cough ; no expectoration. Digestive, respiratory, and other systems are normal. Progress of the Case. — Under local application to the pharynx with a sponge, of the nitrate of silver solution ( 3 ss of crystallized nitrate to '%] of distilled water) the sense of dryness and the difficulty of swallowing saliva were relieved : his strength improved under good diet, and he was dismissed Dec. 29th. Gommeniary . — 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 pharyngitis, and its importance in relation to diseases of the larynx, we are indebted to Dr. Horace G-reen of New York. There can be no doubt that many cases of chronic cough, generally denominated bronchitis, chronic laryngitis, or clergyman’s sore throat, are dependent on this lesion, and as little that they are to be cured or greatly alleviated by appropriate applications made to the part. For an account of these, however, I must refer to what is said under the head of Laryngitis. Case LIT.f — Stricture of the (Esophagus from Epithelioma. History — William Porter, ast. 68, a brassfounder — admitted May 28, 1855. Two years ago a cab ran over his abdomen, across the epigastric region. He vomited a considerable quantity of blood for a few days after, and felt a pain in the back. From the pain then felt he soon recovered, an(l enjoyed ordinary health till four months before admission. He then for the first time experienced a sense of obstruction to the passage of food at the lower part of the gullet. The dysphagia has gradually increased, and has latterly been attended with pain. He has had no cough, and no haemoptysis. Symptoms on Admission. — Skin dry, patient greatly emaciated; pulse 68 per minute, weak and irregular ; the tongue is covered with white fur. The fauces are natural ; his food consists of bread or biscuit, steeped in tea, milk, or water ; he does not dare to swallow more solid food. That which he takes (in the presence of * Reported by Mr. Alexander Turnbull, Clinical Clerk, f Reported by Mr. G. M. Reid, Clinical Clerk.- 468 DISEASES OF THE DIGESTIVE SYSTEM. the clerk) is returned within two or three minutes. The patient believes that the food vomited has not entered tlie 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 the food, which passes the obstruction and enters the stomach, is retained with only slight uneasy sensations. There is no tumor 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 he taken in small quantities at a time in a liquid form often repeated. Progress op the Case. — May Uh. — Tongue clean; pulse 68, stronger than on admission. Vomiting appears to be longer delayed. May ^th. — A probang passed readily along the oesophagus to-day ; there is less uneasiness, but no greater power in swallowing. May %th. — Complains of extreme weakness ; asks for beer, which is granted. May \0th . — About 2 p.m., while taking a mouthful of beer, he suddenly fell back ; the mouth open ; the neck stiff ; the pupils slightly contracted ; the eyes turned upwards ; incoherent muttering, without consciousness. His face was pale ; he lay gasping for breath ; there was a tracheal rale, and a fremitus was felt over the whole chest. An ineffectual attempt to vomit was followed by increased distress. He rapidly sank, and finally expired at ten minutes to three o’clock. Sectio Cadaveris. — Tioenty-two hours after death. Chest. — There was a httle 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 color, and presented a granular section ; it was also friable, and portions of it sank in water. About two inches above the cardiac extremity of the oesophagus there was found an epithelial ulcer, nearly encircling the tube. On slitting it up, this ulcer was seen to be of a circular form, an inch and a lialf 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 Examination. — The ulcer presented the usual structure of epithe- lioma, as described and figured pp. 212, 213. Case — Epitheliomatous Ulceration of the (JEsophagus, communi- cating ivith the Lung — Pneumonia terminating in Gangrene. History. — John Fraser, aet. 55, a flesher — admitted September 19th, 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 first time felt as if a ball of wind rose from his stomach to meet the food, and the food in its passage also gave him pain. The pain was gnawing and 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; ap- petite reported to be good; thirst not great; food consists of gruel or bread and biscuit soaked in fluid. Says that the fluid in 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-colored matter. Abdomen is everywhere tympanitic. No tumor 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 S}unptoms are normal. To have nutritive diet in a fluid form., in small quantities often repeated. Progress of the Case. — From September 2 2d to October 2d. Has been taking * Reported by Messrs. G. M. Reid and R. P. Ritchie, Clinical Clerks. DISEASES OF THE MOUTH, PHAETXX, AND CESOPHAGES. 46S thrice daily the following powders: — Bkmuthi Trisnitrat. 3 j ; Pulv. opi% gr. ij. M. et divide in ptdveres duodecem. The dysphagia continues unrelieved; the pain over ensiform cartilage is felt as formerly ; and there has been also a sharp internal pain over the mammary regions. October 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 blister applied to the epigastrium. Oct. I()^7i . — Ordered three ounces of sherry wine daily^ and scruple doses of the hyposulphite of soda. Nov. 87/i — Xo diminution in the pain, dysphagia, or vomiting. Ordered one drop of Fleming'' s tincture of aconite thrice daily. Nov. \Zth. — Vomiting, pain, d weakness continue. The aconite is discontinued, and naphtha medicinaUs in terv- drop doses, with compound tinct. of cardamoms is substituted. On the 26th Nov. this mixture was also stopped, and ice was ordered. Dec. 1th. — Strong beef-tea injections per rectum are now ordered night and morning. Dec. \Uh. — To-day vomited round masses looking like blood, and under microscope, blood corpuscles are recognised in them. Dec. id. — Blood corpuscles are found in the vomited matters to-day. Pulse small, weak, 120 per minute. Dec. 2%th. — Has had 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. D,h. — Has slight pain over right hypochondrium ; in- creased on pressure ; fine moist rales are audible over base of right lung posteriorly, with inspiration. The urine is not coagulable, but is deficient in chlorides. Jan. Mh. — Deficiency of chlorides confirmed to-day. Dulness, increased vocal resonance, and crepitation with inspiration, are detected over lower two-thirds of right lung posterior- ly. Pulse weak, small, and scarcely perceptible. To have | ij of wine additional. Jan. 1th. — Same signs as in last report. Chlorides are more abundant. W eakness extreme. Jan, %th. — Chlorides again decreased ; the pulse is more imperceptible ; the skin cold ; in the evening vomited three ounces of bright red blood. He died almost immediately afterwards at 9 p.m. Sectio Cadaveris. — Sixty-two hours after death. The body was much emaciated. Throat. — The larynx, pharynx, and cervical portion of oesophagus were natural. Thorax. — The heart was natural. There were a few adhesions in the left pleura, but the lung was healthy. On the right side of the chest there were firm adhesions superiorly, and on the external lateral aspect. In attempting to remove the lung a fungating growth situated over the spinal column was broken into. This growth (connected with the oesophagus) was found to have involved a portion of the tissue of the right lung near its root. On removal of the oesophagus, it was seen that a portion of it, about three inches in length, commencing a little above the root of the lung, and going down to about an inch above the diaphragm, was converted into a fungat- ing 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 fungatiiig ulcer- ated surfaee. The calibre of the tube must in consequence have been much dimin- ished. The lower end of the oesophagus, as well as the stomach and pylorus, were natural. In the stomach there were three ounces of a brownish fluid resembling coffee grounds. On removing and cutting into the right lung, a cavity about the size of a walnut was found in its posterior part, a little above the root of the lung. This cavity was filled with a brown foetid fluid, and the surrounding pulmonary tissue was softened, hepatized, and broken down. Higher up were two smaller cavities, presenting similar characters, and surrounded by a layer of condensed pneumonic substance. The abdominal organs were natural. Microscopic Examination. — The fungating mass presented all the usual appear- ances of epithelioma containing imbedded in the deeper friable portion of the growth, numerous masses of concentrically arranged cells, such as are represented Eig. 233, p. 213. Commentary. — E.pithelioma of the oesophagus was present in the two cases above recorded in different degrees. In case LIL, the dis- ease 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 nourishment, extreme debility was induced, of which he died. In Case LIII., the 470 DISEx^SES OF THE DIGESTIVE SYSTEM. epithelioma was more extensive, surrounding the oesophagus internally over a space three inches in depth, causing great thickening of the tube extending through all the coat, and even affecting 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 evi- dent that at length a communication was formed between the oeso- phagus and the lung, the occurrence of which was indicated by a pneu- monia, with all the physical signs and general symptoms characteristic of that lesion. Case LIV."^ — Carcinomatous Stricture of (Esophagus — Cancer of the Liver — Pulmonary Emphysema and Tubercle — Pneumonia. History. — John Currie, set 63, a cooper — admitted 18th February, 1857. Was accustomed to drink heavily till within the last half year. Was well fed, strong, and healthy. Has had rheumatic fever thrice, the last time being twelve years ago, without any cardiac symptoms which he can remember. Had inflammation of the che-st eighteen years ago. Had general dropsy nine months ago ; entered the hos- pital, and was discharged cured in three weeks. It is about six months ago since the patient first experienced pain in the epigastrium after taking food, with pyrosis and anorexia. For three months he continued in this state, losing flesh and becoming weaker. Three months ago he began to vomit his food, at first in the evening, and subsequently during and after all his meals. He has vomited a little blood on three or four occasions. The character of the vomited matters is reported by him to have been as at present. Symptoms on Admission. — The tongue is clean ; there is no pain nor any diffi- culty in swallowing till the food reaches a point which he indicates as beneath the lower part of the sternum and the epigastrium. He has to rest after each mouthful till the food passes this point. If it passes, he has no further pain ; but the greater part does not pass, and causes him great pain till it is dislodged by vomiting. The matter vomited consists of undigested food and clear mucus. Fluids and solids are equally troublesome for him to swallow. He has often hiccup while eating, and brings up flatus with great relief. He feels a constant “ working ” at his stomach. There is a fulness and resistance on palpation over epigastrium ; but little ten- derness, and no tumor. The area of hepatic dulness vertically below the nipple measures three inches, and laterally three and a half. No splenic enlai’gement detected. No abnormality on examination of abdomen. Bowels are rather costive. The cardiac dulness at the level of the nipple is If inch. The apex is felt and dis- tinctly seen beating in the sixth intercostal space, and it is seen also in the fifth intercostal space. These two pulsations alternate, or are not exactly synchronous. At the apex, over a limited area of about one square inch, a short, blowing murmur, not loud, is heard with the first sound, the second sound being healthy. At the base, both sounds are feeble, but free from abnormal murmur. The pulse is 76 ; irregular in rhythm. The respiratory system is normal, with the exception of a few snoring rales posteriorly. The urine is high colored, sp. gr. 1027 ; not albu- minous. Progress of the Case. — I took charge of this case on the 1 st of May, up to which time his symptoms had continued the same, notwithstanding cai’eful regula- tion of his diet and the administration of morphia, tr. ferri muriatis, creasote, wine, and the application of a blister. The report on J/ay is No improvement ; pain in the epigastrium still severe. He is weaker, much emaciated, and destitute of appetite. May 30^/i. — Patient’s diet now consists of arrowroot twice daily, beef- tea, tea and bread, and 3 iv of sherry wine. He is umfble to take any other nourish- ment. Since admission, has been rarely out of bed. June 10th. — No change in symptoms. Continues same diet. July Is^. — 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 lOth . — 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 2,1th . — Complains now * Reported by Messrs. J. T. Walker and W. H. Davies, Clinical Clerks. DISEASES OF TDE MOUTH, PHAEA'NX, AXD CESOPHAGUS. 471 wholly of the constriction superiorly. Beef-tea enemata with port wine have been ordered four times a day. July z()th . — Enemata discontinued from the resistance of the patient. He is able to swallow wine, which he relishes. Aug. Id . — Since last report, in same state, but more feeble ; lies very much on his left side ; groans at intervals, his voice being comparatively strong; but articulation is very indis- tinct. Has no cough nor apparent dyspnoea. Not taken any food for four days. Aug. 3o?.— 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 an- teriorly ; and throughout the spongy portion, indurated nodules could be felt varying in size from a coffee bean to that of a hazel nut. On section, these presented aggre- gations of miliary tubercle of a yellow color, for the most part of cheesy consistence, 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 Organs. — The posterior third of the tongue presented a tuberculated appearance ; the mucous membrane on section was found thick, dense, almost cartila- ginous, of greyish color, and yielding on pressure a thin greyish white juice. The mucous membrane of the pharynx was natural. In the oesophagus, an inch and a half above the bifurcation of the trachea, there existed a stricture admitting only the point of the little finger. When opened the mucous membrane appeared natural, the sub- areolar tissue somewhat thickened. Lower down, the cardiac orifice was felt exees- sively 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 color and firm consistence was found projecting from the posterior surface of the liver, and firmly adherent to the cardiac portion of the stomach just where the oesophagus enters it. From the surface of the liver there projected other rounded masses of greyish-white color, 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 project- ing from the liver. The stomaeh was contracted, but otherwise healthy. Abdomen. — The kidneys felt indurated; but when examined, appeared natural. The spleen weighed only two ounces; its structure was natural. Other organs healthy. Microscopic Examination. — The cancerous masses in the liver and in the oeso- phagus contained numerous large cancer cells in all stages of development, embedded in a fibrous stroma. The tubercles in the lungs exhibited the usual appearance of miliary tubercle in various stages of disintegration, associated with pus. The red and grey hepatization was composed of an exudation in the air-cells and smaller bronehial vessels, which presented various stages of transformation into pus, being most recent in the former, and most perfect in the latter. Many of the pus cells contained fatty granules, and exhibited different degrees of disintegration. Commentary. — This man literally died of starvation, from the utter impossibility of' introducing nourishment into the system. The can- cerous mass originally fermed in the liver had surrounded and com- pressed the oesophagus and cardiac orifice of the stomach, so as to reduce the canal to the size of a crow’s quill, a stricture that extended through a curved line, nearly two inches long. A second stricture, but not to so great an extent, existed above this in the oesophagus. It is not sur- prising, therefore, that at last no kind of nourishment could pass these obstructions, the absence of contractile power in the diseased oesophagus 472 DISEASES OF TUE DIGESTIVE STSTESf. 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 difficult to determine, but certainly the nodulated groups of miliary tubercle in the lungs were in every respect similar in general appearance and structure to what is observable in phthisical cases. It is true there was no especial accumulation of tubercle at the apex of either lung, neither was there cough, nor any symptoms of pulmonary disease shown throughout the whole course of his disease. But as a decided form of exudation its presence was undoubted. The pneumonia must have come on during the latter days of his life, when he was in a state of extreme weakness. But it occasioned no active symptoms, and though conjoined with great emphysema anteriorly in both lungs, produced no dyspnoea. The pathological fact, however, of the occurrence of these three forms of exudation in one individual is, though undoubtedly rare, well calculated to demonstrate the fallacy of all exclusive views as to their production in individuals of a peculiar diathesis. Temporary dysphagia occasionally occurs in cases of hysteria or of spinal irritation, but when permanent it is always the result of organic disease of the pharynx or oesophagus. In the great majority of cases it is owing to some growth, cancerous, epitlieliomatous, aneurismal, or of some other form, which, by attacking the parts themselves, induces stricture of its wails, or, by compressing them from without, causes a mechanical obstruction to the tube. In a few rare cases it has depended on pouch-like or spindle-form dilations, 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 external tumors compressing the part ; but if it depend on disease of the pharynx or oesophagus, the treatment must be for the most part .palliative. There may be a simple stricture, which may require surgical interference by bougies or catheters, but more generally, as observed by the physician, it is the result of cancer or epithelioma, as in the cases narrated. Under such circumstances, the treatment must be directed to support nutrition by unirritating food, given in small quantities and in a form that the patient can most easily swallow. Bemedies 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 DISORDEBS OF THE STOMACH. Case LV.* — Dyspepsia. History. — James Scott, aet. 61 — admitted 2Vth September, 1852. He states that, about two months previous to admission, he experienced severe shooting pains dart ing from the left scapula to the epigastrium and left hypochondrium. For many * Reported by Mr. James D. Maclaren, Clinical Clerk. FUXCnONAL DISORDERS OF THE STOMACH. 473 years back he has been much addicted to intemperate habits, and latterly his appe- tite for food has been considerably impaired. Symptoms ox Admission. — On admission, the tongue is furred, and cracked in the centre ; he has almost constantly a sour taste in the mouth, worse in the morning 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, generally 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 hardness or tumor to be felt : and there is no dulness on percussion. There is no tenderness or enlargement of the liver ; urine normal. He is of a very desponding disposition, and does not sleep well at night. Other functions normal. Potaasce bicarbonatis 3 ij ; Tinct. Gentian. Co. § i ; Inf us. Gentian, Co. ^ v. M. ft. mist. Half a wine-glassful to be taken thrice a day. Progress of the Case. — December 31s^. — Still complains of flatulence and dis- tension of the abdomen ; considerable pain in the epigastrium, increased on pressure. Applicentur hirudines quatuor epigastrio et postea foveatur. Jan. 3c?. — Appetite improved ; still acid eructations, with sour taste in the mouth ; pain in the epigas- trium, relieved after the application of the leeches and warm fomentations. He is very desponding about his complaints, which he much exaggerates. Jan. \0th. — ■ The sour taste and flatulence diminished ; pain and uneasiness in the stomach much relieved ; no tenderness on pressure ; appetite much improved ; no sickness or vomit- ing; bowels regular; stools natural. Dismissed in order to return to his work. The food ordered has been of a gentle, un stimulating, but nutritious kind. Commentary. — In this case derangement of digestion depended on intemperate habits, and was accompanied by excess of acidity in the stomach. The treatment was directed to counteract this condition by alkalies, vegetable bitters, and a regulated diet, which, to a certain extent, succeeded. But all such cases require exercise, regular habits, and moral control, without which medical treatment is unavailing. Case L VI*. — Dyspepsia — Oxaluria. History. — John Millar, set. 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. Since then, he has had many attacks of the same kind ; and of late, these have been accompanied with pain and palpitation of the heart, and tinnitus aurium. Some years ago he was mueh 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 coun- tenance, and an evident tendency to exaggerate his symptoms ; he complained of ver- tigo, tinnitus aurium, and muscae volitantes. The urine, after standing some time, exhibited a slight deposit, in which numerous large crystals of oxalate of lime were visible on microscopic examination ; sp. gr. 1028 ; otherwise normal. The other functions were normal. IJ Acid. nit. ; Acid, muriat. aa 3 iss ; Tinct. gent. co. 5 i ; Inf us. gent. co. § v if. A table-spoonful to be taken three times a day. Progress of the Case. — January %th. — Since last report, the oxalates have dis- appeared, the appetite has improved, the cardiac and cerebral symptoms are removed, and he is to-day dismissed cured. * Reported by Mr. James D. Maclaren, Clinical Clerk. 474 DISEASES OF THE DIGESTIVE SYSTEM. Commentary. — Dr. Golding Bird was the first to point out that oxaluria, associated with dyspepsia, was a very common disorder, and that its treatment by nitro-muriatic acid was the most successful one. The oxalic acid is probably derived from urea or uric acid, and its presence in the urine is often associated or alternates with these com- pounds. 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 L VII.^^ — Dyspcyosia — Hypochondriasis — Oxaluria. History. — Thomas Pollock, aet. 24, hawker — admitted 26th December 1862* 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, 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 vigor, etc., but has derived no benefit from them. Symptoms on Admission. — On admission, tongue moist, but furred, cracked, and fissured in the centre ; says he experiences a feeling of load after taking food, with occasional nausea. He has no vomiting, but an acid and sometimes disagreeable taste 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 occasional involuntary emissions of semen. The urine contains a slight sediment on standing, which is crowded with large and small crystals of oxalate of lime ; sp. gr. 1020 ; otherwise normal. Sleepless at night ; anxious and desponding about his complaints, which he attributes to the accident formerly mentioned, although it produced no local effects at the time, nor any structural change since. Says that he has frequent vertigo, tinnitus aurium, muscse voli- tantes, and cephalalgia. The other functions are normal. li Add. nitrid ; Add. muriat. aa. 3 i ; Tinct. gent. eo. § i ; Infus. gent. co. 3 v. M. A table-spoonful three times a day. Progress op the Case. — January 3t?. — He has continued to take the acid mixture, but does not admit that he is in any way better. On the 2d, the oxalates disappeared from the urine, and were replaced by a copious deposit of amorphous lithates. Omittatur mist. add. A’ ’ ' Tinct. cardamom, eo. §i; Hh . — 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. January 10th. — Since the application of the blister, the pain in the sacrum has disappeared. He expresses himself as being much better, and was now dismissed. Coynmentary . — In this case the presence of oxalates in tbe urine was associated with the same class of symptoms as in the former one, but the tendency of the patient to exaggerate his complaints was more marked. He had also a firm belief in tbeir being caused by an accident, which possibly never happened, and even if it had, could not have occasioned his symptoms. The acid and tonic mixture reumved the oxalates, but lithates took their place in the urine, which in their turn were got rid of by’ alkalies. Still, the fixed idea as to the cause of the disease continued, and he seemed no better. A blister was now applied to the sacrum, and he readily adopted the idea that his local complaints disappeared with the pain of the blister, and became cheerful and well. No case could better illustrate the effects of mental depression on the * Reported by Mr. William Calder, Clinical Clerk. Infus. quassice § vii. M. Two and morning. January FUNCTIONAL DISORDERS OF THE STOMACH. 475 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 vigor to the constitution. At length, satisfied of their inefficiency, he entered the Infirmary; the error of his practices was kindly pointed out to him, nutritious diet, regular habits, and tonic treatment were obviously bene- ficial ; and fortunately his hypochondriasis yielded to the simple expe- dient of substituting real for supposed pain, and leading him to imagine that the one had cured the other. General Pathology and Treatment of Dyspepsia. By dyspepsia (from 8i;cr7re7rTco, I digest with difficulty) are 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 condition is exceedingly common, and often constitutes the despair of the physician, arising, as it frequently does, from causes which are obscure, or, if discovered, are beyond his control. This will become apparent by considering, in the first place, those circumstances which require to be united to secure a healthy digestion. These are — 1st, A proper quantity and quality of the ingesta. 2d, Sufficient mastica- tion and insalivation. 3d, x\ctive contractility in the muscular coat of the stomach. 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 beon found effectual in various cases. Notwithstanding that you will fre- quently meet with instances which baffle all preconceived rules, there can be no doubt that a careful attention to the essential physiological conditions above enumerated will, in a great majority of cases, conduct you to a successful rational treatment. Thus — 1 . Of all the causes of dyspepsia, excesses in eating and drinking are the most common. An over-extended stomach, or too rich a meal, not unfrequently induces a feeling of weight or fulness in the epigastrium, nausea and eructation of acid, bilious, or gaseous matters, with a loaded tongue, headache, and other general symptoms. This is acute dyspepsia, or the emharras 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 occur- rence, 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 is about to occur, 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 intestines, a purgative should be administered, consisting of four grains of calome 476 DISEASES OF THE DIGESTIVE SYSTEM. with four of compound extract of colocjnth, followed in a few hours hj a draught of salts and senna. If necessary also an enema may be given. The purging, with a day or two’s confinement to farinaceous food, will generally get rid of such an attack ; but their frequent repetition 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 wdiich is derived from watering places. Chronic dyspepsia, however, is far more commonly caused by excess of spirituous and vinous drinks, than by eating; and, in such cases, abandonment of the evil habit is a sine qua non in the treatment. Tea-drinkers are very liable to the disease, and its frequency among female servants is probably owing to over-indul- gence in this beverage. 2. It may frequently be noticed, that those who have acquired the habit of eating rapidly are more or less dyspeptic. I knew a journey- man printer, who had been much tormented 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 could be discovered. I ascertained, at length, that it depended not on the locality -per se, but on its distance from the printing-house. When far olF he ate his dinner witn his family rapidly, having only just time enough to walk home and back within the hour. When he lived near, the time otherwise spent in walking was occupied in eating, or in cheerful converse with his wife and family. Since I made this observation, it has often occurred to me that the distance of the residences of artizans 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 fistulas have formed ; in such cases dyspepsia is generally present, and in some the disordered digestion has been cured by opera- tions that, by restoring the parts to their normal condition, prevent the escape of saliva. Again, persons habituated to the dirty habit of spit- ting, are for the most part dyspeptic. In all cases where dyspepsia can be traced to this source, the treatment becomes obvious. 3. The contractile movements of the stomach, which, by kneading the ingesta, and keeping them in constant motion, secure their intimate admixture with the gastric juice, and the rapid transference to the duodenum of such portions of it as are transformed into chyme, are evidently of great importance to the proper performance of digestion. The experiments of physiologists have shown that digestion goes on in gastri^c juice taken out of the stomach much slower than in the stomachy and that section of the pneumogastric nerves, by arresting the contrac- tile movements, permits only the circumference of the mass in contact with the secreting surface to be digested. These facts at once explain FUNCTIONAL DISORDERS OF THE STOMACH. 477 the well-known influence of mental emotions upon the stomach. Con- tentment and hope are as favorable, as dissatisfaction and despondency are injurious, to good digestion. Nothing is more common than dys- pepsia among literary men who overtask their mental faculties ; among 3 "Oung 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, biliary, and pancreatic juices in the digestion has of late years been much advanced. Thus, the gastric juice operates more especially on the al- buminous, and the pancreatic juice on the fatty compounds of the food. The function of the bile is more obscure ; it probably acts as a means of precipitating or separating some of the excretory matters from chyme, and so facilitates assimilation of the nutritive portions. Digestion may be deranged by all those causes which increase or diminish too much the secretion of these three fluids. Thus, excess of acidity in the stomach is one of the most common causes of dyspepsia, and is associated with that form of it which accompanies scrofulous and tubercular diseases. It may be in such excess as to neutralise the alkaline action of the pancreatic juice, and render it incapable of emulsionising fatty matters. In such cases the alkalies, with bitter tonics and the direct introduction of animal oils in excess, are indicated. On the other hand, the gastric juice may be diminished in quantity, as frequently occurs in persons who suddenly overtask the powers of the stomach at feasts, or in old persons with feeble digestion. The sense of load after eating is generally indicative 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 drink- ing at night a little weak brandy and water. In chronic cases, acids are indicated, especially muriatic acid. The Tr. Ferri co, of the pharma- copoeia is a useful preparation in chlorotic females. The prepared gastric juice of the calf has been lately recommended as a remedy in this case ; 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 sodcB hicarh with vegetable tonics, are indicated. When the bile is deficient, constipation and dyspepsia are usual re- sults, and are to be relieved by gentle mercurial purgatives, with extract of taraxacum, and by remedies, such as rhubarb, and especially the com- pound rhubarb pill, which, by acting on the duodenum, also favor the flow of bile into the upper part of the alimentary canal. Dr. Clay, of Manchester, has recommended in such cases the administration of ox- gall, a remedy, which, although not extensively given, is evidently 478 DISEASES OF THE DTGESTITE STSTEiT. rational, and calculated by its purgative action to be bigbly serviceable. Excess of bile, on the other hand, ought to be treated by drastic purgatives, diuretics, and diaphoretics, according to circumstances, to cause excess of excretion. Exercise should also be insisted on to call the lungs into action, and thus relieve the liver in its office of separating hydrocarbon. 5. A derangement of the consecutive and harmonious action of the alimentary canal is another frequent cause of dyspepsia, for it is as neces- sary 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 intestinal canal, whatever alters the structure of its mucous membrane, or what- ever 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 wso 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 idiosyncrasy^ in which we find this or that particular article of diet to derange the digestive function, and in which avoidance of the offending cause is the only plan of treatment that is at- tended 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 eructa- tions, sense of load at the stomach, cardialgia, vomiting, flatulence, pal- pitations of the heart, and cephalalgia. Some persons talk of a stomach cough, but this is more commonly dependent on sources of irritation in the oesophagus or pharynx, which have hitherto been overlooked. I have already alluded to the mode of treating most of these symptoms. Pal- pitations of the heart often occasion alarm in young dyspeptic persons; and in such cases, besides remedies directed towards the stomach, change of scene, removing attention from the affected organ, and varied reading should be enjoined. The sense of load in the stomach is most fre- quently removed, as I have previously said, by acids ; and sour eructa- tions 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 : — Oase LVIII.* — Dyspepsia — Vomitiny of fermented matter containing Sarcinoe. History. — Thomas Spence, aet. 53, a weaver — admitted September 6, ]852, * Reported by Mr. William Calder, Clinical Clerk. FUXCTIOXAL DISORDERS OF THE STOMACH. 479 ITe states that for fourteen or fifteen years past he has been subject to occasional vomiting, which generally occurred on Sundays, owing, he supposes, to want of exercise at his usual employment. On these days he scarcely ever took his meala from fear of the almost certain vomiting which would follow. For two or three years past he has been liable to frequent heartburn, water-brash, and acid eructa- tions, 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. He has never vomited blood or any dark-colored matter, and has never passed any such by stool. Symptoms on Admission. — On admission, tongue clean ; no difficulty in degluti tion ; appetite capricious, but always best in the morning and early 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 frequent 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 porridge, produces them in the severest form ; broths, vegetables, or any kind of slops, disagree with him ; animal food suits him best, but when 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 consider- able tenderness over the epigastrium. The bowels are generally constipated ; the stools usually of a dark color and hard consistence. He has occasionally slight pain and difficulty in voiding his urine, which is slightly phosphatic. Other functions are normal. Progress of the Case. — On taking charge of this patient on the 1st of November, I found him vomiting from time to time large quantities of fluid mixed with undi- gested matters, on which there gathered, after a short time, a thick brownish scum, exactly resembling yeast. On examining this scum with the microscope, it was ascertained to contain a large number of sarcinge ventriculi (see p. 98, Fig. 88), mingled with starch corpuscles, more or less broken down, and granular matter. From the ward-books I learnt that his treatment had consisted in the successive administration of — 1. The local application of leeches; 2. Of the sulphite 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 intermission, seemed to have produced no good effect. November Wth . — 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 sarcinge, 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. Acid. Hydrocyan. dU. m. xviij ; Syrup. Aurant. 3j. Aquee ^ v. J/., half an oz. three times a day. November '^.Oth. — The hydrocyanic acid checked the vomiting till last night, when it returned with more violence than ever. November 24^7i. — Vomiting still continues regularly every day. Omittatur Mist. Acid. Hydrocyan. ^ Liquor . Potass. 3 ss ; Aquee § vss. Two table- spoonfuls to be taken every four hours. December 2<7. — Alkaline mixtures again checked the vomiting, which, however, returned last night to a slight degree. AppUcet Vesicat. 4x5 Epiejastrio. December 87A. — Vomiting has once more returned daily since last report. H Tinct. Ferri Muriat. ^ i. Sumat 3 ss ter in die ex aqud. December 16th. — 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 shreds of undigested food. It is of intensely acid re-action, and contains only a few sarcinae. The dose of the Acid Tincture has been reduced to M. xv. The diet during this period has been principally animal, porridge and vegetables invariably increasing his 480 DISEASES OF THE DIGESTIVE SYSTEM. complaint. To-day lie left the hospital to visit his friends in the country, expressing himself as greatly relieved. Commentary . — The kind of chronic vomiting and dyspepsia here spoken of has been long known in Scotland, and was described by Cullen as a form of pyrosis. It was supposed to be associated with the habit of largely consuming oatmeal as a principal part of the diet; but its real pathology 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 sarcin(B. He considered that they were of a vegetable nature, and by multiplying fissiparously, gave to the contents of the stomach the appearance of yeast, which is also known to be dependent on the development and growth of vegetable structures. The occurrence of these sarcime in the stomach of course explains their frequent presence in the fieces, although, whether they 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 seen them in the juice squeezed from an oedematous lung. Dr. Tilbury Fox has found them on the skin. The origin and exact mode of development of these struc- tures are unknown ; but their presence is no doubt the real cause of the chronic vomiting and other symptoms of the individual affected ; and the cure of the disease will depend on the use of such means as are capable of insuring their destruction and preventing their return. It is obvious, however, that the means which destroy or check vegetable growths on the external surface of the body (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 only in a fluid. Again, it is very possible that, on being introduced from without, the conditions necessary for their development may be dependent on particular kinds of ingesta — a view which derives support from the facts observed in the case before us, namely, that the sarcinee were always increased by farina- ceous kinds of food. On all these points, however, we are as yet igno- rant, and our efforts at cure hitherto have not so much been directed to cutting off the sources of growth, as to destroying the sarcinee after it has proceeded to a certain extent. AVith this view it has been imagined, that the sulphite of soda would destroy them, by causing, on its union with the gastric juice, the extrication of sulphurous acid, which is so destructive to vegetable life. This remedy has consequently been given, and not unfrequently with success ; but in the present case it was of no benefit. Subsequently a variety of medicines were administered, several of which succeeded in checking the vomiting for a time. Indeed, it was remarked that the mere circumstance of changing the medicine was sufficient to stop the vomiting for several days, 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 re- markable contrast to the one just given, for although of some standing it was rapidly cured by the sulphite of soda. FUNCTIONAL DISOEDEES OF THE CTOruACII. 481 Case LIX.* — Dyspepsia — Vomiting of fermented matter containing Sarcinm. History. — Christina Torrence, set. 18, servant — admitted July 11, 1853. For the last three years has been suffering from more or less pain in the 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 very 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. Prooress of the Case. — On admission she was ordered bismuth and aromatic powders, which slightly alleviated some of the symptoms. On the 14th, however, there was vomiting of a brown frothy fluid, to the extent of 3 iv, which, oa micro- scopic examination, was demonstrated to contain numerous sarclnea. A scruple of Sulphite of Soda was ordered to he taken three times a day. On the 22d, vomiting again returned, but the rejected fluid contained no sarcinse. From this time all pains ceased, other symptoms disappeared, and she was dismissed quite well July 28th. Commentary . — Althougli it occasionally happens, as in the above case, that a cure may be rapidly accomplished, this is not to be hoped for when the disease is very chronic. In addition to what has been said on this subject, I may add, that whenever everything has been tried and failed, I have recently found that complete abstinence from food for one or two days, while the body is supported by nutritive enemata, has checked the vomiting and accumulation of fluid; that full doses of opium, the stomach being empty, will still further diminish irritation; and lastly, that I have caused great relief and prevented vomiting and much exhaustion, by removing the fluid from the distending stomach witli a stomach-pump, instead of allowing it to proceed to such a point as to occasion much pain. OEGANIC DISEASES OF THE STOMACH. Case LX.f — Chronie Ulcer of the Stomach — Recovery > History. — Janet Grant, let. 30, married — admitted 14th November, 1852. She stated that she enjoyed tolerably good health till twelve months ago, when she had an attack of haematemesis, 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. Alter vomiting took place, she generally suffered from severe griping pains in the bowels until they were opened. The stools were often of a dark brown color. 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 occupa- tion until the 3d of November, 1852, when the hmmatemesis 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-colored bbol. The pain in the head, epigastrium, and between the scapulae, 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 31 ^ Reported by Mr. Joseph Johnston, Clinical Clerk, f Reported by Mr. F. M. Russell, Clinical Clerk. 482 DISEASES OF THE DIGESTIVE SYSTEM, 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. ^ Sulph. Magnes, § ss ; Acid. Sulph. dil. 3 i ; Infus. Rosarum 5 viij. Summit. § ij, et repetant. eras mane. Acid. Gallic. 3 i ; Pulv. Opii gr. iij. M. et divide in pulv. xij. Suniat unum ter in die. PuoGiiKss OF THE Case. — November IMh . — Had some vomiting to-day, but no blood. Still considerable pain in the epigastrium. Bowels freely moved by medicine ; stools very dark in color. Nov. l^th . — Omitt. Acid. Gallic. 1^ Bismuthi albi 3ss; Pulv. Opii. gr. iss. M. et div. in pulv. vj. Sumat unum ter in die. P'arinaccous diet. Nov. 18^/i. — Complains of burning pain at lower part of the sternum; former pain in epigastrium somewhat easier; no vomiting since the 16th; bowels open; stools still of a dark color ; great thirst ; tongue loaded and coated with brown fur in centre; with bad taste in the mouth. Nov. 2Qth. — Still 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 epigas- irio, Repetat. mist, cathartic, si opus sit. Nov. 23c/. — Complains still of pain in epigastrium, which was slightly relieved by the leeches ; has had no return of vomit- ing; bowels open. Applicet. Vesicat. (3x2) epigastrio. Nov. 26/A. — Pain in epi- gastrium considerably relieved since the application of the blister. Still bad appetite and sour taste in mouth. U Ca^'b. Potass. 3 i. Div. in pulv. xij ; sumat unum ter in die. Dec. 2th. — Pain in epigastrium much relieved, and only returns at intervals, and in much less degree than formerly. She now takes her food well ; bad taste in mouth gone ; bowels still costive; pulse 80, of good strength. Dec. 11th. — Her former stomach symptoms have entirely disappeared. Dismissed. Commentary. — The vomiting excited on taking food, the hgema- temesis, and the local pain increased at the epigastrium on pressure, in- dicated the presence of an ulcer in the stomach, which, by opening blood- vessels, had several times caused extravasations of blood. Before I saw her, an astringent mixture, with gallic acid, had been ordered to check the tendency to hemorrhage. For this I substituted quietude, a farinaceous diet, to be taken in small quantities at a time, frequently repeated, and powders of white bismuth and opium, to check acidity and relieve pain. The pain not subsiding, six leeches were ordered to the epigastrium, fol- lowed by 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 LXL ^ — Chronic Ulcer of the Stomach — Cure. History. — Mary Keid, set. 38, married — admitted Deeember 20th, 1852. She states that about four years ago, having been exposed to cold and w^et, she was seized with shivering, followed by severe pains in the epigastrium, with uneasy sensations in the lower part of the abdomen, resembling labor pains ; these were aceompanied by thirst, loss of appetite, siekness, and vomiting. These symptoms disappeared, but re-occurred at intervals up to December, 1851, when she had a more severe attaek 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 hypo- chondrium, 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 appear- ance of finely-grated earrots. The loss of appetite, thirst, pain in epigastrium and bowels, with frequent severe headaehe, have continued up to the present time. She has had no return of the haematemesis, but generally vomits her food about half an hour after it has been taken. Symptoms on Admission. — On admission, she has a pale amemic appearance. The tongue is furred, appetite bad, pain in epigastrium and distension, with a sense *■ Reported by Mr. F. S. B F. de Chauraont, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 483 of load at the stomach after meals, which continues till relief is afforded 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 palpitation, but the heart sounds and impulse are normal ; pulse 96, small, and rather soft ; micturition normal ; urine of a pale color, 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 muscte volitantes, pain in lumbar region, but no tenderness over spine. Other functions normal. To remain quiet in bed. Farinaceous diet in small quantities. To have the bowels genthf opened. Progress of the Case. — December 23c?. — Bowels moved since last report; com- plains of much pain in the epigastrium ; has had no vomiting of blood since admis- sion, Applicent. hirudines iv part, dolent. et postea foveatur. Omitt. alia. 1^ Lactis Recent. § xii ; Aq. Colds 3 vj M. To be taken as a drink when thirsty. Dec. ZOth. — Continues somewhat easier ; complains still of occasional pain in stomach ; appetite rather improved ; less thirst. Bowels very costive. Jan. Aih. — 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 beaf-steak, contrary to orders. Pulv. Scammon. et Pulv. Jalap, aa gr. x. M. P't. palv. hora somni sumend. Jan. Q>th. — Bowels Avell opened, tongue much cleaner, feels better, and slept well during the night. To have rice diet. Has been com})laining again of pain in stomach ; tongue furred, but moist; appetite rather better; slept well during the night; bowels open. Jan. i)tJi. — 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. Apjpllcet. Veslcat. (3 x 2) part, doleyd. Jan. 12th. — Has been much relieved since the application of the blister, and expresses herself as feeling a great deal better. Tonguu moist, and cleaner than be- fore ; less thirst ; appetite improved ; bowels still costive. Jayi. %)th. — Dismissed cured. Commentary . — 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. The same treatment was pursued, but was not so carefully followed out, for it was ascertained tliat she was continually getting out of bed, and committing indiscretions, which caused returns of the symptoms. Case LXII .'^ — Chronic Ulceration and Perforation of the Stomach — PeritO‘ nitis — Limited Pneumonia with Gangrene — Abdominal Ahscees, simu- lating Pleurisy — Death. History. — Evina Clark, aet. 29, single, housemaid — admitted December 7, 1852. From the age of fifteen, she had more or less derangement of the functions of the stomach, as exhibited by frequent vomiting of greenish matters, not preceded by any 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 bicarbonate 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 faintness. Her mistress, on being summoned to her bedside, administered to her half a glass of brandy in some hot water. Immediately after this was swallowed 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 opium was administered, and she was sent to the Infirmary. The cata- menia have always been regular. - Reported by Mr. F. S. B. F. de Chaumont, Clinical Clerk. 484 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms on Admission. — On admission she was in a state of extreme depression, the surface cold, face livid, pulse 108, almost imperceptible ; and the house-clerk administered a draught, which was at hand, composed of Sp. Ammon. Aromat. min. X ; S'p. jEther. Sulph. min. xv ; Sol. Mur. Morph, min. xx ; Aquce § ss. Warm fomentations to the epigastrmm 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 hypochondrium, which was increased by pressure. The tongue w as slightly furred in the centre, but moist. She had great thirst, no nausea ; bowels had been freely opened at five o’clock in the morning. Heart sounds normal ; pulse 136, the strength having much improved since the draught, Avhich caused no increase of the pain. Is evidently under the influence of opium. All the other functions are nor- mally 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 diminished to a feeling of soreness; pulse 129, small; lividity of face and depression continued; surface cold; no rigors. Has had, at intervals of three hours, lour enemata of beeldea, with an egg, two containing an ounce of brandy, and two with one drachm of laudanum. She has also been sucking ice to relieve her thirst. December ^th. — There has been profuse sweating during the night; face is still pale, pulse 126, weak and thready; 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. Bisrnuthi albi gr. xviii ; Pulv. Opii gr. iii. M. Jiant pil. vi. One to be taken every six hours. The nutritive and an6dyne enemata to be continued. Dec. 2th. — She vomited yesterday afternoon, 3 p.m., about a pint of green fluid, and at the same time passed a fluid fmculent stool. Slept a little during the night. To-day she is somewhat refreshed, but the symptoms are the same as yesterday. Dec. \Qth. — Yesterday evening, the epigastric pain having increased, and extended into left hypochondrium, six leeches were applied, followed by warm fo- mentations. 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 suck ice to relieve the thirst. Dec. \lth. — Bowels were open shortly before the visit; pulse 128, full; tongue dry; thirst continues; but appetite is returning. Tender- ness of epigastrium and abdomen has nearly disappeared. To have beef-tea^ by the mouthy in table-spoonfuls at a time., and occasionally toast and water to relieve the thirst. Dec. V2th. — The beef-tea produced a disagreeable but not painful sensation in the stomach, but there has been no vomiting. Pulse to-day 128, of good strength; feels much easier, and can turn herself more freely in bed. There have been two faecal evacuations since yesterday. Dec. \Zth . — She has no pain; pulse 128, of mode- rate strength. To have a little toasted bread soaked in beef-tea. Dec. lAih. — The toast and beef-tea occasioned uneasiness and tightness in the epigastrium and both hypochondria, followed by dyspnoea and general restlessness, 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 two hours. To suspend the administration of food by the mouth. Dec. \^th. — 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 interrogated, she states that she had a rigor and feeling ot cold j^ester- day afternoon. On percussing the chest posteriorly, there is dulness over lower third of right lung, with double friction murmur and segophonic vocal resonance ; on the left side also slight dulness inferiorly, with crepitation, during inspirations, pulse 132, feeble. The enemata, which have been continued at intervals, are no longer retained. Intermittantur enemata. To have a little calfs-foot jelly by the mouth, alternated with a table-spoonful of clear brown soup every two hours. B Solutionis tartratis antimonii 3 iij ; Potassm acetatis 3 ij ; ^P- cetheris nitrici 3 v j aqute ^ v. M. Fiat mistura. A tahle-spoonftd every four hours in two or three table-spoon- fuls of water. Dec. \Uh. — Yesterday evening there was great exhaustion and feebleness; the mixture was suspended: and a table-spoonful of wine was ordered every two 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 vibrating; there is much flatulence. At her own request, she was allowed OP.GtANIC DISEASES OF THE STOMxiCH. 485 fifteen grains of the hi-carbonate of soda. To continue the jelly and brown soup., with half an ounce of sherry every hour. Dec. \lth. — Feels better to-day ; urine loaded with lithates ; flatulence has been relieved by the bicarbonate of soda. Dec. ISb'i. — Xo change. To have milk and lime-water to drink. Dec. \^th. — Coni- ])lains of increased pain in inferior portion of right side of chest, where there is still dulnes.'! and loud friction. Some dyspnoea. Six leeches to be applied. Dec. ‘iOit/i. 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 posteriorly. Dec. 'list. — Has had copious sweating during the night ; otherwise the sa no. Dec. Ti l. — Much weaker ; pulse 13C>, small and weak ; lithates have disappear- ed from the urine ; great dyspnoea. H Sp. TEth. Nit. 3 ss ; Tinct. Colchici I ij ; Ajuce 3 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. 23c?.— Is free from pain ; general symp- toms unchanged; pulse 124, weak; sliglit subsultus tendinum; appetite capricious; prefers arrow-root to rice. Dec. loth. — Complains now of diarrhoea. Habeat enema c. Tr. Opii min. xl. Dw. IQth. — Diarrhoea continues ; early this morning took the fol- lowing draught; — Sol. Mur. Morph, m. xv ; Tinct. Catechu 3 ss ; Syrup. Limonurn Z j M No change in the febrile symptoms, dyspnoea, or the pulmonary physical signs ; has no pain ; pulse 121, weak ; skin clammy ; states that slie felt very cold during the night. Dec. Idth. — Diarrhoea continues. 2h haw an enema of starch and opium. Dec. 28? i. — Diarrhoea has ceased; dyspnoea and febrile symptoms increased ; no pain; face pale and anxious. Dec. THh. — Evidently weaker ; breathing labored ; pulse 140, weak and thready ; countenance of a yellow waxy tinge. There was profuse sweating this morning ; other symptoms unchanged. Dec. 30?/i. — She continued to sink, and died this morning at 3 a.m., death having been preceded by repeated vomiting of dirty brownish-green matter. Sectio Cadaveris. — Thirty-three hours after death. Head not examined. Tiioiiax. — T wo drachms of clear serum in the pericardium ; heart healthy ; the right lung healthy, but its lower lobe and the diaphragm on that side were considerably 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 interiorly, where it rested on tlie 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 peri- toneum anteriorly and externally, and false lymph of considerable tenacity internally. liVmph 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, Avere gelatinous in consistence, and could readily be torn through by the fingers. In the left hypochondrium there Avas 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, Avith 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-broA\m, grumous liquid, con- taining coagulated masses, apparently of milk, tinged of a dark-red color by port Avine. In the posterior part of the stomach, about its centre, was observed an oval ulcer, the size of a five-shilling piece, with smooth, thickened edges, and surrounded by puckered folds of the mucous membrane, which Avas otherwise healthy. The ulcer was adherent to the pancreas behind, which constituted its base; but the adhesions round its supe- rior half were composed of the same gelatinous lymph as has been previously alluded to. On dissecting the ulcer from its attachments, it was seen to have completely per- forated the coats of the stomach, althoiigh the opening behind, viewed on the serous surface, Avas not above the size of a shilling. On removing the intestines from the pelvis, flakes of purulent lymph were observed between several of their coils and on the serous membrane of the pelvic cavity. All the other organs healthy. 486 DISEASES OF THE DIGESTIVE SYSTESI. Commentary . — All the facts connected with this case were obtained wdth 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 morn- ing of the day she was admitted, had perforated the organ, and induced the violent pain she complained of. The peritonitis, which may have been induced by the perforation alone, was undoubtedly augmented by the brandy and water administered to rally her from the state of collapse into which she was thrown by the immediate effects of the accident. On entering the house also about five hours after she became ill, a stimulat- ing and anodyne draught was administered by the clerk to rouse her from her depressed condition. As this was followed by no increase of local pain, but by improvement of the vital powers, we may fairly conclude that the practice, though highly questioiiable, was not productive of injury. Nothing, indeed, is more natural on the sudden occurrence of violent pain in the epigastric region with a feeling of syncope, than to have re- course to stimulants, for perforations of the stomach are rare occurrences, and it is not every one who at such a moment, even among the profes- sion, has sufiicient coolness and discrimination to detect the real nature of the disease. Hence, why so frequently these perforations are fatal, not so much from their own natural results as from the stimulating reme- dies administered, which pass through the aperture into the abdominal cavity. Indeed, had not brandy and water been given in this instance, there is every reason to suppose that the perforation might not have occasioned much mischief, for it occurred early in the morning, before breakfast, and long after her evening meal, and consequently when the organ was empty ; and, besides, it is to be observed that such perfora- tions have a great tendency to become re-closed by the rapid formation of fibrous lymph round their edges. In this case, however, extensive peritonitis was already occasioned when I first saw her, and the subse- c[uent treatment was directed— 1st, To prevent the introduction of further matters into the stomach; 2d, To rally her from collapse by stimulating and nutritive enemata ; and 3d, To conduct the inflammation to a favor- able termination by local fomentations and opiates largely administered in the form of enemata, and subsequently in pills by the mouth. This treatment w^as attended with apparent success, so that on the fifth day nourishment was cautiously administered by the mouth, and also with tolerable benefit. On the eighth day, however, rigors appeared, followed by fever, which was attributed to a pleurisy on the right side, where in- creased thoracic dulness was discovered infer iorly, with loud friction and gegophony. Circumscribed pneumonia evidently also existed on the left side, as indicated by crepitation. This formidable complication was attempted to be relieved by gentle salines, and topical bleeding by leeches. It was soon apparent, however, from the appearance of dyspnoea and other symptoms, that there was now little hope of recovery, and notwithstand- ing the liberal use of stimulants, the patient sunk 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 dia- phragm 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 com- ORGANIC DISEASES OF THE STOMACH. 487 municatiDg by a gangrenous ulcer in the diaphragm, -with the lymph ex- uded above and around the spleen. The edges of the ulcer of the stomach were firmly united to the pancreas, so that the patient undoubt- edly died from the extensive peritonitis. Case LXIIL * — Chronic Ulceration in the Stomach — Perforation occasioned hj a Fall {?) — Recovery. History. Barbara Ferguson, servant, aged 51 — admitted January 6, 1853. States that she enjoyed excellent health till about eight yeais ago, when she tirst began to complain of her stomach— suffering from pain of a cutting or grinding character, 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 exacerbation. On January the 4th instant, stepping upon a chair, her foot slipped, and she fell wkh 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 ot some coffee, with a few mouthfuls only of bread. She was immediately ordered a one-grain pill ol opium, which was to be repeated every four hours. On the next day, as the acute pain still continued, four leeches were applied to the epigastrium, followed by warm fomentations. She has had nothing by the mouth except the opium pills, up to the date of admission. SvMPTOMS ON Admission. — 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 excessively tender on liressure ; she has had great dysuria and pain on micturition ever since the accident. All 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 be followed in two hours by an opiate enema, with 40 minims of tincture of opium ; to be kept quiet and not get out of bed. Progress op the Case, — January *lth . — Was almost free from pain yesterday evening, and felt altogether much better, having slept a good deal during the afternoon. The beef-tea enema, with yolk of egg, has been repeated at intervals of four hours, and she had another opiate at 4 A. m., after which she slept well. To-day she feels easier ; pain, or rather tenderness, in epigastrium somewhat diminished ; and considerable pressure may now be exerted without causing uneasiness. She has still thirst ; tongue dry; very little inclination for food; pulse 100, soft. Jan. 8th. — Was considerably easier last night, and expressed a desire for some food ; the pulse was of better strength, 90. To-day is still improving ; complains of no pain when lying quiet, but still pain on pressure in epigastrium ; she expresses fear and pain when other parts are touched, but not to the same extent ; pulse 95, of moderate strength. 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 patient desires it. Jan. Wi . — 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 un- easiness, and rather refreshed from the beef-tea. To-day she feels not quite so well, and her general appearance is more depressed. She has continued the beef-tea, but has had an egg and beef-tea twice a day in addition ; pulse 88, of good strength ; bowels have not been open since admission ; to have a warm water enema, with an ounce of castor oil, followed, if necessary, by an opiate one. Jan. \0th. — Felt rather weak and exhausce i after bowels were opened ; the opiate enema was administered two hours afterwards, and she has felt better since ; had some tea, with a little toast, by the mouth this morning ; takes beef-tea for dinner, but cannot eat rice or any farinaceous food ; no bad effects have followed taking food by the mouth ; pulse 88, of good strength ; little pain complained of, and she can now sustain considerable pressure on epigastrium without suffering. Slept less last night than before ; urine clear, sp. gr. 1020, eontains phosphates. Omit the enemata. Jan. ‘l\th. — Since the last report she has been doing well, and gradually gaining strength. Dismissed. * Reported by Mr. F. S. B, F. de Chaumont, Clinical Clerk. 488 DISEASES OF THE DIGESTIVE SYSTEM. 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 favorable termination of the lesion. The symptoms at the commencement were very like those of Case LXII., but were induced by a blow on the epi- gastrium, instead of coming on after straining at stool. Violent pain, tenderness on pressure, and collapse were the immediate effects. For- tunately, I saw the patient immediately after the accident, and took care not to administer brandy or stimulating draughts. A grain of opium in the form of pill was administered every four hours, quietude enjoined, and complete abstinence insisted on. Next day the local pain continued, and on the following morning I sent her to the Infirmary. Nourishment was administered by enemata, and on the fourth day was cautiously given by the mouth, and no untoward symptom ensued. From this time she slowly recovered. Of course we have no positive evidence that there was a perforation in this case. For eight years, however, she had been subject 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 symp- toms, 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 think- ing that had brandy and water been given in this as in the former in- stance, there is every chance that here also fatal peritonitis would have been occasioned. From what I have observed of post-mortem examinations in the Eoyal 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 tnan it appears to be. Its morbid anatomy was first admirably described and figured by Cruvel- hier.f The ulcer is chronic, of circular or oval form, generally varying in size from a fourpenny to that of a crown-piece, having an abrupt, slightly thickened margin, as if it had been punched out, and an indurated smooth base. It may be shallow or deep, and frequently perforates all the coats of the stomach, in which case the external is larger than the internal aperture. It has a great tendency to contract adhesions by its external borders to neighboring viscera, .more especially the pancreas, immediately over which, in the posterior wall of the stomach, the ulcer is most commonly situated. When it occurs in the anterior wall, it less * See an able Memoir on the subject by Dr. Brinton. London, 1857. I Anat. Pathologique. Liv’s. x. et xx. ORGANIC DISEASES OF THE STOMACH. 489 readily contracts adhesions, and therefore is more likely to induce per- foration. 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 coii' traction may even be circular, causing a stricture of the organ. Mineral deposits are now and then found adherent to the cicatrix. The three leading symptoms of chronic ulcer of the stomach are pain, increased on pressure, vomiting after taking food, and haematemesis. Of these, the last is the most important in a diagnostic point of view, be- cause its presence renders certain, what would otherwise oidy be conjec- tural. The disease, however, may exist without as yet having so iujured a blood-vessel as to occasion hemorrhage. Hence the symptoms of chronic dyspepsia, with vomiting after food and fixed pain, if long con- tinued, should invariably give rise to the suspicion of an ulcer, and lead to an appropriate treatment. The remedies I have found most efficacious, in simple chronic ulcer of the stomach, are quietude, careful regulation of the diet, bismuth and opium pills or powders, and sometimes warmth, at others cold applied locally. It may frequently be observed that the mere coming into a hospital and remaining quietly in bed has a favorable effect in modi- fying the distressing symptoms. I have also remarked that those patients who are always getting up and walking about suffer much more than those who remain in bed, especially at the commencement of the disease. Hence, repose in an easy position should be enjoined. The diet should consist of farinaceous pulpy substances, occasionally mixed with beef-tea, or milk, given in small quantities frequently repeated. If the stomach will not tolerate the food warm, it should be given cold. When, despite this treatment, vomiting continues, it is best to suspend all nourishment for a day or two, and give nutritive enemata. As the patient gets bet- ter, 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 limewater, mingled in equal proportions. The pain is alleviated best by bismuth and opium, combined in the form of pill or powder. Some- times local warmth, but more frequently pounded ice, mixed with salt in a bladder, applied over the part, will give relief. Two or three leeches, or a counter-irritant, may succeed when everything else fails, and should be tried. Quietude and suspending all ingesta for a time, I believe to be the best remedies for hemorrhage, and where exhaustion from want of food exists, nutrient enemata, with wine, must be administered. When a perforation occurs, I have already pointed out the great im- portance of avoiding the giving of stimuli by the mouth (Cases LXII. LXIII.), and have stated the practice which should be perseveringly followed, namely, the administering of opium in the form of pill, quiet- ude, avoidance of purgatives, and nourishing at first by enemata, and then cautiously by unirritating substances, given in small quantities by the mouth. 490 DISEASES OF THE DIGESTIVE SYSTEM. — Cancer of Stomachy Pancreas, a7id Mesenteric Glands — Cystic Atrophy of Right Kidney. ITistory. — Thomas Gaffney, aet. 50, married, a laborer — admitted November 24, 1856. States that up to twelve months ago he was in good health, but since that time he has been troubled with pyrosis, occasional vomiting, and diminished appetite. Three months ago, feeling much pain in the epigastrium, he noticed tliat he had a tumor 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 paiu in wliatever position he places himself. Symptoms on Admission. — Teeth and gums dry ; tongue dry, with a longitudinal fissure dovm the centre. Thirst only occasionally felt. Has no api^etite. Has no difficulty in swallowing ; but complains of constant pain in the epigastrium. It is not distinctly increased on taking food. The food cannot be retained on his stomach, coming up in mouthfuls from an hour to an hour and a half after ingestion. The vomited matter is described as resembling in color 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 tumor about the size of a walnut, of an irregu- lar margin superiorly. The convex surface looks outwards and downwards. It may be moved upwards and to the right, but not dowinvards or to the left. In left half of epigastrium, over a space of two square inches, there is dulness on percussion, and on palpitation, a deep-seated, strongly-resisting tumor is felt, with a distinct margin to the right side. It appears to pass upwards under the superior part of left hypochondrium, where percussion gives forth a comparatively dull, resonance. Percussion elsewhere over abdomen, tympanitic. Over the hepatic organ and over the tumor there is great tenderness on percussion. Occasionally the tumor is felt more distinctly, and is then rough and nodulated. The chest is barrel-shaped. Percussion is unusually resonant. Kespiration is feeble anteriorly and is harsh posteriorly, the expiratory murmur being prolonged. No dyspnoea. Sputum scanty. Priecordial 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 to he carefully regidatcd ; small quantities of nutri- tive food and wine to he taken at frequent intervals. A mixture of snow and salt put into a bladder is to he applied over the tumor. To take two of the following pills every night : I^ Morph,. Acet., gr. iss ; Conserv, Ilosar., gr. xij. Fiat niassa in pilidas sex dlvidenda. Progress of the Case. — Decemher 1st. — The local application of cold has afforded him considerable relief, so much so that he docs not like to be without it. He is unable to take a sufficient amount of aliment, and is gradually getting weaker. Dec. 4:th. — 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 little, and continues to sink. Dec. Mh. — Died at 10.30 a.m. Sectio Cadaveris. — Twenty -eight hours after death. Abdomen. — Permission could' only be obtained to examine the abdomen. On opening the stomach it was seen to contain a considerable quantity of yellow^ pultace- ous substance, being half-digested food tinged with bile. The pyloric orifice w’as compressed by a mass of cancerous exudation, seated in the smaller curvature, and projecting into the stomach ; this mass w'as 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 wdiich a finger could be easily passed behind them. The thickness of this mass was in one place two inches, gradu- ally diminishing towards the margins to half an inch. The tissue w'as friable, easily breaking down under the finger, but not yielding cancerous juice. The pancreas was generally healthy, but an inch of the duodenal extremity was involved in the cancerous tumor. The cardiac orifice, wdiich was half an inch from the margin of the cancerous tumor formerly described, was quite healthy, as was the rest of the stomach not involved. Several mesenteidc glands in the neighborhood of the pan- creas w'ere enlarged, nodulated, and filled wdth cancerous exudation. Anteriorly the stomach was strongly adherent to a portion of the liver, wdiich below, over the tumor described, felt hard and nodulated. In the position of the right kidney was a cyst, the * Reported by Mr. 'William Guy, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 491 - size of the human head, containing a yellow serum. Internally it presented a smootli serous surface, here and there interrupted by circles, and fragments of circles leading into pouches. Some of these openings were perfectly circular, with smooch abrupt mar- gins, and were about the size of a fourpenny piece ; others were about the size of half a c'-own or five shilling piece. Here and there, on the surface of the serous membrane, were corruo-ated indurated lines with black calcareous plates upon them, the result of cicatrizations. Externally the pouch was smooth, covered with shreds of cellular tissue ; at its inferior portion was an induration, measuring two inches in length, and being cut into four, was found to consist of cortical renal substance about one-sixth of an inch in thickness. Immediately behind this renal substance^ was a cyst, communicating with one of the pouches previously described, about the size of halt a crown. No trace of tubercular structure 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 color. Microscopic Examination. — The cancerous mass in the stomach presented cancer cells in all stages of formation, with granule cells here and there embedded in masses of molecular substance. The mesenteric and epigastric glands on being cut presented a fragile surface, from which a glutinous substance could readily be scraped. This contained, when examined microscopically, large cancer cells multiplying endogen- ously; here and there granule cells, with a few fibres and numerous molecules. The rounded masses in the lung were of the same structure. Case LXV.* — Colloid Cancer icith 'perforating Ulcer of Stomach — Peritonitis. History. — James Douglas, mt. 55, a porter — admitted September 15, 1854. About fourteen weeks ago, being previously quite healthy, he began to experience a burning pain in the epigastrium, more severe after taking food, and also a sensation as of a ball rising in his throat. For three weeks he continued to work, but gradually grew worse ; eight weeks ago, he vomited, for two days, dark colored matter like coffee grounds. Has since been troubled with pyrosis, has lost his appetite, and become weaker and thinner. Sympto.ms on Admission. — Is greatly emaciated. Tongue moist, slightly furred ; appetite bad ; no dysphagia ; feels pain in the epigastric region constantly of a burn- ing 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 tumor stretching across the abdomen ; movable under the integument ; not very tender to the touch. Bowels habitually costive. Has no cough, Pulse 56, vveak. Urine not coagulable, of sp. gr. 1019. Other systems normal. Progress op the Case. — September IMh to October 2th. — The patient has been treated by the administration of antacids, bismuth, and magnesia ; by the injection of nutritive enemata ; by occasional opiates at night ; by suitable aperients, and care- ful regulation of the diet. He has gained no strength ; is indeed much weaker ; at present he has a burning sensation along the whole course of the oesophagus. Oct. \Mh . — This morning experienced acute pain in the abdomen, which is now distended, 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. lUh. — Has had much vomiting this morning, of dark coffee- colored fluid ; pulse is feeble, and extremities are cold. While eating his dinner to- day, he fell forward, and immediately expired. Sectio Cadaver is. — Twenty -tivo hours after death. Body very much emaciated. Thorax. — Thoracic organs normal. Abdomen. — On opening the abdomen a large quantity of dark-colored 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 Wm '-h. The fingers alone were sufficient to * Reported by Mr. Robert Rhind, Clinical Clerk. 492 DISEASES OF THE DIGESTIVE SYSTEM. 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 -^ indies 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 lists. On opening the stomach, the mucous membrane, towards the car- diac extremity, was perfectly 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 pancreas, liver, and surrounding organs were healthy. The texture of the growth was as hard as cartilage, and creaked under the knife, but on section presented the usual charac- ters of colloid cancer. (See p. 232.) The mucous membrane of the intestines was perfectly healthy. The other abdominal organs were normal. Microscopic Examination. — The colloid cancer presented the characteristic struc- ture described and figured p. 232. 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, hsematemesis, indicating ulceration in Case LX., and in addition, sudden 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 constriction was not great. On the other hand, ulceration was more extensive 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 excep- tion of hmmatemesis, may be produced by a tumor 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 frem the latter, which, however, occurs rarely. (See p. 520.) In many cases the lesion hitherto described as scirrhus of the pylorus or stomach seems to be a simple hypertrophy of their muscular and fibrous coats, which may or may not be associated with cancer of the neighboring 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 necessary to overcome the obstruction, just as happens in the intestines, bladder, and other hollow viscera, when the parts below them are strictured. (See Figs. 170 to 172, p. 190.) I have recorded four cases of this kind in my work on “ Cancerous and Cancroid Growths” (Edinburgh, 1848, p. 46, et seq.) Tn 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- ing 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 DISEASES OF THE STOMACH. 493 most distressmg; 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 frigorific mixture, as recommended by Dr. J. Arnott, and the ap- plication of a few leeches to the epigastrium, are also occasionally bene- ficial. In Case LX. the cold application was of marked service. The histological changes which occur in various disorders of the stomach were first investigated by Dr. Handfield Jones, who has described and figured the appearances presented by the follicles, their contained cells, and other minute structures under a variety of circum- stances.'^ There may be hypertrophy and atrophy of the solitary glands; atrophy of the glandular tubes; fatty degeneration; wasting and black discoloration of their epithelial contents ; fibroid thickening. etc. His researches have been for the most part confirmed by Dr. F. Schlapferf and Dr. Wilson Fox.J The latter observer has added some important fiicts connected with chronic catarrh of the stomach, thicken- ing of the limitary membrane, and cystic degeneration of the glands. * Pathological and Clinical Observations respecting Morbid Conditions of the Stomach. London, 1845. f Virchow’s Archiv. B. 7, p. 158. 1854.. ^ Medico-Chir. Trans, of London. Yol. XLI. 1858. Fig. 417. 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. 418. Commencing cystic formation in a gastric follicle, which is constricted in some places (6, c) and swollen at others. «, Shows the thickening of the limitary membrane ; and c?, slight fatty degeneration of the epithelium — ( Wilson Fox.) Fig. 419. A cyst in the pyloric portion of the stomach, composed of a fibrous envelope, and contents wholly composed of cylindrical epithelium. At a, the limi- tary membrane of the gastric glands commences to be thickened ; and at d, tht-ir contents have undergone the fatty degeneration, so common in chronic catarrh. — ( Wilson Fox.) 340 diam. 494 DISEASES OF THE DIGESTIVE SYSTEM. Dr. Habershon,* as well as Dr. Fox, points out tlie rapid changes which take place in the glands of the stomach after death, and the great caution 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 foundation 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 Fig. 420. Fig. 422. long these researches may be extended by clinical histologists, and ulti- mately lead to a more exact knowledge of the dyspeptic and organic diseases of this important organ. As a further contribution to this subject, I may observe that in the case of a man — Robert Lindsay — aet. 60, who died in the clinical ward, March 27, 1860, with a well-marked tumor of the pylorus, a careful histological examination revealed the following facts. The history of the case, and the appearance presented by the thickened structure of the pylorus, presented nothing unusual. Various sections through the thickened and indurated white pyloric structure, with a Valentin’s knife, showed the morbid growth to be compostM of hypertrophy of the gastric follicles, as represented Fig. 423. The cells of some follicles had undergone the fatty degeneration, so that they were filled with molecular and granular matter, in which * On Diseases of the Alimentary Canal, p. 62. 8vo, bound. 1857. Fig. 420. The gastric glands in chronic catarrh of the stomach, the breaking down of the upper portion being probably due to 'post-mortem change. «, a mass of pigment ; 6, 6, free fat drops ; c, thickened limitary membrane ; d, d, d, complete fatty degeneration of the epithelium . — {Wdson Fox.) Fig. 421. 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 fibrous tissue, and gives a cloudy appearance to the follicular epithelium . — ( Wilsori Fox.) Fig. 422. Fatty degeneration affecting the upper layer of the follicular epithelium, c, and fil)rous connective tissue, a, a, producing erosion of the surface •, 6, fatty degeneration of the epithelium and sub-mucous fibrous tissue . — ( Wilson Fox.) 340 dia7Ti. DISEASES OF THE STOMACH. 495 all structure was lost. In others, however, even where the follicles. Fig. 423 were enormously distended, as seen at d in the figure, the gland struc- ture was still preserved. Case LXVI.^ — Poisoning hg Oxalic Acid — Recovery, History. — Thomas Clarke, set. 47, shoemaker — admitted May 21st, 1859. He was brought to the hospital by the police at 9.10 p.m. At 8 p.m. he had swallowed a penny- worth of oxalic acid (about 6 drachms), partly dissolved in a tea-cupful of water, and partly in a crystalline state. At about 8.20 p.m. he ’tvas conveyed to the police-office, where he vomited twice, and refused to take some medicine which was offered him. He was then brought to the Infirmary. Patient stated afterwards that about 8.20 P.M. he felt a burning sensation in the lower part of the oesophagus and stomach, which * Reported by Dr. Carter, Resident Physician. Fig. 423. The gastric and pyloric glands hypertrophied in a cancroid tumor of the pylorus, a, Enlarged follicle ; 6, transverse section of such a follicle ; c, out- line of another follicle ; (/, the largest follicle observed, mostly drawn in outline. The whole of it, however, was composed of enlarged epithelial cells, as seen in the upper part of the drawing. In the centre the appearance of the isolated cells is seen, which were very numerous in the field of the microscope, e, Fragment of a follicle; many of these of all sizes and shapes, resulting from sections in various directions, M'ere observed, as will be at once understood by the histologist. /, Mass of cells undergoing the fatty degeneration, y. Another mass completely disinte- grated. The follicles presented all sizes and shapes intermediate between a and tZ, and many of them all the stages of fatty degeneration. 250 diam. 496 DISEASES OF THE DIGESTIVE SYSTEM. was followed by vomiting. The matters thrown up consisted of some bread which he had taken at about 6 o’clock p. m., and some of the crystals of the acid. Symptoms on Admission. — At the time of admission — 9.10 p.m. — he was pallid; skin cold, but without moisture ; his features pinched ; pupils if anything rather dilated ; pulse 72 and weak. He complained of burning sensation about his gums, the lower part of his throat, and in his stomach, which latter was very painful when pressed upon. He answered questions intelligently, but was unwilling to give much information. He vomited twice after entering the hospital, and was seized with a rigor which lasted for about ten minutes. An attempt was made to pass the stomach pump tube, but as this seemed to occasion excessive pain, and as he had vomited so frequently, it was not employed. He was, at 9.25 p. m., made to drink about three parts of a pint of warm water, in which was suspended one ounce of prepared chalk. This remained on his stomach for about ten minutes, and was then rejected. He said that he felt immediate relief from the burning sensation after he had taken the chalk. A similar dose was again administered and retained permanently. He was placed in a bed a short distance from the fire, and warm bottles applied to his feet. At 10.80 he felt much better, and took about half a pint of strong beef-ten, with an ounce of brandy in it, and was ordered to have the same mixture at 1 o’clock, and to drink milk ad libitu7n throughout the night if thirsty. Progress of the Case. — May ‘I'id. — Expresses himself as feeling tolerably well; but complains of some slight uneasiness in his throat and stomach, and of weakness, which, however, he has felt for some time as a consequence of illness and of privation. His tongue is covered with a thickish fur; he has little appetite and great thirst; his bowels were open during the night. Pulse CO, still weak. He continued to feel pain in the stomach, with dyspeptic symptoms, for son;e time ; similar, he says, to those he labored under before taking the poison. Ihese weie diminished and ulti- mately got rid of by powders containing five grains of bismuth, and a quarter of a grain of opium. He was dismissed cured, June 18. Case LXYII .* — Poisonmg hj Sulphuric Acid — Recovery. History. — John Calder, aet. 2 — admitted July 21st, 1868. This healthy child shortly after breakfast, having been left alone in a room, was heard by its mother to utter a scream. He was found with a bottle in his hand containing sulphuric acid, which he had applied to his mouth, and from which he had subtracted about § ij. Some of this had been spilt on the child’s chin, breast, and clothes. Water was given to it, and the child immediately brought to the Infirmary in its mother’s arms. She says that on the way a brownish colored fluid, with the milk and bread previously eaten, was vomited. SyxMptoms on Admission. — The resident physician on hearing the nature of the case, immediately administered 3 ij of carbonate of magnesia suspended in water, when the child eructated a considerable quantity of gas. The pulse then was 100, weak ; sur- face pale ; tongue of a dead white, as if acted on by the acid, which has also flowed ovei’»the lower lip, chin, and breast. Otherwdse the child w’as quite healthy. Progress of the Case. — Vespere. — Up to this time the child has been quiet, dozing occasionally. Deglutition is painful, but milk and beef-tea have been given at inter- vals. Has had one stool ; pale and pultaceous. My 22d — Has passed a restless night, but this morning does not seem to suffer much pain. Chalk in lime water has been given from time to time during the night, and a beef-tea enema this morning, which was retained. Pulse 145, weak. The tongue, a few patches inside the mouth, the centre of the lower lip and chin, forming a streak about an inch broad, ai e covered w'ith eschars. There is another also, the size of half a crown, on the breast. My 28(/. — Takes nourishment with some pain on swallowing. Desquamation of the dorsum of the tongue has taken place in patches. My ^ith . — Eschars have separated. July 25/A. — Still slight pain on swaliowing, otherwise well. Dismissed. Case LXVIII.f — Poisoning hg Corrosive Sublmate — Recovery. History. — Alexander Tweedle, aet. 19 — admitted May 24th, 1861. He stated that a quarter of an hour previously he had swallowed by mistake, instead of whisky, * Reported by Mr. Alfred Lewis, Clinical Clerk, f Reported by Mr. John Simpson, Clinical Clerk. DISEASES OF THE LIVED. 497 half a wine glassful of a bottle marked poison, which was found to contain camphor, turpentine, and corrosive sublimate, and used to destroy insects. Had not vomited since. Symptoms on Admission. — Only complained of great dryness and heat in his throat, otherwise was quite well. An emetic of sulphate of zinc (gr. xx) was imme- diately given, and a quantity of fluid, smelling strongly of camphor and turpentine, was at once ejected. The whites of six eggs were then administered. The tests of caustic potash, iodide of potassium, copper and nitrate of silver, indicated a consider- able quantity of corrosive sublimate iu the fluid contained in the bottle he had brought with him. Progress op the case. — May l ^ th . — Complained of no bad symptoms last night ; slept well — dismissed. Commentary . — In the first of these three cases of irritant poisoning, the man was induced to commit suicide when laboring under dyspepsia, want of food, and impossibility of obtaining employment. In the second case — that of a young child — vomiting having oecurred before admission, an antacid was immediately given, which neutralised what was left of the sulphuric acid in the stomach. Fortunately also the irritant was swallowed shortly after taking a meal. In the third case, an emetic acted perfectly before the corrosive sublimate had time to occasion bad consequences, and white of eggs was at once administered. Prompt judicious measures induced in all of them recovery. DISEASES OF THE LIVER. Notwithstanding the obscurity which still rests upon the functions of the liver, the progress of histological pathology has tended to make us better acquainted with the minute changes which occur in many diseases of the organ. The nature of fatty enlargement, of cirrhosis, and of the disintegration of cell-texture following obstruction of the bile-ducts, is now understood, but much research is still necessary. A careful comparison of the structural changes observed in the liver after death, with the clinical history and symptoms observed in the liver during life, is what is greatly desired to advance onr knowledge of hepatic diseases. This knowledge, however, can scarcely be hoped for, until medical men, and especially such as practise in the East, become efficient histologists. More recently some light has been thrown upon diagnosis, by paying attention to the transformations which bile undergoes during its excre- tion by the kidneys. 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 system of inquiry, is likely to yield more useful results. Case LXIX.^ — Acute Congestion of the Liver — Hepatitis — Recovery. History. — Thomas Russell, get. 38, laborer at a gas-work — admitted January 26th, 1855. States that about three weeks ago, after indulging freely in the use of * Reported bv Mr. W. J. Marshall, Clinical Clerk. 32 498 DISEASES OF THE DIGESTIVE SYSTEM. ardent spirits, he experienced general shivering and pain in the right hypochondrium with tinnitus aurium and a sense of faintness. Subsequently he felt pain in the ii<>-ht shoulder, and at length w'as obliged to leave off work. His comrades who w^nt honic 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 fora fortnight, but was very weak, and suffered much from the pain in his side' and in the shoulder. Since then he has been confined to bed, under medical care, applyino- counter-irritants locally, and taking pills which have made his mouth soi e. Symptoms on Admission. — On admission, he complains of pain in the right hypo- chondrium and right shoulder, in the former of which situations it is peiTiianent and increased by pressure, while in the latter it is only occasional. The tongue is covered Avirh a moist white fur ; the breath has a mercurial foetor ; the gums are painful ; appe- tite good. Bowels open. Pressure and percussion over the liver painful. Vertical hepatic dulness 44 inches. Pulse 72, soft. Sleeps little in consequence of the pain ; Urine normal ; no jaundice. Other functions w'ell performed. To apply six leeches to the right hypochondrium, and the parts afterwards to he fomented. To take two compound rhubarb pills every night. PkogPxEss op the Case. — February — The leeches and fomentations have in no w'ay benefited the pain, which to day is as severe as on admission. Bowels still open. Stools darker than formerly, but healthy. February Sd. — Since last report all pain has left him ; he declares himself to be w-ell, and at his own request was discharged. Case LXX.* — Acute Jaundice. — Albuminuria. — Recovery. History. — Walter Halliday, aet. 61, tailor — admitted July 6th, 1867. States that he has generally been a temperate man, although occasionally he has taken spirits moderately. On the first of this month, wdien working below an open windotv, he was suddenly seized with rigors, followed by great thirst, heat of skin, and headache. Next morning he w'ent to work as usual, but w'as 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. Symptoms on Admission. — The tongue is moist and covered with a wdiitish fur. No difficulty in taking food, nor pain afterwards. No tenderness or pain in abdomen ; but feels a pain in the lumbar region, wdiich sometimes darts round the right side towards the umbilicus. Appetite impaired. Bowels costive. Vertical dulness of liver on percussion 4 inches. The skin over the whole body is of a deep yellow tint, dotted with spots of purpura the size of pin heads ; but is cool and moist The urine is deep colored, like Madeira wine. It is very albuminous on the addition of heat, and contains a large quantity of bile. Pulse 88, small and weak. Other organs healthy. Potass. Acet. 3 ij. ; Sp. jEiher. Nit. §ss ; Aquee § vi ; AI. One ounce to be taken every three hours. Jidy 8th. — Bowels were freely opened yesterday in conse- quence of a Calomel and Jalap powder which was given. Stools w ere fluid and of a Clark -brown color. Progress of the Case. — Jidy 0^7i. — On microscopic examination of the urine it was seen to contain numerous casts, with delicate w^alls, having in their interior large epithelial cells. Passes more urine than formerly. To have Pidv. Doveri gr. x, at bed-time, followed by a diaphoretic dra^lght. Two compoxmd rhubarb pills to betaken every night. Jidy \ Wi. — The urine and skin are now of a healthy color. The pulse, however, remains low, and the patient weak and languid. Nutrients, tonics and wine, with gentle exercise, were now given, under wdiich 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 eo 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 •Reported by Mr. W. H. Davies, Clinical Clerk. DISEASES OP THE LIVEPw 499 in a few clays. 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 color, 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 contrary, the disease increased. But under the action of diuretics and diaphoretics, to favor secretion of the bile already absorbed, as well as of mercurial purgatives to rouse the duodenum and upper parts of the alimentary canal to a more healthy action, he rapidly recovered. AVhether the disorder in these cases was congestive or inflammatory, or both, cannot be de- termined. Whatever the lesion, it so operated in the one case as to induce great pain, and in the other to obstruct the gall-ducts and occa- sion jaundice. In jaundice, the diminished excretion of bile by the intestines is attempted 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 tubuli uriniferi, 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 interfered with the functions of the organ. In the skin the deep layer of round epidermic cells contain 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 alimen- tary canal. A new impulse has been given to the diagnosis of the causes on which jaundice depends by the writings of Frerichs, Harley, and others. Jaundice may be a symptom — 1st, of various affections of the blood, as in fevers, disease of the heart, lungs, and nervous system ; 2d, of mechanical obstruction in the duodenum, from accumulation of fieces in neighboring bowels, or from tumors; 3d, of hepatic congestion, occa- sioned by fright and other temporary circumstances ; 4th, from obstruc- tion of the ducts in the liver itself or the gall-bladder; and 5th, from structural changes in the hepatic tissue. Hence jaundice may be con- veniently divided, as was originally done by Hr. Alison, into jaundice from obstruction and jaundice from non-elimination. The symptoms are chiefly referrible to the skin, which is tinted yellow; to the bowels, the discharges from which are clay-colored, and Frerichs, Klinik der Leber Krankheiten, 1858, pp. lOY-8, and plate 1. 500 DISEASES OF THE DIGESTIVE SYSTE:^!. more or less fatty ; and to the urine, the chemical constituents of which vary greatly. It is by the chemical analysis of this fluid, that new light has been endeavored to be thrown on our appreciation of the nature of jaundice. In our attempts to arrive at results by the chemical investi- gation of this fluid, we must first remember what are the constituents of bile ; and, secondly, how they are to be detected. The chemical constituents of bile are — 1st, Biliverdine, — a green, nitrogenized, non-crystallizable coloring matter derived from the blood. 2d, Two acids, — the glycocholic, which, with soda, is crystallizable ; and the Taurocholic, which is non-crystallizable. 3d, Cholesterine, — a fatty crystallizable matter. 4th, A brown resinous matter, resembling shoe- maker’s wax. 5th, Sugar. 6th, Inorganic matters, chiefly soda, potash, and iron. When the secretion of bile has been suppressed, that is, when this fluid has not been formed, it is said that no bile acids are to be found in the urine ; not having been formed, they do not enter the blood and are not excreted by the kidneys. It must be confessed, however, that we require more characteristic tests for the bed-side than those furnished by Pettinkofer (p. Ill), or by the method of Hoppe. To me it has not appeared, from numerous trials, that any amount of skill and experi- ence will ever enable the physician to come to a conclusion on this point, when all that has to be determined is the difference between a rich brown and a purple color — constantly passing as they do into one another — in order to distinguish the absence or presence of an acid, on which depends a conclusion so important. According to Frerichs, acute atrophy of the liver is to be determined by the presence of tyrosine and leucin in the urine — two products never found there in health. (For mode of detection see p. Ill, and Figs. 112 to 114.) I have endeavored to ascertain the correctness of this test in several cases which entered the clinical wards during the years 1863-64, but only succeeded in obtaining unequivocal crystals of leucin in one case. Here, also, I believe that unless the mode of detec- tion can be simplified, it will be some time before we shall be enabled to judge of the correctness of this new diagnostic sign. Notwithstand- ing the trouble I and my various assistants have recently taken in en- deavaring to arrive at useful results,^ by these new modes of inquiry, the facts I have arrived at are as yet too few and uncertain to warrant publication. The true method of further investigating these matters, however, is to extend chemical and histological knowledge among medical students, so as to obtain a larger number of skilful workers at the bed-side, who have time and ability to grapple with the present difiiculties of such questions. The profession at large cannot be too grateful to those who have indicated new sources of information in diseases hitherto so mysterious, which I firmly believe are yet destined to yield most im- portant results. * Among these I am much indebted to my late resident physicians, Drs. Smart and Duckworth. DISEASES OF THE LIVER, 501 ^'Iase LXXI .^' — Abscess of the Liver^ bursting into the Right Thoracic Cavity, and into the Retro-peritoneal Cellular Tissue — Pneu- monia and Gangrene of Right Lung — Pneumo-Thorax. History. — Robert Steinkopff, tet. 45, native of Prussia, merchant — admitted Nov. 5 18G4. Tlie patient states that he was in easy circumstances; passed his time chiefly in hunting, and in so doing he was often accustomed to the free use of spirits; until a year ago, when he lost his property and came to tliis country. lie was now obliged 10 live on very insufficient diet, and this, combined with great mental anxiety, impaired his strength. Three weeks ago, after exposure to wet on a rainy day, he was seized with sudden and severe pain in the right hypochondriac and epigastric regions ; en- liu^ement and protrusion of the abdomen, more especially when standing; diarrhoea of six thin and copious stools per diem, accompanied with much flatus ; feverish attacks, occurring every afternoon from 3 to 6 o’clock ; diminished appetite and con- stant thirst. These symptoms continued up to the period of admission. He left Leeds, where he was first attacked, and went to York and Newcastle, whence he came by sea to Edinburgh, eight days ago. Since then there has been some oedema of the legs. SvMPTOMS ON Admission. — Tongue clean, fissured transvcrsly, bad taste in the mouth. No appetite; thirst. The epigastrium is swollen ; tympanitic on percussion, and very painful on pressure. Lateral hepatic dulness 6 inches vertically. The lower border of the organ may be felt 2 inches below the ribs, which bulge very much on the right. Splenic dulness normal. Bowels moved from three to seven times a day. Stools are slimy and contain no blood. No dyspnoea. Slight cough, with scanty expectoration. On right side anteriorly from clavicle to nipple vocal resonance and thrill much increased. Percussion and breath sounds normal. Below the line of the nipple absolute dulness, and complete absence of breath sounds and vocal resonance. Posteriorly, from the level of a transverse line passing 2^ inches below the spine of the scapula downwards, there exists complete dulness on percussion, with absence of respiratory murmurs. Percussion over this area causes great pain. Above this line vocal resonance is bronchophonic. The left side of chest is normal. No friction sounds audible either before or behind. Heart healthy. Pnlse 108, weak. Both legs are slightly oedernatous below the knee. Patient sleeps badly at night, and feels very weak. Urine normal in color; no albumen; density 1015. Tr. Catechu ^j; Mistarain, Cretcead % vi, mUce. A tahlespoonful thrice a day. Progress of the Case. — Nov. Sth. — Friction heard on right side immediately above the nipple ; none behind. Copious deposits of urates in urine. U &pt. jEth. Nit. 3 ii ; Sol. Amm. Acetatis § ss ; Aquarn ad § vi, M. A lableapoonful four times a day. Nov. 9th. — Friction heard more distinctly at same spot. Otherwise as yester- day Hot poultices to he applied orer the affected side. Nov. \{)th. — Distinct segophony heard on the right side posteriorly. Urine clear ; pulse soft. Nov. \2th — At evening visit last night, patient complained of excruciating pain in the right side. 7b have 3 ss of chlorodyne. Slept well last night and feels refreshed to-day ; pain in the side less severe. Friction and legophony persist. Hot poultices to be cotdinued, at intervals. Nov. \Uh. — Slight friction heard over the third right costal cartilage. Above this, increased vocal resonance and harsh breathing. The pain is nearly as great as formerly. A3gophony still audible. Thirst is excessive; tongue parched and cracked. Pulse 96, soft and weak. Diarrhoea is now reduced to two evacuations per diem. To have wine § iv, and nutrients. Nov. Vlth. — Diarrhoea continues. Pulse 110, weak. Pain in upper part of abdomen and the right side still excessive. The poultices afford only slight relief. To resume his chalk and, catechu mixture, which he had discontinued for a day or two. Nov. %dh. — Slept better last night than for some time past. No friction audible, and aegophony completely gone. Nov. 227. — This evening he coughed up about 12 ounces of a reddish grumous m itter. Nov. ‘‘ISd. — Friction again heard on the right front, mixed with crepitation, accompanying inspiration. Pulse 106, soft and weak. Copious expectoration of the thick red fluid continues, which under the microscope is composed of blood and pus corpuscles, with numerous molecules and granules. N'ov. 2&th. — O 71 riyht side of ciiest, both in front and behind, there is now comjflete dulness and absence of vocal resonance and thrill. Bi-eathing distant and tubular. Pulse weak. Tongue pale, moist and furrowed. Nov. 21th. — Pulmonary signs as yesterday. Tongue dry. Copious bloody expectoration continues. Delirious last night. Pulse very weak. * Recorded by Mr. J. S. Torrop, Clinical Clerk. 502 DISEASES OF THE DIGESTIVE SYSTEM. Nov. 28th. — The diarrhoea was for a few days somewhat checked by the suppositories, but gradually returned, and is now very severe ; the bowels having been opened twelve times yesterday. The urine has continued albuminous, and loaded with desquamative casts and fatty tubes. To-day its spec. grav. is 1007. There is now great debility, and occasional stupor and drowsiness. May l"lth. — 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 ether, 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 diarrhoea first abated, and was soon after checked. In August his health was so much improved that he was allowed to go out of the house for the benefit of air and exercise. He was readmitted Septeniher 1 S/'/i, having enjoyed tolerable health in the interval, although the hepatic swelling is about the same size. He was now ordered, R Hydrary. Proto-iodidi, gr. vj ; Pulv. Opii gr. ij ; Ext. Taraxaci 3 ss ; Conserv. Rosarum ^y. v. Fiant pil. xx. Sumat unam ter indies. These pills on the %)th produced salivation, when they were dis- continued, and an astringent gargle was ordered. The abdomen now measures thirty six inches in its broadest circumference. Oct. iWi . — Complains of oppression on walking, of shooting pains through the chest and abdomen. Ascites seems once more to be increasing. Tr. lod'inei to he 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 addi- tion of heat and nitric acid, but is voided in natural quantity. Dec. IZth. — The liver is now so reduced in size that its lower margin is only two inches below the false ribs in front, and one inch on the right side. All his functions are apparently healthy, the urine healthy, and his strength appears perfectly re-established. Dismissed. Commentary. — The enlargement of the liver which existed in this man was probably simple hypertrophy, which, by pressing upon the large abdominal veins, caused ascites. It is worthy of remark, that it underwent a sensible diminution 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 be- came perfectly healthy. He has since been seen by the clerks walking about the town, and informed them that he is quite well, and carries on his occupation without any inconvenience. Case LXXVI."^ — Fatty Enlargement of the Liver. History. — James Grant, set. 29, l)lacksmith — admitted October 14th, 1851. His occupation consists of watching an ap])aratus worked by steam, in a room of elevated temperature; ho has no heavy labor, though constantly standing on his feet; he drinks whisky to a large amount. Since September 1849, he has been three times in the house for various periods, from which he has been as often dismissed relieved. The liver began to enlarge two years ago, and has been very slowly increasing ever since. Symptoms on Admission. — On admission, he labors under slight diarrhoea, hav- * Reported by Mr. W. M. Calder, Clinical Clerk. 512 DISEASES OF THE DIGESTIVE SYSTEM. ing had two or three stools daily for several weeks past. He has, moreover, a dull heavy pain in the abdomen, extending to the lumbar region. The belly is evidently enlarged at its upper part, w^here a firm tumor exists, forming a protuberance 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 lirie drawn one inch above the superior spine of the ilium. The whole of the right and part of the left hypochondriac regions are dull on percussion. The tym- panitic 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 tumor feels smooth, and presents no tenderness. The splenic dulness m.easures 6^ inches verti- cally ; skin dry : no oedema of the legs ; general appearance pale and cachectic ; occa- sionally he has frequent desire to micturate, but the urine has always presented its normal characters ; considerable breathlessness on exertion, but the lungs and heart, on examination, were apparently quite healthy ; other functions well performed. He was ordered a mixture containing the Iodide of Foiassivm^ six grains of which were to be taken three times a day. Frictions with the Unguent, lodinei were also to be employed daily. Progress of the Case. — Tov/ards the end of October, the bowels became regular, and his general health was somewhat improved. Frequent micturition, with discharge of pus in the urine now came on, which subsided in a few days. From this time, although the size of the liver underwent no diminution, his bodily strength gradually improved. He occasionally had slight return of looseness in the bowels, wdiich w^as checked by appropriate remedies. The difficulty of breathing after exertion also slowly left him ; and he was dismissed greatly relieved, January 26th, 1852. Commentary . — Fatty liver was first sliown 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 cir- cumstances, frequently enlaiged, 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 demonstrated under the microscope to contain an unusual num- ber of fat granules, and there can be little doubt that considerable varia- tions may "exist in this respect quite compatible with a state of health. Almost all stall-fed animals that do not labor, possess a large amount of fiit in their hepatic cells. It is only \^here the organ is much enlarged, altered in color, and pressing upon neighboring viscera, that its fatty degeneration can be said to interfere with the vital processes. Fatty degeneration of the liver has been observed to be very common in drunkards who are continually taking alcoholic liquids. Of 13 indi- viduals who died from Delirium Tremens, 6 had very fatty liver, in 3 the organ contained little, in 2 none at all, and in 2 there was cirrhosis (Frerichs). In such cases the quantity of carbon taken in the torm of spirits being too great in amount to be excreted from the lungs as car- bonic acid, and from the liver as bile, is stored up in the liver as fat. In tropical climates, the same pathological condition comes on under dif- ferent circumstances. A high temperature, and a rarefied atmosphci e, indispose persons to take bodily exercise; and Europeans, instead of Fig. 425. Hepatic cells in various stages of fatty degeneration. On the right of the figure, yellow granular pigment is also contained in the cells, which were taken from a cirrhosed liver. 250 diam. Fig. 425. DISEASES OF THE LIVEF.. 513 living according to the simple manner of the natives, too often continue to consume the food habitual to them in their native country. But the ex- cretory power of the lungs being, at the same time, diminished, the excess of carbon in the tissues and food is thrown upon the liver, and there con- verted into fat. Dr. Macnamara * found that, among the first regiment of European Bengal Fusileers, during seven years, the mortality among the officers was 11 per cent, and among the men 80 per cent, so that the whole of the fighting men of the regiment were changed about once in every ten years. From the circumstance that the great majority of these men were young, healthy, and vigorous, when tliey left home, and other circumstances, he attributes the deaths to high feeding, indulgence in spirits, and to slothful habits, causing fatty degeneration of the textures. The maimer in which the livers of geese are made fatty at Strasburg is as follows : — The geese are confined in close cages, in a heated atmo- sphere, and largely supplied with food. Want of exercise and heat dimi- nish the respiratory functions, and cause that of the liver to be disorder- ed; and the result is enlargement of the organ from accumulation of fat. In the case before us, the cause of the disease seems to have been exactly the same. A man is kept stationary watching a steam-engine, in an ele- vated temperature, consuming his usual food, and indulging in alcoholic drinks. Fatty liver is also common in phthisis pulmonalis. Here the excreting function of the lung is more or less interfered with, and the car- bonaceous 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 pre- sented fatty liver in the highest degree, whilst there were 62 others with the hepatic cells loaded with oil-globules. On the contrary, in other dis- eases of the pulmonary organs, ho found fatty liver to occur very seldom. This view of the pathology of fatty liver has been objected to on the following grounds : — 1st, That the connection between fatty liver and disease of the lungs is not general; 2d, That there is no evidence that a fatty liver does not excrete bile as usual ; and 3d, That as a considerable portion of bile is absorbed into the blood to be excreted from the lungs, the liver must be considered as preparing material for tliese 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 dimin- ished by disease (Biidd). But if fatty liver be not always conjoined with diseased lung, it will be found associated with some circumstance which diminishes the function of that organ, in relation to the work it is called upon to perform ; for instance the diminished exercise and great heat of tropical climates. Further, although it be granted that the liver may in health prepare carbonaceous matters for pulmonary excretion, it must be clear, that if the lungs cannot accomplish this function, such matters must be thrown back or retained in the liver, and constitute a powerful cause of fatty degeneration of that organ. On the whole, there- fore, we must regard excess of carbonaceous matters in the system, and the diminution of pulmonary action, as the chief causes of fatty degencra- 33 * Indian Annals of Medical Science, 1855, p. 170. 514 DISEASES OF THE DIGESTIVE SYSTEM. tion of the liver ; a view which has the merit of pointing out to us as remedies a diminished diet, a temperate climate, appropriate exercise, and an endeavor to promote the functions of the lungs and of the skin. There is another structural alteration of the liver, whicli, from its color and general resemblance to bees’-wax, has been called “ waxy,” and sometimes “brawny ” liver. This disease has been confounded with fatty liver, but an examination of their minute structure shows that the hepatic cells present a very different character in this condition. Instead of being enlarged and filled more or less with oil-globules, they arc colorless, shrunken, and for the most part destitute of contents, and the nucleus disappears. (See Fig. 319.) I have previously described this lesion as one of the forms of albuminous degeneration. (See p. 249.) Its clinical history will be given under the head of Phthisis. (See case of Margaret Clark.) Case LXXVII .'^ — Cirrhosis with Atrophy of the Liver— Ascites. History. — John Harper, aet. 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 exer- tion, A short time afterwards, he was exposed to cold and wet, and he observed that the abdomen gradually enlarged, and dyspnoea supervened. On two occasions para- centesis abdominis was performed ; at the first operation a quart, and at the second a pint, of fluid was removed, without producing much relief. He has had considerable pain in the epigastric region at times, and latterly the appetite has been diminished, and the bowels costive. Symptoms on Admission. — On admission, the abdomen is slightly srvollen, and evidently contains fluid. Round the umbilicus it measures 39 inches. Ko anasarca. The hepatic dulness extends three inches downwards on the right side, commencing two inches under the nipple. Tongue is furred ; appetite diminished ; no epigastric pain or uneasiness ; bowels irregular, but at present costive. There is slight dulness on percussion under the right clavicle, with harsh inspiration, prolonged expiration, and increased vocal resonance ; urine scanty, depositing lithates. The other functions are well performed, and he appears to be a strong, well-nourished person. Progress of the Case. — The treatment consisted of diuretics {8p. ^ther. Nit. mid Tr. Digitalis) and sudorifics {Pulv. Doveri) ; but, feeling the confinement of the Hospital to disagree with him after his usual active occupations, he insisted on going out, which he did July 6th. Commentary . — The dimiinshed extent of the hepatic dulness, the ascites, and the chronic nature of the disease, point out this case to be one of cirrhosis. This morbid change in the liver consists of the forma- tion of fibrous tissue between the lobules of the organ, whereby its secret- ing cells are compressed and atrophied. As a further result, the large venous trunks are also compressed, and their commencing ramifications so congested that effusion into, or dropsy of, the peritoneal cavity is in- duced. Notwithstanding the extensive organic changes which are fre- quently observed in this disease, danger is not so much to be apprehended from them as from the ascites, which, by distending the abdomen and compressing the lungs and liver, so interferes with those important organs as to destroy life. Case LXXVHII.f — Cirrhosis with Enlargement of Liver — Hypertrophy of Spleen — Slight Leucocythemia — Jaundice — Constriction of Arch and descending Aorta. History. — James Kerr, let. 28, a laborer — admitted July 22, 1852. This iran * Reported by Mr. John Matthews, Clinieal Clerk, f Reported by Messrs. Douglas and Dewar, Clinical Clerks. DISEASES OF THE LITER. 515 first had jaundlea, with swelling of the abdomen, between four and five years ago ; and since tlien lie h.is been several times in the Infirmary, The treatment has con- sisted of various alteratives internally, with the occasional application of the Tr. lodinei, blisters, and leeches externally. The swelling, however, has continued to increase very slowly, and for the last two years he has been incapacitated fi“om work- ing. The blood fur some time has contained an excess of fibrin, and a slight increase of°the colorless 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. Symptoms on Admission. — On admission the hepatic dulness commences an inch below the right nipple, and extends down to the umbilicus, measuring twelve inches vertically. The splenic dulness reaches from the lower margin of the fifth rib to a transverse line drawn an inch below the umbilicus, and measures eight inches verti- cally. The liver presents a protuberance anteriorly, which extends in the form of a ridge, four inches broad, from the epigastrium backwards towai'ds the false ribs. The girth of the abdomen over this ridge is 4i inches. The interior 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 aloud rough murmur synchronous with the systole of the heart, and ac- companied by a distinct impulse. Tnere is a slight cough, with a little mucous expec- toration, but auscultation and percussion of the lungs reveal nothing abnormal. Urine rather .scanty, high-colored, spec. grav. lOifi, contains some biliary matter, and de- posits on cooling a pretty copious pinkish sediment of lithates. The integuments and conjunctivae are still tinged of light bile-yellow color. There is considerable tender- ness over the liver in the right hypochondrium. lie says slight epistaxis returns about once a week. The bowels are open daily ; no diarrhoe;i. After vadking or unusual exertion oedema of the legs comes on. On examining the blood microscopically, the colorless corpuscles are not so numerous as when he was last in the house. Four leeches to he applied to the right hypochondrium. Progress OF THE Case. — This man left the house in August. He was readmitted Novemlier 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 pissed considerable quantities of dark grumous matter from the bowels. In other respects his condition is the same as formerly reported. November IH/i. — Vomited about nine or ten ounces of blood. 29. Catechu ? ss ; Sol. Mur. Morph. 3 j ; Mist. Crel(M comp, ad 5 viij, J/. Smnat 3 j tertid qudque hord. Progress of the Case. — T he bowels have been opened twelve or fourteen times since yesterday’s visit. Pain still very severe in the left iliac fossa. A considei’able quantity of blood and mucus in the stools. Applicent. hirudines xij parti dolenti. Lijiciatur Enema Amyli cum Tr. Opii 3 i- November 2Sth . — Six stools since yester- day, very watery, with traces of blood. No tenesmus, Continuetur Mist. Nov. ZOth. — Six stools, more faeculent, and without blood. From this time he rapidly recovered, and was dismissed quite well, December 9th, Case LXXXIY.^ — Suh-Acute Dysentery — Recovery. History. — J ohn M‘Gee, set. 38, a mason’s laborer — admitted June 29th, 1853. Says that last summer he was confined to his house for twenty-six weeks, in conse- quence of severe bowel complaint; and has been subject to diarrhoea every now and then ever since. He returned to his work last February, but was again obliged to desist nine weeks ago in consequence of the sevei’ity of the bowel complaint and weakness. Three v^eeks since he observed the stools to be tinged with blood. Six days ago he vomited a tenacious mass of the appearance of white of egg. He has been much addicted to the use of ardent spirits, and is very intemperate. The medi- cines he has taken have been of little benefit. Symptoms on Admission, — Tongue smooth and moist anteriorly, but somewhat loaded at the base. Appetite tolerably good. No fever. There is tenderness on pressure over the abdomen generally, and frequently griping pains. Has about thirteen stools a day, which are thin, of pale yellow color, containing a quantity of pus. Pulse 80, weak. Other systems healthy. Pll. Plumb. Acet. Sumai unam quartd qudque hord. Habeat suppositor. cum Mur. Morph, gr. ss vapere. July Is^. — Increased pain in the# abdomen. Applicent. hirudines vj. July 2d. — No change. Complains of thirst. Intermit. Pil. Plumb. H Confect. Aromat. 3 ss ; Pol. 2Iur. Morph. 3 iss ; Tr. Catechu 3 vj ; Mist. CreUe § v. M. A table-spoonful to be taken every four hours. Habeat Enema Amyli cum Tr. Opii min. xl. H Lactis recentis § x; Aq. Colds § viij. M. To be used as drink. July Mh. — Has now only six stools in the twenty-four hours. Complains of dysuria, and has only passed nineteen ounces of urine daily for three days. Pp. Hither. Nit. 3 ss ; Pot. Acet. 3 ij ; Pyr. Aurant. 3 j ; Aquee 3 ivss, M. A table-spoonful to be taken three times a day. July 1th. — Has now only three or four stools daily, which are fmculent. No dysuria. Urine more copious. Considerable uneasiness in the epigastric region. Omit. 3Iist. diuretica. Applicet. Emp. Lyttce (3 x 4) epiyastrio. Habeat Enema Opiatum ves- pere. July 2oth. — Since last report has had about three stools on an average daily. He feels much stronger. Aug. Is^. — Has had occasional exacerbations of fever, with thirst, accompanied by increased looseness, which have been checked by the Pil. Plumb. Opiat. From this date he continued slowly gaining strength, taking occa- sional exercise, but subject now and then to relapses, for which he was ordered tannin with opium, and occasional suppositories. Gradually the pus disappeared from the stools, which became more faeculent and regular. He was dismissed quite well, September 20th. Case LXXXV.j — Chronic Dysentery — Ascites and (Edema of the Legs — Leucocythemia — Cirrhosis of the Liver — Cancer of the Lung. History. — T homas Crease, sot. 28, single — admitted May 2 Yth, 1857. Has been of intemperate habits. Sinee November 1856, has been troubled with violent cough — sputum being tinged with blood ; voice hoarse ; feet and legs more or less swollen. * Reported by Mr. J. D. Maclaren, Clinical Clerk, f Reported by Messrs. John Lowe and Stewart Lockie, Clinical Clerks. 528 DISEASES OF THE DIGESTIVE SYSTEM. hot and tender, especially around the ankles. This attack dated from a definite day which he could not name in November 1856, after exposure to cold while crossing at Queensferry. He was under treatment in the Infirmary from March 6th to April 28th, 1857 ; there were present during that time cough, with bloody or rusty sputum, which, however, occasionally became frothy and mucous; a doughy and oedematous condition of the feet, and latterly of the hands ; an unusual temperature of skin, and a pulse more or less thrilling and hard. There was no diarihoea. After leaving hospital he was for four weeks under quack treatment ; getting steaks, ale, and bi’andy almost ad libitum. No relief was obtained ; the heat of skin, thirst, and exhaustion continued, and the bowels became loose. The cough became less trouble- some, and the expectoration scanty. Symptoms on Admission. — Percussion note is rather fiat on the right side of thorax anteriorly, and over the upper half on same side posteriorly. The respiratory murmurs are very feeble. When audible they are harsh ; no sibilus nor moist rale ; vocal resonance increased under right clavicle ; no dyspna a ; no cough nor sputum to-day. Cardiac impulse weak; the transverse dulness is noimal; the sounds are normal. The pulse 126, rather full and hard. The tongue is covered with fur; thirst great, appetite bad. Abdomen on palpitation is natural ; no dulness on per- cussion, nor tenderness on pressure. The bowels are reported loose, but patient does not complain of their frequency. Urine is quite natuial. The skin over the body generally is of an unusually high temperature and dry. No lesion of the neivous system ; is exhausted, and is mentally despondent. As ordered vine ( § iij) and mime diaphoretics. Progress op the Case. — May 81st. — Sputum rather frothy, semi-transparent gelatinous, slightly tinged with blood; pulse 114; febrile condition the same; the diarrhoea has not ceased. Jeme 8d. — Diarrhoea continues ; faeces of a light yellow color and pea-soup consistence, of an extremely faeculcnt odor, presenting on n icro- scopic examination no blood discs nor other abnormial bodies. Ordered an astringent and chalk mixture. June '1th . — Febrile s}miptcms continue; ordered 8 grains of ejuir nine thrice daily. The diarrhoea slightly abated ; continue the astringent mixture. June nth. — Diarrhoea continues with much tenesmus; frequent calls (from 6 to 8 times) at night to stool ; evacuations at each time are scanty ; stools watery, let him have an opiate suppository at night.^ and after every stool let the follcuing enema he administered : — Plumb. Acetat. Dj ; Aep Distill. § iss ; Sol. Mur. Morph. 3 ss. June IMh. — Patient expresses himself as better, and the febrile excitement is dimi- nished. June lAth. — The diarrhoea has not ceased ; the injections cause pain, and are speedily ejected ; they are now discontinued ; orelered half ounce of the decoction of the Inelian Bad thrice daily. June Pith. — In addition to the decoction., let him have, thrice daily, one of the following powders : — D P^dv. Cretce prep. 3 ij ; Confect. Arcmat Vj ; Pedv. opii gr. iij. M. et divide in chartulas duodccirn. July ‘id. — Febrile symptoms and diarrhoea much diminished ; skin cooler; pulse 86, of miOderate strength ; oedema of the lees is much less than formerly. On the 4:th, he becomes worse; on the hth, feels better ; on the 8th, diarrhoea again more severe, and febrile symptom,s renewed. On the ^th, the blood was microscopically examined, and an increase of white cor- puscles was detected (from 20 to 25 being visible in one field), and the red discs ar- ranged themselves in irregular masses. On the ll^A, the powders and decoction are discontinued, and a mixture of Kino, Catechu, and Simaruba was given. On the lo.Ai, the diarrhoea being persistent, the use of the powders is resumed, and at night an astringent injection. On the 15^/i and 17/A, is better; on the 20/7i, is worse and seldom off the stool; on the 21.s7, is better, having had only three stools; on the 24^A, has six stools, skin being burning hot, pulse 120, hard, and appaiently strong, but patient complains of great debility. July i^th. — Great thirst ; pain over abdo- men, which is relieved by a turpentine epithera. Abdomen is tense, with skin white, glistening, and dry ; percussion very tympanitic anteriorly ; is slightly dull over the flanks. July i8th. — Patient is extremely weak ; faeces are passed in bed. Urine is examined and found non-albuminous ; has been delirious this moining. July 29//n — No return of the delirium; swelling of abdomen increased; the diairhaa and febrile state continue; pulse 112, very weak; great thirst. July 8Qih. — Died this morning at 9.30 a.m. Sectio Cadaveris. — Forty -eight hours after death. Body. — Moderately emaciated ; oedema of feet and legs ; face with a peculiar fever- ish expression. Thorax. — Heart was quite natural. The two upper lobes of right lung healthy ; DISEASES OF THE INTESTIXES. 529 the lower lobe felt heavy, presenting a rounded prominence about three inches in dia- meter projecting from its surface. On section it was found to be a mass of soft cancer, of an oval form, about the size of a fist ; greyish or pinkish-white in color, with some opaque yellow patches (reticulum) intermixed with it. It readily broke down under pressure, and part had already undergone softening. In its neighbor- hood were two other masses of similar character, about the size of small marbles. In the lower lobe of the left lung there was a cancerous mass of the size of a filbert ; otherwise the lung was healthy. The bronchial glands were natural. Abdomen. — The peritoneum contained nearly a gallon of a somewhat opalescent serum. The liver was of small size, and presented a coarsely granular surface. On section it was found in a moderately advanced state of cirrhosis ; it weighed 2 lbs. 8 oz. The spleen was quite natural, and weighed 6 ounces. Kidneys healthy. Stomach normal. The coats of the small intestines were generally thickened and oedematous, but there was no trace of ulceration. The mucous membrane of the large intestines was found extensively ulcerated, chiefly in the transverse and descending colon. There were a few ulcerations in the caecum and upper part of the rectum ; they ceased alto- gether about 3 inches above the anus. The calibre of the intestine was diminished. The ulcerations were of a very chronic character, there being no increased vascularity of the surrounding mucous membrane. They were generally arranged in a linear direetion, parallel to the long axis of the gut. Many were nearly cicatrized, present- ing in the base and margin an aecumulation of dark-colored pigment. There were pretty numerous slate-colored cicatrices, indicating the position of former ulcers. No other lesion was found. Microscopic Examination. — The cancerous exudation in the lungs contained numerous cancer cells in all stages of development. Some of them were very large, and contained from three to five secondary cells. Several of them contained clear collections of fluid, as represented Fig. 294. Commentary . — The three cases now related present the same disease in different degrees of severity. In the first, there is every reason to suppose that, though severe, it was not extensive. In the second, it was more chronic, but ultimately the patient got well. In the third, it went on to such extensive ulceration, kept up such constant irritative fever, and so interfered with nutrition, as, conjoined with the other lesions under which the man labored, to cause death ; on dissection afterwards it was seen that he had had chronic disease of the liver, which had caused ascites and oedema of the extremities. On this had supervened the in- fiamination of the lower bowel, especially of the colon, which had pro- ceeded to ulceration, extending over a considerable portion of the mucous membrane. In many places the ulcers had healed, while in others there was exhibited a tendency to cicatrization ; and it is very possible that a recovery might have occurred in this case, as in the one which pre- ceded it, but for the hepatic disease, which, by keeping up constant congestion of the portal system, and therefore of the intestinal venous capillaries, must have opposed itself to all successful efforts at cure of the ulcers. The masses of cancer developed in the lower portion of the hings, and which gave rise to many of the symptoms of pneumonia, especially cough and bloody expectoration, cannot be said to have had any influence in producing the fatal termination. In the case of Crease I employed, as an astringent, a decoction of the unripe fruit of the Indian Bael, commonly called the Bengal Quince. It is said to contain tannin, both free and in a combined state, an aromatic principle, mucilage, and a small amount of a bitter substance supposed to be sedative. The decoction must be used fresh, and is prepared by sim- mering two ounces of the unripe fruit in a pint of water down to a fourth, of which from one to three table-spoonfuls constitute a dose. In the case of a gentleman under my care, whose obstinate diarrhoea had 34 530 DISEASES OF THE DIGESTIVE SYSTEM. resisted all the usual means, this decoction checked the disorder perman- ently after a few doses; and I have since given it wdth great advantage in similar cases. In the case of Crease it was of no benefit whatever. Indeed it cannot be supposed that where actual ulcerations exist over a considerable portion of the mucous surface of the colon, any remedies can produce an impression on the alvine discharges. These are the result of the organic lesion, so that medicines merely directed to the symptoms, unless they favor cicatrization, cannot operate with effect. This requires time, general health of body, avoidance of irritating food and mental excitement, quietude, a good atmosphere, pure water, etc. etc. — in short, local agents must be combined with all those general remedies and hygienic conditions calculated to improve the vital powers, and favor regeneration of tissue. Diarrhoea and dysentery pass into one another; a great variety of lesions may induce the first, but the last is considered to be a true in- flammation of the large intestines. Hence the symptoms of dysentery are local pain, accompanied by fever, and attended with a discharge from the bowels, first of blood and then of pus. The blood results from rup- ture of the capillaries consequent upon their congestion, and is mingled with the mucous discharge. Fluid exudation is at first poured out on the surface and passes away from the bowels with the excess of mucus and blood, but subsequently purulent matter is thrown off from the ulcerated surface of the mucous membrane. The character of the faecal evacuations should be carefully attended to, not only in dysentery, but in all forms of intestinal disease. In health the faecal evacuation consists of a soft solid mass, forming a mould of the outlet at the anus. It is mingled with bile, and presents a dark brown color. Its odor, though faecal, is not putrid. As a general rule, the more the alvine evacuation departs from its normal consistence, color, and odor, the more violent is the cause which occasions the change. Thus, as regards consistence, the dischai'ge from the bowels may be fluid, though faeculent, sometimes resembling pea-soup, the characteristic stools of active typhus. The discharge, again, may be watery through an excessive amount of serum, resulting from congestion of the vessels, or occasioned by saline and drastic cathartics. In cholera the discharge resembles rice-water, and is largely mingled with pure desquamated epithelium. It may consist of shreds of glairy mucus, which is very common in females with uterine disease, and sometimes of masses of recently coagulated exudation, or a substance like white of egg. In color it may be paler than natural, to such a degree as to be clay-colored or almost white, indicating a diminished quantity of bile. It may be red, reddish-brown, grass-green, or absolutely black, from the presence of blood, and according as blood has been poured into the in- testine more or less near its outlet, or as chemical changes have occurred in it before being discharged. In other cases it may be of a dark leaden hue, or of a dirty yellow more or less resembling pus. If pus and blood appear in the stools almost pure, then these fluids have been poured out not far from the orifice ; the more they are mingled with faeculent or fluid matter the more is their origin distant. Constant fluid stools of a uniform color arc generally derived from the small intestines. As to DISEASES OF THE INTESTINES. 531 odoi’j the more offensive and putrid, the greater is the indication of absence of bile in some cases, and prostration of the vital powers in others. In the examination of the feces the microscope will be found of the greatest service. (See p. 90.) The morbid anatomy of dysentery and of enteritis generally is a most extensive subject, for vdiich I must refer you to the various special works which treat of it. It will suffice to say that the seat of the exudation is for the most part the areolar texture below the basement membrane, but pressing principally on the mucous surface, and giving rise to hemor- rhages, ulcerations, purulent discharges, etc. If the disease be chronic, the muscular coat becomes hypertrophied, causing thickening and rigidity of the intestinal tube. If violent gangrene occur, the mucous surface after death presents a deep red color, which is caused by congestion of the vessels; sometimes bright green patches are mingled with the red, and result from alteration in the color of extravasated blood; then again, brown or blackish sloughs may be observed from decomposition of the injured texture. Typhoid enteritis will be subsequently described (See Fever.) Tubercular enteritis is a common complication of phthisis, generally hurrying on the fatal result. Cancerous enteritis is by no means uncommon. The structural changes observed in the mucous membrane in cases of diarrhoea and dysentery are — 1st, Degeneration of the epithelium ; 2d, Congestion of the vessels and hemorrhage; 3;i, Exudation; 4th, Mor- bid changes in the various glauds; 5th, Waxy degeneration. 1. The readiness with which the epithelium is separated from the basement membrane of the intestinal mucqus membrane varies much in different animals. For instance, I have found it to be easily separable in dogs, while in cats it is very firmly adherent. This circumstance ex- plains, to a certain extent, the different ideas put forth by experimental- ists as to the function of the epithelium in digestion. Some maintain that it is cast off so as to admit of endosmose through the naked villus ; whilst others maintain that endosmose is carried on through the agency of the epithelial cells themselves in which I believe to be the cor- rect doctrine. In man the epithelial cells are easily separated, and their separation consti- tutes a morbid state of great importance, be- cause if, as I suppose, they be the organs of primary assimilation, their removal must interfere with nutri- tion. This I consider to be one of the reasons why chronic diarrhoeas, and more especially Fig. 430. Vascular congestion and sugillation of the mucous membrane of the small intestine in cholera, a and 6, Congested tortuous vessels in villi, which are deprived of epithelium ; c. The veins only congested in four villi ; d. — • Vomiting more frequent: is much troubled with flatulence; tongue pale, smooth, and glossy ; bowels regular. Dec 25th. — Tr. lodinei to be painted over the abdomen. Dec. 2^th. — The iodine caused her great pain, which was, however, relieved by warm fomentations. The swelling of tlie abdomen and tympanitis, the cough, and the ex- pectoration, have increased ; breathing slightly laborious. ^ Sp. uEth. Sulph. 3 iij ; Sol. Mur. Morph 3 j ; Mist. Scillce ^ iiss. To be taken-in half ounce doses when the cough is troublesome. Dec. 80th. — Abdomen measures 34 inches in circumference. Bowels regular ; percussion normal over chest ; mucous and sibilant rales heard on auscultation. Coughs much ; expectoration abundant, purulent, and tenacious ; pulse small and weak ; legs and feet very oedematous ; ui ine as before. Jan. 2c?. — Jaun- diced tint of skin is growing deeper ; distension of abdomen from tympanitis increased ; pulse rapid and thready; vomits all her food immediately after taking it, together with a quantity of black matter ; thirst .great ; stools pale-colored but consistent. I'o omit the Squill and Digitalis Pill., and to take Potass. Bitart. Dj ter indies. Jan. Ath. — Jaundice increases; urine very small in quantity, and contains bile. Swelling of ab- domen augmented ; great protrusion of lower ribs, but breathing is not much affected. Vomiting continues. There isoedema of feet, legs, and hands ; she is getting decidedly weaker. Pulse 96, steady and weak. Jan. 5th. — Died this morning at 2 a.m. Sectio Cadaveris. — Fifty-eight hours after death. The body emaciated ; the surface of a moderately yellow tinge ; abdomen much distended and fluctuating. Thorax. — The pericardiuxn 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 mas.^es, some immediately under the pleura, others embedded in the pulmonary tissue ; the masses visible externally had a cir- cumference equal to about that of a fourpenny piece ; their margins were slightly prominent, while they were depressed or flattened in the centre; they appeared of a greyish-white color, and felt firm and hard ; on cutting into the lung, pretty nume- i-ous masses similar in size could be seen scattered through it ; they were generally of a white or greyish-white color, while some were yellowish, as if stained by biliary matter ; most of these masses felt tolerably firm, but yielded on pressure a small PERlTOXmS. 553 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 the 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 tumors 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 color, mottled by the presence 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 color, 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, the substance of the liver w.as 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 color; some parts of it, however, were opaque, while intervening portions were clear and semi-trans- parent ; other parts, again, were intermediate between these conditions ; the matter was generally tolerably firm, but ,the more opaque parts had a tendency to crumble down. The hepatic tissue itself was of a yellowish color, and moderately firm. The weight of the entire liver was 7 lbs. ; behind the liver a mass of enlarged glands surrounded and compressed the vena cava, the gall-bladder, and common duct ; the vena cava was somewhat diminished in size : the gall-bladder was much con- tracted, 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 2i- 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 tungating excrescences of a greyish-white color. The margins of the ulcer were elevated above the surrounding mucous membrane, but were irregular looking as if they had been gnawed by some animal. There was no perforation. The stomach and the duodenum otherwise healthy. Some of the gastric lymphatic glands, particularly some of those connected with the lesser curvature, were enlarged and cancerous. The spleen was natural. The kidneys, when cut into, were of a yellowish color : their surface was a little irregular, apparently resulting from old cysts ; a few cysts were seen in the surface, and also in the cortical portion ; several of the lumbar glands, lower down than the mass found behind the liver, were enlarged and similarly affected. The uterus and ovaries were healthy. Microscopic Examination. — On examining a little of the juice squeezed out of any of the masses above described, tolerably large nucleated cells were found. Many of them presented the usual appearance of cancer-cells ; others, however, were small, and many nuclei were seen free. In the opaque portions, the cells were less distinct, and there was a large quantity of fatty matter. The cells of the liver con- tained a good deal of biliary matter, but they were otherwise quite healthy. The kidneys, when examined microscopically, also appeared healthy. Commentary. — This subject of cancer of the lungs, liver, stomach, and other organs, when she entered the clinical ward, presented all the symptoms of acute peritonitis, including great tenderness, with disten- sion of the abdomen, fever, and increase of urates in the urine. There was, however, no evidence, on palpation, of the nodular swellings found after death j these were masked by the accumulation of fluid and tym- 554 DISEASES OF THE DIGESTIVE SYSTEM. panitis. Neither did physical signs indicate the cancerous deposition in the lung, it being so diffused as not to occasion any marked abnormal respiratory symptoms; such as did exist were explicable by the abdo- minal disease. The facts presented in the three last cases indicate the uncertainty of our diagnosis in abdominal diseases. In the first, it 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 exudation ; while the third case presented all of them in a marked and characteristic degree, in connection with cancer of the abdominal organs, and elfusion 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 peri- toneal membrane was covered with lymph, the present one, where it was healthy, exhibits a remarkable discordance with systematic descriptions of disease. The true exudation had not one of the so-called symptoms of that lesion, whereas, in the last case, there was every symptom, with a perfectly sound peritoneum, I have recorded therefore this case at groat 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 peritonitis, see Gases LXVll. and LXXXVII. Case XCVl.^' — Cancerous Peritonitis — Ascites and Hydrothorax — Paracentesis Abdominis — Arrested Phthisis Pulmonalis. Historv. — Margaret Pardon, aet. 63, a widow, has had two children — admitted December 15th, 1856. Three years ago she had profuse hsematemesis, accom- panied by loss of blood per anum, which caused faintness. In a few days, however, she quite recovered, and remained perfectly well until three months ago, when she first observed that the lower part of the abdomen was swollen, but not painful. About a fortnight afterwards she experienced severe pain in the left lumbar region, together with a sensation as of cold water trickling down her left thigh as far as the knee. Two months after the first symptoms had shewn themselves, the abdo- men had become gradually much distended, and she experienced a “ dead pain ” in the epigastric region, which, she says, was constant, but not aggravated by pres- sure, and caused great shortness of breath. Simultaneously with this epigastric pain a scantiness and turbidity of the urine appeared, and a day or two subsequently 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 purgative action of which has been followed by considerable alleviation of her symptoms, and diminu- tion in the size of the abdomen, and of the dropsical swelling of the inferior extremities. Symptoms on Admission. — The abdomen ts so distended as to measure at the epigastrium 20^, and at the umbilicus 35 inches round. It fluctuates on palpation, but there is no pain on pressure. In every position the lower portion of the abdo- men is dull, and the upper tympanitic on percussion. No tumor can be detected, * Keported by Mr. Alexr. M‘Leod Pemberton, Clinical Clerk. PERITONITIS. 555 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 open naturally every other day. No flatulence. There is considerable dyspnoea , a slight cough, but no sputum. Percussion is resonant over the whole chest. At the ape.v 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 oedematous, the right one most so. Does not sleep well on account of the dyspnoea. Urine sp. gr. 1012 ; con- tains phosphates in solution, but no albumen. Progress op the Case. — January 5th. — Since coming into the house she has had an occasional dose of castor oil, and her symptoms have on the whole been much alleviated. There is, however, great orthopnoea at night, and she says it is easier to lie on the left side. A careful examination to-day has determined that there is great dulness on percussion over the lower half of right lung, and that the respira- tory murmurs there are audible. The abdomen now measures at the epigastriu'n 3l|, and at the umbilicus 37 inches. Pulse 92, feeble. Passes urine, loaded with phosphates, freely. To have extra nutrients.^ and four oimces of wine daily. Jan- uary 12th. — 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 o-f the sp. gr. 1012, and formed a solid, gela- tinous mass on the addition of heat. On standing it became slightly turbid, but exhibited nothing but a few scattered blood corpuscles under the microscope. The operation was followed by a tendency to syncope, which was removed by the free use of port wine and brandy. Jan. 13^/i. — Feels greatly relieved by the operation. Several nodulated swellings can now be felt under the flaccid abdominal integuments, especially on the left side. Ja7i. lUh. — Though greatly relieved, complains of great weakness. Jan. \5th. — Though liberally supplied with stimulants, died this morning at half-past two, apparently from exhaustion. Sectio Cadaveris. — Thirty-five hours after death. External Appearances. — Great emaciation. Abdomen flaccid, she having been tapped a short time before her death, and 190 ounces of serum removed. Thorax. — The external surface of the pericardium contained a number of can- cerous nodules, varying in size from a pepper-corn to that of a small bean, of a white and pinkish-white color. 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 Iburth was spongy, but most of the three inferior fourths were carnified, and contained little 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 color, 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 similar 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 pleurae at the apex were adherent and thickened. On section this was found to correspond to an old tubercular cavity of the size of a small filbert, also surrounded by dense tissue loaded with pigment. The substance of the lung was otherwise healthy, and the pleurm generally presented only a few small cancerous masses scattered over them, similar to those on the opposite side. The bronchial and mediastinal glands were healthy. Abdomen. — There were two or three pints of clear fluid in the abdominal cavity. The whole of the peritoneum (parietad and visceral) was studded over with cancerous masses. Tiie 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 points. The transverse colon was dragged up towards the stomach, and much compressed by this mass. All the adjoining veins were greatly congested. The peritoneum covering the lower surface of the diaphragm 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. Over the o‘her parts of the peritoneum, nodules and small 556 DISEASES OF THE DIGESTIVE SYSTEM. patches of cancerous matter were scattered about. The whole of the mesentery waa studded with little masses from the size of a grain of sand to that of a pepper-corn. Similar masses were found in the serous coat of the small intestines. The meso-colon and meso-rectum were thickened and covered with cancerous masses. The uterus, urinary bladder, and ovaries were matted together by cancerous exudation. None of the abdominal viscera or glands were involved in the cancerous disease, which was exclusively confiupd to the serous membrane. Microscopic Examination. — The different 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 ; in others, debris and fatty degeneration, forming yellow masses of the reticulum. Commentary . — The in.sidions approach and development of so large an amount of cancerous exudation on the peritoneum is worthy of ob- servation. It is very possible that the disease existed three years previous 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 supervened, in conse'|uenee or the pressure of the indurated cancerous masses on the abdominal veins inducing effusion. At no time was there any general fever, pain, or tenderness on pressure. In this respect the case strongly contrasts with the last. Here, with extensive disease of the peritoneum, there were no symptoms of peritonitis; there, with the peritoneum per- fectly healthy, violent symptoms of peritonitis were manifested. Indeed, the only symptoms occasioned, were those resulting from pressure on the lungs by the accumulation of serum in the peritoneal and right pleural 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 experienced, she rapidly sunk. Indeed, it seldom happens when, in ascites resulting from organic disease, this operation is had recourse to, that death is long delayed — a remark- able proof of the fallacy of that system which is based on the treatment of symptoms. (See p. 517.) In a case very similar to the above, occurring in a young man, aet. 20, admitted under my care during the winter 1858, there was the same universal cancerous peritonitis, and the same distension of the abdomen from fluid, without local tenderness. Instead of “nutmeg liver” — that is, incipient cirrhosis — however, the organ presented the disease in a more advanced condition. Difficulty of breathing, noth withstanding, was never so urgent, the pleurae being healthy, and three weeks before death, the abdominal tension spontaneously disappeared, so as to enable me to feel the nodulated omentum through the abdominal walls, and thus determine the nature of the case. He was a groom, and the first symp- tom of the disease appeared in the form of varicose veins in the lower extremities. These on admission were enormously swollen and tortuous, especially in the popliteal and inguinal regions, where they formed tumors the size of pigeons’ eggs. After death the swellings were found to consist of distended veins filled with firmly clotted blood of a red brick color. The cause of the varicosities in the extremities was the pressure occasioned by the tight and thickened omentum over the ex- ternal iliac veins, just before they passed under Poupart’s ligament. It results that the cancer must have existed in the abdomen when he was actively pursuing his employment, for the varicosities appeared a year before his admission. In both cases the ascites may have been mainly owing to the hepatic disease. (See also Case LXXXVI.) SECTION VI. DISEASES OP THE CIIICDLATORY SYSTEM. Before proceeding to narrate and comment on lesions of the heart and large vessels, allow me to remind you of some of the rules which the laborious researches of many able men have established for }'our guid- ance in the diagnosis of cardiac diseases. They are as follows : 1. In health, the cardiac dulness, on percussion, measures, imme- diately 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 lit- tle to the inside of the left nipple. Any variations that may exist in the position of the apex are indications of disease either of the heart itself or of the parts around it. 3. A friction murmur, synchronous with the heart’s movements, indicates 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 insufficiency. 6. A murmur with the second sound, loudest at the apex, is very rare, but when present it indicates — 1st, Aortic disease, the murmur being propagated downwards to the apex; or, 2d, Roughened auricular surface of the mitral valves; or, 3d, Mitral obstruction, which is almost always associated with insufficiency, when the murmur is double, or oc- cupies the period of both cardiac sounds. 7. A murmur with the first sound, loudest at the base, and propa- gated 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 diseases 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 me tliat 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. Hypertrophy of the heart may exist independently of valvular disease, but this is very rare. In the vast majority of cases it is the left ventricle which is affected, and in connection with mitral or aortic 558 DISEASES OF THE CIRCULATOEY SASTEM. disease. 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, eii- ahle 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 assis- tance from an observation of the concomitant symptoms such as-^lst. The nature of the pulse at the wrist; 2d, The nature of the pulmonary or cerebral derangements. Thus, as a general rule, but one on which you must not place too much confidence, the pulse is soft or irregular in mitral disease, but hard, jerking, or regular in aortic disease. Again, it has been observed that cerebral symptoms are more common and urgent in aortic disease, and pulmonary symptoms more common and urgent in mitral disease. I have purposely said nothing now of diseases of the right side of the heart, and of a few other rare disordered conditions of the organ, because I am convinced that an appreciation of the rules above given is the best method of enabling you to comprehend and easily detect any exceptional case which may arise. In truth, however, I have remarked in our examinations at the bedside that your difiiculty is, not how to arrive at correct conclusions from such and such data, but how to arrive at til'’ data themselves. You have to determine — 1st, by percussion, whether the heart be of its normal size or not; 2d, Whether an abnor- mal murmur does or does not exist; 3d, If it be pre.sent, 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, and must ever essentially depend upon the existing knowledge of physiology and pathology. But no instruction on my part, no reading or reflection on yours, will enable you to ascertain these facts for yourselves. In short, nothing but percussing the cardiac region with your own hands, and carefully listening to the sounds with your own ears, can be of the slightest service, and the sooner you feel convinced of this truth the sooner are you likely to overcome these preliminary difficulties. 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, re- flect on the probable correctness of the diagnosis formed at the bedside, watch the various complications and the elfects of treatment, and finally, obser'/e how, in the fatal cases, by following the rules given, the ac- curacy of the diagnosis has or has not been confirmed by post-mortem examination. After you have made yourselves familiar with the ordinary forms of heart disease, you will find that occasionally ver}’' 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 ph}^sical diagnosis throughout Europe, with a view if possible of determining the characters which distinguish disease of the right from disease of the left side of the heart ; those indicative of lesion of the pulmonary artery, of chronic forms of peri- carditis, of open foramen ovale, of clots in the ventricles or auricles, PERICARDITIS. 559 etc. etc. Well observed cases of these rarer diseases, however, are still too few to enable us to generalise confidently regarding them. I have frequently examined exceptional combinations of signs with the utmost care, and then been denied a post-mortem examination, or again have stumbled on rare forms of lesions after death, in cases where during life sufficiently careful and repeated examination of the physical signs had not been made to secure accuracy. I would strongly advise you to attach little importance to the record of such exceptional cases, and never to record such yourselves, unless equal care have been shown in the examination of physical signs and functional symptoms during life, on the one hand, and in anatomical investigation after death on the other. PERICARDITIS. Case XCVII.* — Acute Pericarditis — Recovery. History. — Jane Stambroke, set. 25, servant — admitted January 7th, 1857. Six months ago she entered another ward in the Infirmary, on account of rheumatic pains in tlie 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 expex’ienced 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 prtecordia, which compelled her to desist from working, and retire to bed at an earlier hour than usual. The next day she felt somewhat easier, but on the following one the symptoms increased in intensity, and have continued up to the present time.. Yesterday evening six leeches were applied, and caused relief, which however was not permanent. Symptoms ox Admission. — Cardiac impulse is faintly felt between the fourth and fifth ribs. Dulness on percussion, at the level of nipple, extends transversely four inches from the right edge of the sternum, which is its internal boundary. On aus- cultation 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 in- audible 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 comparative dulness over the two lower thirds of left back, and there is audible over the same space increased vocal resonance and aegophony, without rales. Inspi- ratory murmur on right side is somewhat harsh, but otherwise normal ; is sleepless in consequence of cardiac uneasiness and dyspnoea, which is considerable. Has not menstruated for the last two months, but the other functions are well performed. Warm fomentations to be constantly apjMed to the prcecordial region. Progress of the Case. — January 2th . — The pains and dyspnoea have been greatly relieved by the fomentations. No friction murmur audible. The urine densely loaded with urates. Pulse 80, soft. Nutrients with wine § ij. January 10th. — 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 quarter of an inch. Physical signs of left lung the same. No crepitation. Chlorides in the urine abundant. January 11th. — No friction audible over heart, but cardiac sounds are distant. From this time she rapidly became well. On the 13th, marked dulness, increased vocal resonance, and aegophony 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 aegophony. 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 January 31st, * Reported by Mr. McLeod Pemberton, Clinical Clerk. 560 DISEASES OF THE CIRCULATORY SA^STEM. Commentary. — This was a pure case of pericarditis in a rheumatic girl, in which all the symptoms and physical signs were very carefully examined. The disease went through its natural stages with great rapidity. On the fifth day, when she was admitted, there was great distension of the pericardium from exudation, with friction sounds. Then for a day these were absent, probably from the two surfaces being separated by serum. On the seventh day, distension of the pericardium 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 XC VIII.^ — Pericarditis and Endocarditis — Hydropericardium: History. — Barney Kilpatrick, let. 25, a miner — admitted July 8th, 1850. Nine weeks ago he was suddenly seized with dyspnoea and a feeling of weight or dull pain in the cardiac region. A fortnight since this became much more acute, and has continued no to the time of admission. For five years he has been much exposed to wet and chn.nges of temperature, but never had rheumatism. Symptoms on Admission. — 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 six ribs, two inches below, and considerably to the right of the nipple. All over the dull region a double friction sound is heard, resembling a roughened bellows murmur, but superficial. Beyond the region of the dulness these murmurs suddenly cease. Action of the heart regular. Pulse 96, regular, small, 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. Treatment and Progress of the Case. — Twelve leeches were ordered to be applied to the cardiac region, and a calomel and opium pill to be taken every six hours. On the 11th, the friction murmurs were much louder at the base than at the apex. The pulse 108; feeble at left wrist; at the right wrist it had a double impulse — a pretty strong beat being followed by a weaker one. 3 vj of blood to be drawn from, the cardiac region by cupping., and a pill to be taken every four hours. On the 13th, the breath had a mercurial foetor. Pulse stronger; less dyspnoea; friction munnurs more faint; pain in arm diminished. On the 14th, pulse full; slight fever; six leeches to be applied to the cardiac region, morphia draught at night. On the 15th, friction murmurs only heard at the base; anorexia; can take no food; omit calomel and opium pills. \Uh. — Friction murmurs have disappeared, but there is a soft bellows murmur with the second sound, heard at the base. 18^A. — Had an attack of severe dyspnoea and syncope; pulse 100, regular, but feeble; § iv of wine; cardiac dulness increased. 19^A. — Orthopnoea ; pulse weak and fluttering; a quivering pulsation felt in the cardiac region ; faintness ; oedema of feet and legs. Stimulants to be freely administered. Died early in the morning of the 20th. Examination of the body was not allowed. Oommeniary. — This was a well characterised case of pericarditis. At first the endocardial murmur was masked by the friction sounds, but as these disappeared, its existence became apparent. It was observed that as the mercury affected the system, the friction murmur diminished ; but there is every reason to believe that this was not so * Reported by Mr. David Christison, Clinical Clerk. PERICARDITIS. 561 much owing to absorption of the exudation, as to increase in the amount of serous effusion. To the combined effects of pressure on the heart from liquid without, and incapability of performing its function from incompetency of the aortic valves, the fatal result must be attri- buted. Since this case occurred, upwards of fourteen years ago, I have satis- fied myself that the treatment pursued was not judicious, and that the local abstraction of blood, with administration of mercury under such circumstancCwS, is not only useless but injurious. It is true no fair com- parison 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 differently. Case XCIX.^ — Acute PericardHis followed hy Acute double Pneumonia — Recovery — Aortic Incompetence — Subsequent Articular Rheu- matism — Sudden death — Adherent Pericardium — Fatty enlaryed Heart — Thickening of Ao,ydic Valves. History. — Jessie Douglas, set. 22, employed in a paper warehouse — admitted November 19th, 1855. Has never been very healthy; has had several attacks of rheumatic fever, the last being about seven years ago. On the 9th current, after exposure to cold and damp, she was seized with rigors and pain in the back. These disappearing, were succeeded by pain and slight swelling of the knees, lasting only for a few days. During all this time, though ill, she had no headache, vomiting, nor pain in the chest, but the shortness of breath and palpitation to which she is subject became aggravated. She was under medical treatment, and got purgative medicines, but was neither bled nor leeched. Symptoms on Admission. — Apex beats distinctly between the fourth and fifth ribs, immediately under and a little to the inside of the nipple ; heart’s impulse is heaving, and sensibly moves the whole mamma ; it can be felt but very indis- tinctly in the normal position ; there is no thrill. Transverse dulness at the level of the nipple 4f inches. Heart sounJs 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 sound there is heard a soft blowing murmur. Pulse 80, full, regular, incompressible. Breathing is rather labored ; respirations are 34 per minute, but regular ; there is slight cough and no sputum. Percussion is everywhere good ; vocal resonance is greater under the left than under the right clavicle ; no rale is audible, but respiration is exaggerated under the right clavicle, and inspiration is blowing under the left. She speaks languidly, does not sleep, and on sitting up feels faint. She is thirsty, and has no appetite ; the bowels 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 art oanoe every fourth hour of the following: — Liquor. Ammon. Acetat. et Aquee aa 3 ij. Proorkss op the Case. — November 20^4. — At the apex, the cardiac sounds continue 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, labored. Ordered twelve leechen to he applied over the prmcordxa.^ and mbsequently warm fomentations. 2Lain in the region of the tumor, which was relieved by the occasional application of two leeches, foflowed by warm fomentations. Various remedies were given with a view of checking the vomiting, of which small pieces of ice allowed to dissolve in the mouth appeared most elfectual. Nourishment was frequently given in small quantities. During the months o'i August and September., the vomiting became far less frequent, although oc- casionally still distressing. All this time nutrients were constantly 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 colorless corpuscles. A series of observations also was made to determine whether fat was passed in the faeces, but they were quite healtliy, and the bowels on the whole were regular. She also slept well. During the months of Sep- tember., October., and November, she remained much in the same condition, occasionally complaining of a little more local pain in the epigastric tumor 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 s[)ecitic gravity, occasionally presenting under the microscope a few waxy casts and pus corpuscles. During March the emaciation was apparently extreme, the pnl.se 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 conjunctivitis. There was also restle.ssness at night, which was relieved by morphia draughts. Her weakness very gradually increased, and without any other symptom she expired, April 16th, 1855. Sectio Cadaveris. — Forty hours after death. Thorax. — Roth lungs had some puckerings near the apex, and contained some old tul)ercular matter. The heart was healthy. Near the lower j)art of the thoracic aorta was an aneurismal dilatation, about the size of a walnut, which projected to the left of the vertel)ial colutim, 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 cceliac axis and superior mesenteric artery, Avas an aneurism of a rounded form, about two inches in diameter, which projected forwards, and was nearly filled Avith firm layers of fibrin. Both the vessels named Avere thrust forwanl, separated to the extent of an inch, but were in themseh'es healthy. (University Museum, Prep. 2333, a.) The stomach Avas of natural size ; on its lesser curvature, about half- Avay between the cardiac and pyloric orifices, but rather nearer the latter, there Avas an ulcer of an oval form Avith depressed surface, callous margins and base, and about the size of a filbert. The edges were smooth, and dense as ligament, presenting on section a Avhite glistening appearance, and in some places Avere a quarter of an inch thick. The liver Aveighed 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 Avas waxy. The right kidney Avas very small, being inches long and 1|- inch broad. Oil section there escaped a yelloAvish Avhite fluid and some cheesy matter. The tissue of the kidney vvas quite gone, and its place supplied by the cavities, Avhich presented the usual appearance of scrofulous abscesses. This kidney weighed one ounce. The left kidney was of large size and Avaxy. The spleen was natural. Commentary . — On the admission of this woman it became a question whether the tumor in the pyloric region was an aneurism or a can- cerous ma.ss 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 tumor could be more easily handled, and its rounded form and marked impulse favored 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 620 DISEASES OF THE CIKCULATORY SYSTEM. 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 dissec- tion 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 observed. The lungs and liver exhibited well-marked examples of tuber- cular and scrofulous deposits which had been arrested in their progress. The diminution of the stomachic symptoms also was accounted for by the gradual healing and cicatrization of the gastric ulcer. It might have been supposed that the abdominal aneurism was progressing toward a spontaneous cure, as it was nearly filled with dense coagulated fibrin. The commencement of a thoracic aneurism above, however, sufficiently accounts for this, as will be explained more particularly in the commen- tary on the next case. Case CXXYI.* — Aneurism of the Superior Mesenteric Artery mid Aorta — Ohscure Aneurism of JJescendiny Thoracic Aorta — Treatment hy the method of Valsalva — Pleuritis — Caries of the Vertehree^ softening of Spinal Cord and Paraplegia — Sudden death hy Poisoning with Tincture of Aconite. History. — Henry Smith, a:t. 85, sailor — admitted Deeember 19th, 1849. States that, al)oiit twelve months ago, while r.t sea, he received a severe blow on the back from the tiller 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 after the accident, he was admitted into the Liverpool Inlirmary, where he remained for about eleven mouths. He was treated by opiates and other anodynes, and latterly also by leeching and cup- ping over the pained part of the abdomen. From this treatment he did not receive much benefit. Symptoms on Admission. — On admission, he is of a dark complexion ; appearance strong and robust. A tumor is distinctly seen pulsating 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 jiortion 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 tumor, and of a beating which 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 during the day. The pulsation of the tumor is forcible, synchronous v ith, or immediately suc- ceeding, the heart’s impulse. On auscultation, a soft bellows murmur is distinctly heard over the tumor, 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 h.alf inches. On auscultation, the sounds are normal in character; the first is heard loudest over the apex, just below the nip- ple ; 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 per- cussion than the left, both in front and behind. On auscultation the respiiatory mur- murs are normal. Appetite tolerably good. Bowels regular. L^rine natural in (pum- tity ; sp. gr. 1025, not coagulable ; presents a deposit of lithate of ammonia. Ordered a morphia draught at nieiht. Progress of the Case. — December 2dd. — Has never slept properly since his ad- mission. States that it requires a very large opiate to produce any effect upon him. Ordered to he hied to syncope.^ and his diet to be as follows : Breakfast., Bread, four * Ivcported by Messrs. II. M. Balfour, W. Clark, and A. Dewar, Clinical Clerks. AXEURISM. 621 ounces ; milk, eight ounces. Dinner^ Steak, two ounces ; bread, two ounces. Supper^ Bread, two ounces ; tea, eight ounces. 24^A. — He was bled to thirty ounces without syncope or nausea being induced. The blood drawn exhibits a distinct buffy coat, r.ulse, 88, weak and soft. Pain easier, and sleeps better at night. 2oth. — Dislikes beef for dinner, and would prefer a little rice pudding with the bread at dimier. To have one ounce of mutton and three ounces of rice pudding for dimier. Twelve leeches to he applied over the tumor. 26^/i. — Leeches bled freely, and he is now easier. Urine still presents a deposit of lithates. %^th . — Complains of constipation ; pain in abdo- men rather increased. To have Elect. Sennce 3 j daily. Ten leeches to he a 2 )plied to the region of the tumor. 31.s^. — Leeches did not bleed so well. Pain still severe. Applicet. Emplast. Cantharid. (3 x 3) parti dolenti. 1850, January 2d . — Blister gave some relief. Pulse stronger. Ordered to he hied to I xij. 3d — The blood exhibited the buffy coat, but in a less marked degree than formerly. No faintness or nausea was induced. Two ounces of bread to he taken off his breakfast and half an ounce off his supper. To he allowed a bottle of lemonade daily. *lth. — Sleeps very badly. 1^ Sol. Mur. Morph. ; Tinct. Hyoscyam. aa 3 ss ; Aquce § ss. Jd, to he taken every evening, 'dth. — Sleeps rather better. Pain in tumor somewhat increased. Eight leeches to he applied. 10th . — Leeches gave relief. 13^A. — Still complains of constipation. To have a colocynth and hyoscyamus pill dcdly. 10th. — States that for the last three or four days he has felt much stronger, and the pain and pulsation in the tumor have increased proportionally. Ten leeches to he applied. 11th. — Leeches gave relief, but still he does not sleep well. 21st . — Pulse tolerably strong. Ordered to he hied to syncope. 22d. — He wms hied yesterday to twenty-six ounces, without inducing faintness or nausea. To-day his pulse is weak and soft, and he expresses himself much easier. The blood exhibited a distinct buffy coat. Urine loaded with lithates. 2oth . — Yesterday he was ordered to be bled until some faintness was induced, and 28 oz. were abstracteil 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. 20th . — Again bled to 10 oz. Eeh. Qth. — Great pain in the tumor at night, preventing sleep, for which sedative draughts and enemas afford little relief. 20 oz. of blood were in consequence taken from the arm to-day, which pro- duced faintness, and at otic e removed the pain. — Size and impulse of tumor evidently diminished. Does not think he is much weaker since admission, but is un- able to sit up so long. Pulse small. To-day pain returned in tumor. 12 leeches to he applied. March 2d. — Bled yesterday to 14 oz., without inducing syncope. Blood not buffed. 10th.. — Pain returned with violence. Again bled to 23 oz. 10th. — Again hied to 8 oz. He has continued on the low diet, which was altered to-day as follows : — Breakfast, 1 biscuit (1-^ oz.) ; tea, half a pint. Dinner, 2 biscuits (2-^ oz.) ; eggs, 2. Su-pper, 1 biscuit (1|- oz.) ; tea, half a pint. The analysis of the blood drawn on the 10 th is as follows : — Specific gravity of serum 1028 Solids in 1000 parts : — Fibrin 4‘6 Globules 42-7 Serous solids ....... 88’2 Water .......... 864'5 Total 1000 April 0th. — Bled again to 13 oz. l^th. — Was strong enough to wntlk in the back- green, but felt exhausted after it. 21st. — Bled yesterday to 34 oz., at his urgent re- quest, insisting that he felt nothing, until he fell back in a state of syncope, from which he slowly recovered. To-day appearance anemic, pulse feeble, feels weak. May Wi. — Has been suffering from constipation, which has been relieved by colocynth and henbane pills. Pulsation in the tumor evidently diminishing. To-day, com- plains of shooting pains in the back, between the shoulders, and down 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. 11th. — 2 oz. of meat instead of the calves’-foot jelly. July 11th . — Has occasionally been walking a little in the open air, which, however, causes some pain. Apply 12 leeches. Aug. 0th . — Pain on walking, caused by hemorrhoids, for which injections of cold water have been ordered with benefit. 10th. — Pain in tumor returned. Apply 12 leechxs, which caused faintness, for which § ij of wine 622 DISEASES OF THE CIECULATORY SYSTEM. were given. SOth. — Went out of the house yesterday by permission. Od. 20fh. — Has been allowed to go out of the house once a week for exercise. To-day pain in tumor severe. Apply 8 leeches. 2bth. — The tumor 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. Wov. 20ih. — Complains of a sharp pain under the left clavicle, and six leeches were applied thei'e in consequence. 2i)th. — Pain under clavicle continues, but was removed by cupping on the 22d and to-day. Dec. 2*lth.-^Bled to 3 viij, to remove pain in tumor. 1861, February \*~dh. — Since last report, has continued to feel pain in the tumor. Again bled to 3 viij. 2{)th. — Present diet : Breakfa.d, one roll and tea ; Dinner^ part of a fowl and two potatoes ; Bupjnr., one roll and tea, wine § iv. The tumor now feels hard and solid, is the size of a pigeon’s egg. March ZOth. — Bled to § vj. Apn'il 2d. — Bled to § xij. The bleeding generally relieved the severity of the pain, but on this occasion failed to do so, and a blister was applied. May 2d. — Bled to 3 x, with relief. Z^th. — 11 leeches were applied. June l.st — No relief followed the application of leeches. To be cupped on the bad: to 3 vj. June Zth . — Pain not diminished, and he was bled to 3 xij, which caused great relief. 2Mh . — Cupped to 3 viij. 2>6th. — Bled to 5 xij. Oct. 2^th . — Bleeding has been occasionally resorted to, to relieve pain ; otherwise he has remained the same. Diet at present is : Breakfast., one roll and a pint of tea ; Dinner., one flounder and, two potatoes ; Supper, one roll and pint of tea, brandy, 3 iij. Dec. 12th . — Since last report has been comparatively easy, getting up daily, and feeling pain only for about two hours after rising in the morning. To-day, the pain having increased, 12 leeches were applied. 1852, January IDth. — Complains of weakness, so that he is obliged to use a stick in walking. Ihth . — Tumor fully the size of a walnut. Aneurismal murmur greatly diminished. Complains of numbness in left side, and pain in right leg. ^^"alking is more difficult. Bled to 3 viij. 2Zd . — Weakness in lower extremities during walking increased. On the 29th, was seized with general coldness, without distinct rigor. He had also severe pain in the left side of the chest, increased on inspiration. 30t'7i.^ — There is fre(iuent cough, and copious expectoration not tinged with blood. The left shoulder is also very painful. Skin hot, total loss of appetite, great thirst, pulse feeble, great prostration. On percussion, the Avliole of the left side of the chest is dull through- out. On auscultation, the respiration is feeble superiorly, and inaudible inferiorly. A friction noise is heard external to the nipple. No crepitation can be discovered ante- riorly or posteriorly. Mixture of ipecacuanha and morphia ordered. 31sd — Cough and pain diminished. B'eb. 2d . — Sputum slightly tinged with blood. 4,th. — Cough and expectoration diminished. Sputum consistent, free from blood. Friction still present anteriorly, aagophony posteriorly. Qth. — Beturn of pain in chest and shoulder. Fliy- sical signs the same. Blister to left side. lQ>th . — Dulness less below left clavicle, and slight motion of ribs observed there during respiration. March Isd — Friction now audible over the wliole of left side of chest posteriorly, and over apex of lung anteri- orly. I’ercussion clear over upper third of lung, but still completely dull inferiorly. Fain, cough, and febrile symptoms have now disappeared. A bedsore has formed in the sacral region, which has been poulticed, and now exhibits a disposition to slough. The abdominal aneurism has undergone no change. Decided paralysis ol motion in the inferior extremities, but their sensibility is unaffected. March Zth . — Slough has separated from sacrum. April Hth. — Since last report, parrdysis in inferior extremi- ties has become complete. He has lost all voluntary povrer over them, and when they are pinched or pricked, no sensation is produced. He experienced, however, twiteh- ings and startings in the paralysed limbs, but no pain. His evacuations are passed in bed, and the sore on the sacrum continues to discharge. In this state he continued uiitil May 31st, — the lower limbs paralysed, but, wdth the exception of increasing weakness, much the same as at last report. To-day he sw’allowmd a considerable por- tion of a liniment, containing one-fourth its volume of tincture of aconite. He rapidly became pulseless. The intelligence, for three or four minutes, was unaffected. The respiration was embarrassed, and he w'as dead in a period variously estimated at from five to seven minutes. Sectio Cadaveris . — Twentij-five hours after death. Tii.ORAX. — General firm adhesions between pleurae on the left side ; on the right side, slight adhesions betw'een pleurae at the apex. The pericardium contained three and a half ounces of straw-colored serum ; the blood everywhere fluid ; heart ANEURISM. 623 healthy ; right lung mostly crepitant, with considerable induration and puckering at the apex. On section, several cretaceous, encysted concretions existed in the pul- monary tissue at the apex, surrounded by considerable carbonaceous deposit. Here and there also small portions of the lungs were collapsed. The left lung somewhat cwnpressed posteriorly, but otherwise crepitant, and apparently normal. It is at- tached at the posterior part of lower lobe to a sacculated tumor, the size of a foetal head, in front of the dorsal vertebrae, evidently arising from the descending aorta. The tumor is situated more to the left than to the right side, and, on being cut into, is found to be only partially filled with recently coagulated blood. At that part of the sac which is adherent to the lungs, its wall is strengthened by the depo- sition of fibrin in laminas, the whole at its thickest part being an inch thick. The bodies of the 5th, 6th, 7th, and 8th dorsal vertebrae were to a great extent absorbed, being apparently scooped out, leaving the intervertebral cartilages prominent between them. The caries had also affected the heads of the corresponding ribs on the left side. Posteriorly the tumor had projected about an inch, presenting an oval, rounded surface, which had compressed the spinal cord for about an inch and a half of its length opposite the 8th and 9th dorsal vertebrm. On I’emoving and bisecting the cord, its medullary substance at the compressed portion was somewhat softened, an alteration much more marked for two inches both above and below where it w’as pultaceous, gradually passing into the spinal medullary matter of normal con- sistence. The softening was white throughout, with no red spots. Abdomkn. — The pancreas is stretched over an abdominal tumor, the size of a small cocoa-nut, in front of the aorta, which is movable, and tolerably resistent and firm. The stomach was healthy, and about a third full of pultaceous lumpy matter, smelling strongly of linimentum saponis. The other abdominal organs were healthy. On dissecting the tumor, it was ascertained to be an aneu- rism formed at the root of the superior mesen- teric arteiy, and partly involving the anterior w^all of the descending aorta. It was of an oval shape, with one extremity resting on the vertebne, the other lying immediately below the integuments. Its long diameter measured four, and its transverse three inches. On taking off* a thin slice on the left of the tumor, so as not to interfere with the exit of the mesenteric ai’tery, it was seen to be almost wholly occupied by concentric layers of fibrin, except where a channel, larger near the aorta, but becoming smaller at its distal extremity, allowed a free communication of blood with the efferent vessel. Fig. 447. (Uni- versity Museum, Prep. 2229). Microscopic Examination. — Portions of the spinal cord when examined under the mi- croscope, with a power of 250 diameters linear, were everywhere ascertained to consist of broken up medullary tubes. Many of the varicosities had enlarged and separated, forming round, oval, and variously-shaped transparent corpuscles, with double lines, mixed with fragments of the tubes, and numerous molecules, granules, oil globules, and broken- down ganglionic cells. Xo granular corpuscles wmre anywhere visible. Commentartj . — This case was in the Infirmary two years and a half, and during the whole of that time its progress excited unusual interest. AVehad to do with,— 1st, A thoracic aneurism; 2d, An aneurism of the Fig. 447. AHew of the thoracic and abdominal aneurisms, the carious vertebral, etc. 624 DISEASES OF THE CIKCULATORY SYSTEM. superior mesenteric artery;* 3d, The treatment of aneurism by Valsalva’s method; 4tli, Acute passing into chronic pleurisy ; 5th, Gradually in- creasing, and at length complete paraplegia; and 6th, Poisoning by aconite, and the most rapid death by that drug on record. I shall notice the principal facts of his case in succession, point out the difficulties of the diagnosis, the effects of the treatment employed, and state what oc- curs to me with regard to the mode of his death. The Thoracic Aneurism , — The thoracic aneurism in Smith’s case was not suspected durir.g 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 abdomi- nal 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 that it would have been confirmed, although now, on looking back, the importance of the facts above stated are apparent, and 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 Infirmary, I find it stated that, on the 6th of April, when under the care of Dr. Christison, he “ com- plained of shooting 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 occasions 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, were ascribed to pleurisy with a large amount of exudation, and on carefully weighing these symptoms 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 friction during life, and by the dense chronic adhesions found after death, although now we can have little doubt that the dul- ness, increased vocal resonance, and other signs, were for the most part dependent on the aneurismal tumor. Another symptom usually pre- sent in thoracic aneurism was absent, viz., hsemoptysis, or bloody sputum. On one occasion only was this observed, viz., on February 2d, four days after the pleurisy was established. I remember that it induced me to examine his chest with the utmost care, with a view of discovering if pneumonia also existed ; but as stated in the report, no crepitation could * 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; l)v Dr. Eiiiotson, in Lancet, August 29, 1835 ; by Dr. Arthur Wilson, Medico-Chir. Transactions, vol. xxiv. ; by Mr. James Douglas, in Medical Gazette, February 25, 1842; by Dr. W. Gairdner, in Monthly Journal of Med. Science, January 1850; by Dr. John Ogle, in Trans, of Fatholog. Soc., vol. viii. ; and by Dr. Haldane, in Edinb. Med. Journal, October 1858. ANEURISM. 625 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 laboring under chronic pleurisy on one side, who presented all the thoracic symptoms and signs which existed in Smith. It appears, tliere- fore, that the detection of the aneurism was almost impossible ; for, supposing even that it had been suspected, and that attention had been directed to confirm such a theory, I am not aware of- any arguments by which it could be supported. An idea, however, that it would be im- possible at any time to discover such an aneurism, would be erroneous, and would do discredit to physical diagnosis ; 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 tumor existed in the chest, and if so, that tumor, from its seat and concomitant circumstances, would have been declared to be aneurism low down in the thorax. It was simply because no suspicion of its existence occurred to us, and because no physical examination of the chest was made at that time, that the tumor was not detected during life. The Abdominal Aneurism. — When Smith entered the house the 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 tumor, 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 inteofuments about the size of a small hen’s eo-s: ; — in some of the re- ports, it is said of a pigeon’s egg, and of a walnut. Yet, as you see, it is the size of a large orange, elongated. Its form is a long oval, one extremity of its long axis resting deep upon the vertebrae, the other directed toward the skin. Hence, during life, we could only feel one of its rounded ends. You observe, however, that the whole tumor is dense and resistent, — and on section it presents numerous concentric laminae 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 tumor on the duo- denum and biliary ducts. The Paraplegia and Spinal Softening. — He first complained of weakness in the lower extremities early in January 1852; at the end of that month my period of attendance on the wards ceased. In the leport 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 sti- 40 626 DISEASES OF THE CIRCULATORY SYSTEM. muli applied to them failed to induce sensation. Involuntary move- ments, however, occurred, consisting of twitchings and startings, but he never had pain in the limbs. In cases of myelitis the usual symptoms are, pricking and tingling 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 gufl&ciently attended to in pathology. (See p. 358.) You will observe that the aneurismal tumor commenced pressing on the left side, and from before backwards, and the symptoms indicate that weakness was felt in the left inferior extremity before the right one was affected, — and that motion was paralysed first, sensation last. Treatment hy Vahalva''s Method . — A short time previous to the admission of Smith, I treated another case of abdominal aneurism by the method of Valsalva, for a period of forty days, — at the expiration of which time, he walked out of the house, with little assistance, to the nearest cab-stand, a distance of nearl}* 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 was even more diminished ; and yet, after nearly a month’s treatment, the pulse was of such good strength, that I ordered venesection to syywope — an effect that was not produced after the loss of twenty-six ounces of blood — so that the clerk, afraid to proceed further, bound up the arm. Three days afterwards, twenty- eight ounces of blood were removed, with the effect of only producing a feeling of faintness. Similar bleedings were practised at no distant inter- vals, 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 suppose, therefore, that in this case, as in the preceding one, the treatment had not been carried out to its full extent. The nurse, indeed, now informs me, that perhaps during the first two months his diet was really limited ; but she thinks so, simply because at that period he suffered great pain, and seemed very anxious to follow the advice given to him. Subsequently, there is every reason to suppose that he obtained food from his companions, or from some other source. I find from the reports, indeed, that whilst his diet was still nominally at a very reduced amount up to July, he was at the same time walking about with considerable vigor. From my attempts at carrying out Valsalva’s treatment in these two cases, I con- clude that it is impossible to practise it on patients in an open ward, or indeed under any circumstances, without a degree of surveillance that it would be very difficult to obtain. The good effects of the treatment, notwithstanding its imperfect nature, were so evident as to strike all who witnessed it, and to cause the patient continually to r(jquest that he might be bled. In fact, after every general bleeding, the aragging pains, and other uneasy sensations * See Monthly Journal, February 1850, p. 169. ANEURISM. 62 i fio experienced in the abdomen, invariably left him, and he enjoyed longer or shorter periods of perfect ease ; then, as the pain gradually returned, and it became unbearable, he was again relieved by bleeding ; and so on. During the progress of his case, also, it was observed that the abdominal tumor gradually diminished in size, and became harder. In October, the tumor was ascertained by Dr. Christison to be some- what movable ; but in the following December, when I examined it, it was again stationary. During the whole of 1851 he enjoyed compara- tive comfort, — occasionally, however, feeling abdominal pain, which was relieved by leeches or bleeding. At the beginning of 1852, the general opinion of all who examined him was, that, on the whole, this case was a remarkable example of the good effects of Valsalva’s treatment. Then, however, the paraplegia came on, indicating that the disease was really not conquered, but, by its pressure backwards, was affecting the spinal cord. Then came the attack of pleurisy and the paraplegia : and from this period it was evident the disease would terminate fatally. The examination of the body after death was, in this case, not only important, as determining the nature of the aneurism, and in a diagnostic point of view ; but it served, in 1113 ^ opinion, to point out what value ought to be attributed to Valsalva’s treatment. It affords an example of a wide generalisation to which the cultivators of rational medicine have been gradually tending, — viz., that not oidy 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 this man had died at the commencement of 1852 from the attack of pleurisy, and that, as so often happens, we had been refused permission to open the body, my conviction is, that under such circumstances this case would have been recorded in the annals of medicine as a successful instance of cure by the method of Valsalva. But now, when all the facts are before us, it is evident that the diminution of the abdominal swelling was owing to the increa.se 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 tumor below. In consequence, the concentric depositions of flbrin, the lessened size of the abdominal swelling, and the more permanent relief of pain, instead of being attributable to the treatment, as we had supposed, must now be more rationally ascribed, to the increase of a thoracic aneurism, not detected during life, which had produced these results mechanically, and altogether independently of art. The treatment of internal aneurisms by the method of Valsalva, has for some time been discouraged in this country, on the ground that it gives rise to a general irritability, and to .symptoms of a distressing nature, which are often intolerable ; whilst, on the other hand, it is seldom attended by a permanently good effect. In the case before us, as well as in that I formerly treated, no unpleasant symptoms could fairly be ascribed to the practice ; but, on the contrary, it produced (especially the bleedings) well-marked relief. The question of the permanency of these good effects is, I admit, in no way supported by my experience. But another important practical point, namely, the temporary relief 628 DISEASES OF THE CIRCULATOKY SYSTEM. which bleeding causes, without arresting the progress of organic malar dies, here meets with an excellent illustration. Poisoning Toy Aconite . — The facts which I have been able to make out regarding the poisoning of this man are as follows : — On Monday, May 31st, about 11 o’clock in the morning, the attention of Mr. Broad- bent (non-resident clerk) and of Dr. Murchison (resident clerk), both of whom were at the time in the ward, was directed to Smith, by a groan or cry. He was then observed to be sitting up in bed, leaning forward, and groaning like a man laboring under colic pains. Mr. Broadbent, who was nearest at the time, went to his bedside, and asked, “ What is the matter ? ” Smith made no immediate reply, but continued to groan, and moved his arms in a feeble manner, and it was noticed by Mr. B. that his hands dropped considerably when the arms were raised. He then tried to reach the spit-box, but not being able to do so, it was given to him, and he seized it, raised it to his mouth, and spat into it. He then said, with short pauses between his words, “ Is there anything wrong with my face ? — it is very painful ; what medicine have I been taking?” On being asked to point out the bottle on the shelf, he did so, saying, “ That little bottle there.” On looking at it, Mr. Broadbent saw by the label that it was a liniment, composed of Tr. Aconiti § ss ; Lin. Saponis c. Opio gjss. Dr. Murchison, on being informed what had happened, also went to Smith, found him pulseless, and on letting go his arm observed that it fell down powerless at his side. Smith then repeated more than once, “ Can nothing be done for me ? — -What can you do for me ? — Can you get me a vomit ? ” etc. An emetic of sulphate of zinc was immediately sent for, and it was further observed that the pupils had undergone no marked change, that there was no lividity of the lips or other part of the countenance, that no impulse could be felt in the cardiac region, and that the respiration was more slow and labo- rious than usual. Dr. Murchison now left the patient to get a stomach- pump, and Mr. Broadbent saw Smith retch twice, as if endeavoring voluntarily to vomit. He therefore went into the side-room to get a feather, or some object to tickle his fauces with, but was immediately summoned back by the intelligence that Smith was worse. On returning to the bedside he found that the patient had fallen on his bed, the head thrown back, face and lips remarkably pale, a little saliva running from the corner of the mouth, the respirations occurring at long intervals with gasping, the pupils neither dilated nor contracted, and the eyelids paralysed, when opened remaining fixed, and not contracting on blowing into the eye. He was now insensible, and consequently the emetic, which at this time arrived, could not be given. About a minute after. Dr. Murchison, on hurrying back with the stomach-pump, found him dead. Notwithstanding, more than a pint of semi-pultaceous matter was immediately drawn off from the stomach, smelling strongly of the lini- ment, and artificial respiration was kept up in vain for five minutes. The period that elapsed from first noticing Smith’s cry or groan until Dr. Murchison’s return, when he was dead, is differently estimated by the gentlemen concerned at five and seven minutes. The liniment con- sisted originally of Liniment. Sapon. C. Opio 3 jss ; Tr. Aconiti | ss, and it is believed that the whole of this quantity (viz. two fluid ounces), was ANEURISil. 629 in the bottle when Smith began to drink it. There were found in the bottle afterwards five drachms remaining, so that the presumption is, that he swallowed three drachms of laudanum, and upwards of two drachms of tincture of aconite. Whether Smith’s death arose from accident, or whether he com- mitted suicide, is not likely ever to be known. Those who knew him best in the ward, as well as the nurse, are of the latter opinion, based principally on the character of the man, which was such as to prevent his mistaking a liniment for a draught. It seems also, that no one was more habitually careful as to the medicines he took, — that the liniment was not ordered for him ; that he took it from a patient in a neighbor- ing ward, and kept it on his shelf for some days ; and lastly, that since the paraplegia had become complete, he had been unusually despondent and morose. With regard to the phenomena produced, it is most likely that, immediately after swallowing the poison, he experienced those violent tingling and stinging sensations in the mouth and fauces which aconite produces, and hence the pain complained of in his face. Being already paraplegic, nothing is known as to how far the poison affected the muscles of the lower extremities ; but it is evident that, whilst the intelligence remained perfect, the arms became weak, then powerless. Subsequently, he could not support himself in the sitting posture ; and, on his falling back, the muscles of the face and of respiration were paralysed, and he died asphyxiated. Previous to this, however, a powerful sedative effect had been produced on the heart, for when first noticed he was pulseless, and shortly after, no impulse could be felt in the cardiac region. According to Dr. Christison, the least variable symptoms of poison- ing by aconite in the human subject are, “ first, numbness, prickling, and impaired sensibility of the skin, impaired or annihilated vision, deafness, and vertigo — also, frothing of the mouth, constriction at the throat, false sensations of weight or enlargement in various parts of the bod}^, — great muscular feebleness and tremor, loss of voice, and labori- ous breathing, — distressing sense of sinking, and impending death, — a small, feeble, irregular, and gradually-vanishing pulse, — cold clammy sweat, and pale bloodless features, together with perfect possession of the mental faculties, and no tendency to stupor or drowsiness ; finally, sudden death at last, as from hemorrhage, and generally in a period varying from an hour and a half to eight hours.”* Although in this case many of the symptoms just mentioned were not noticed, it must be evident that the leading ones, indicative of the physiological action of the drug, were observed. When the large dose of the poison is con- sidered, and the great rapidity of its effects, it may be easily under- stood how the minor symptoms, and especially those having reference to the sensations of the patient, were not ascertained, if indeed they really existed. Dr. Fleming considers that aconite may cause death, “ first, by pro- ducing a powerful sedative impression on the nervous system ; second, by paralysing the muscles of respiration ; and third, by producing syncope.” He observes, “ that the second mode of death has never been On Poisons, fourth edition, page 871. 630 DISEASES OF THE CIRCULATOKT SYSTEM. recognised in man ; the quantity of the poison taken in no case having been suflBcient to exert such an effect on the nervous and muscular systems as is necessary to induce it.”* The case of Smith, indeed, is the only one of this description, so far as I am aware, that has ever occurred in which the dose of poison was so large, and the death so rapid. It is difficult to separate the effects of syncope from those of asphyxia in such a case, as the first condition must induce the other. Both were apparently combined. It is also difficult to determine how far the effects on respiration were occasioned by paralysis, creeping from below upwards, as in the case of Gow, formerly given (Case XL VI II., p. 459). There are some facts, however, noticed by Dr. Christison, which lend support to such a doctrine ; and it will be observed that paralysis of the hands and arms preceded that of the muscles of the back and face in the case of Smith. The general diagnosis of thoracic aneurisms has always been con- sidered a matter of great difficulty. When, indeed, a tumor with a distinct impulse is perceptible, we, in the majority of cases, know with what disease we have to do. But even here occasional errors by men of the greatest experience have sufficiently proved that the art of detect- ting these tumors with exactitude is imperfect. Again, when aneuris- mal tumors are seated at the upper part of thorax, it is important to determine whether they arise from the aorta, or from the large vessels coming from it, and if the latter, which vessel is affected. Then aneurisms originating from the upper part of the descending aorta press upon neighboring nerves, as the superior and inferior laryngeal and pharyngeal branches of the pneurno-gastric, giving rise to various symp- toms ; or they compress the larynx, trachea, bronchus, oesophagus, or the lung itself, and so occasion laryngeal, oesophageal, or pulmonary symp- toms. Lastly, when deep in the thorax, their progress is often latent. Hence the signs and symptoms of thoracic aneurisms vary — 1st, Ac- cording to their scat ; 2dly, According to the size of the tumor and its pressure upon neighboring parts ; 3dly, On the character of the aneurism, its formation, and state of the vessel. The means at our disposal for detecting these aneurisms are, — 1st, Percussion ; 2d, Auscultation ; 3d, Palpation ; 4th, Symptoms. 1. Percussion . — That the situation and size of the aorta can be accurately determined by percussion, was first proved by Piorry.f I have frequently succeeded, in favorable 'cases, in marking out on the chest the size of this vessel. To do so with accuracy, it is first necessary to limit the margins of the heart in the manner previously explained (see p. 56), and then carrying the pleximeter upwards in the course of the aorta, and over the sternum, the dulness of the vessel when com- pared with the resonance of the lung on both sides, may be made very apparent. In the same manner, the extent of saccular, or simple aneu- risms by dilatation, may frequently be determined with accuracy when seated in the ascending or transverse arch. In such cases, however, the existence of pain often renders percussion impossible, and at all times * An Inquiry into the Physiological and Medicinal Properties of the Aconitum Napellus. Edinburgh, 1845. P. 42. De i’Examen Plessimetrique de T Aorta, etc. 1840. aneueism. o31 it should be conducted with great gentleness. When an aneurism is seated in the descending thoracic aorta, its limitation is more difficult, as we have then to percuss through the lung anteriorly. But careful . manipulation, and varying the force of the blow, together with percus- sion posteriorly, will frequently enable us to determine the position and size of the swelling. If, on the other hand, the aneurism be small and deep-seated, while the lungs are healthy, and if, at the same time, no suspicion of the disease be entertained by the practitioner, he is very likely to overlook the importance of slight dulness on one side of the chest. 2. Auscultation . — There may be no sounds heard over an aneurism, and when present they may be either single or double. Considerable discussion lias taken place whether, in the latter case, the second sound originates in the tumor, or is propagated along the vessel from the heart. This is a theoretical point which is not yet decided. Whether single or double, they must be judged of according to their character and seat. With regard to their character., they maybe, — 1st, Soft and blowing; 2d, Harsh and rough (in the latter case, the vessel is generally diseased, and its lining membrane more or less atheromatous or calcareous) ; 3d, There mny be a peculiar clink, or abrupt harsh resonance, approaching towards, but never reaching, a metallic sound. It is generally heard when a saccular aneurism, free from coagula, is present, with a small opening, having thin and elastic margins. With respect to the seat of these sounds, when near the heart, they are generally synchronous with those of that organ, and their discrimination is very difficult. When situated in the arch of the aorta, there is a distinct separate source of sound. This latter can only be successfully studied by carefully com- paring the moment of impulse of the heart with that of the tumor, as well as the character and intensity of the cardiac and aneurismal sounds. You should carry the stethoscope carefully from one to the other, and observe the diminution and increase of the murmurs, as you lengthen or shorten the distance from the origin of the sounds. It is necessary also to study the direction in which the sounds are propagated — those of a blowing or rasping character having a tendency to pass in the directiou of the current of blood. Hence in aneurisms of the innominata, the murmur is prolonged in the course of the right carotid and axillary arteries, while those of the aortic arch, and especially its descending portion, may be heard in the aorta, on applying the ear to the back. In this manner careful and repeated auscultation, conjoined with percussion, will enable you, in the majority of cases, to determine exactly, not only the existence and seat of the aneurism, but in many cases its form and structure. 3. Palpation . — When an aneurism points externally, at umor and an expansive impulse can be felt by the hand. The position of the tumor varies according to the part of the aorta, or the large vessels from which it originates. Thus, saccular aneurisms immediately above the aortic valves pass downwards. When situated in the innominata, they manifest themselves above the clavicle on the right side. If originating in the transverse portion of the arch, there is often no external tumor ; and when it does occur, it generally 632 DISEASES OF THE CIRCULATORY SYSTEM. appears on the left side of the sternum, above or below the sternoclavi- cular articulation. Aneurisms lower down in the arch are most com- mon in the left thoracic cavity. These rules are by no means absolute ; for, although an aneurismal tumor for the most part tends to enlarge in the direction in which the impulse, from the course of blood, is applied — this, in several cases, cannot be determined in the living body. The impulse of the tumor is synchronous with, or follows the systole of the heart. Occasionally there is no impulse, a circumstance most frequently observed when the tumor does not present externally, and is only determined by percussion. The pulse of arteries connected with the aneurism may be weakened or retarded. The pulse at both wrists should be always carefully studied ; for if one be weaker than the other, it is clear that an interruption exists in the current of the blood in the axillary artery. This may arise from two causes — 1st, From the vessel being involved in the tumor ; 2d, From its being compressed by it externally. The former condition exists most commonly 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 af’cording to the size of the tumor, 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 harsh cough, and stridiilous 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 resonance. Pressure of the tumor on the axillary vessels and nerves may induce more or less oedema of the extremities, and paralysis more or less complete. Some- times 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 constriction — dyspnoea with or with- out 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 in- finitely in different cases, and their careful detection, combined with a knowledge of physiology, will in the majority of cases enable us to form a correct opinion as to the nature of the disease. It must not be for- gotten, however, that there are some cases which have been so obscure as to baffle the efforts of the most able physicians; and that, generally speaking, the deeper the aneurism the greater the difficulty of detecting its exact nature, and the complications connected with it. It is also well ascer- tained that the symptoms may be simulated by a tumor situated out- ANEUKISSr. 633 side and upon the vessel ; and occasional mistakes, made by the most experienced surgeons — men, who, during their professional lives, have carefully examined a large number of these tumors — prove the excessive difficulty of detecting aneurisms, even when situated in the limbs or in the necL How much more difficult must be the appreciation of these symptoms, when the aneurisms are below the sternum or clavicles, not to speak of their occurrence deep in the thorax. Yet these very symptoms, together with the results obtained by percussion and ausculta- tion, enable the physician frequently to overcome the greatest difficulties, and to demonstrate what may properly be called the greatest triumph of his art. The physical phenomena most distinctive of abdominal aneurism are a swelling more or less defined, an expansive impulse on applying the hand, and a bellows murmur synchronous with, or immediately following, the heart’s systole on applying the stethoscope. This bellows murmur is generally loudest over the tumor, and is propagated down the aorta — • although, when immediately below the diaphragm, it may be confounded with the first sound of the heart. The symptoms are very various, con- sisting of dragging, or other pain, more or less acute and prolonged, owing to pressure and stretching of the neighboring nerves, together with functional disturbance of one or more of the abdominal viscera. Various cases on record, therefore, have presented a train of very anomalous symptoms, and at various times been considered as difiPerent diseases by medical practitioners. A complete re-investigation of the symptoms and signs of abdominal aneurisms is much required. This is a task, how- ever, which will require a thorough knowledge of all that is now known of physical diagnosis and morbid anatomy, combined with great powers of observation, and such opportunities as fall to the lot of few individual members of the profession. The pathology of aneurism is sufficiently treated of under the heads of “ Vascular Growths,’’ p. 216, and of “ Fatty Degeneration of Blood- vessels,” p, 256. The latter, by inducing weakness or want of elasticity in the vascular wall, permits of its dilatation by the successive impulses of the blood on the enfeebled tissue. Occasionally the inner coat of the vessel is lacerated by external violence, or by sudden exertions, when a similar morbid condition gives rise to like results. As the aneurismal tumor enlarges, it presses more and more upon neighboring parts, giving rise to atrophy, ulceration, and interstitial absorption of parts, and occa- sioning a great variety of symptoms, according to the situation of the tumor, the organs and tissues influenced by it, and the amount and kind of pressure exerted on the textures concerned in the functions of nutri- tion and innervation. The treatment of aneurisms may be curative or palliative. The for- mer is carried out by the surgeon. The general treatment by Valsalva’s method has already been alluded to (p. 611), and is now seldom practised. All the physician can do is to palliate symptoms, diminish the chances of rupture, and favor the obliteration of the enlarged vessel ; to this end enjoining quietude, especially avoidance of sudden or long sustained 634 DISEASES OF THE CIRCELATORY SYSTEM. exertion. Occasional local and even general bleeding, topical applica- tions of ice or warmth as may be found most useful, and sedatives, tend to diminish pain. Constipation should be carefully guarded against, and healthy nutrition secured by attention to the various animal functions, gentle exercise, etc. etc. DISEASES OF VEINS AND LYMPHATICS. Case CXXVII.* — Phlebitis of the Left Iliac Vein, supervening on Cancer of the Stomach and (Esophagus. History. — Alexander Henderson, aet. 23, baker — admitted June 22d, 1863. Pa- tient states that he has enjoyed good health, until about a year ago, when he began to be troubled with heartburn. This annoyed him daily ; and six weeks ago, half an hour after dinner, he vomited for the first time. Since then he has vomited every time he has taken food, and generally immediately on swallowing it, experiencing during the act of deglutition a feeling as if the bolus was obstructed in its passage to the stomach. Symptoms on Admission. — Tongue pale and clean in front, but loaded behind. No appetite. He vomits immediately upon sivallowing food, except to-day when he has been able to retain a little beef-tea. Any bolus of solid food feels as if suddenly ob- structed in its course down the oesophagus, at a point about two or three inches to the left of the xiphoid cartilage, and this sensation is succeeded either by vomiting, or by his distinctly feeling the bolus slip downwards into the stomach. He has constant pricking pain in the epigastric and left hypochondriac regions, which is increased by pressure, and greatest at the point where he feels the obstruction on swallowing. No tumor can be felt. Hepatic dulness inches. Bowels constipated. Cardiac impulse between 4th and 5th ribs, one-half inch internal to and below the nipple. Its dulness on percussion measures transversely 24 inches. A soft blowing murmur aceompanies the first sound at the apex. Pulse 72, very weak. Frequent cough, with muco-purulent expectoration. The breathing over the whole back is somewhat harsh, and expiration is occasionally accompanied by sibilation. Considerably emaciated. Cheeks of a livid hue. Other functions normal. Progress of the Case. — The gastric symptoms of the patient were greatly alle- viated by careful arrangement of his diet, consisting of small quantities of unirritating food taken four or five times a day. The vomiting had ceased, and he was walking about the ward when, at 3 p.m., July 13th, he experienced a rigor, followed by febrile symptoms, and in the evening he complained of severe pain in the epigastric region, which was distended and tympanitic on percussion. Has no appetite. Face much flushed. Pulse 102, very weak. lor some days previously he had noticed slight oedema of the ankles, for which diuretics had been ordered. July lAth. — The febrile symptoms diminished. Pulse 84, weak. July l^ih. — Has had repeated shiverings during the day. Pulse 82, weak. Complains also of severe pains shooting down the left leg from the groin, and on examination, it is found to be greatly swollen, pitting very much on pressure. Some enlarged lymphatic glands can be felt in the left groin. The oedema of the right leg is much diminished. Urine passed during 24 hours, 20 oz., containing no albumen. A large warm, 'poultice to he applied to the left groin, July 18^7i. — Continues to have occasional rigors followed by febrile symptoms. No appetite. (Edema of the legs the same as in last report, the left leg being greatly, while the right is but slightly, swollen. The pain in the left groin still continues. Jxdy 207/i. — The oedema of the left leg is increasing, while there is now no swelling of the right. Still eomplains of great pain shooting down the left leg. Has no increase of appetite, but the feeling of obstruction on swallowing is now absent. Bowels which have been hitherto rather constipated, were moved last night by castor-oil. The abdo- men is distended with flatus. Pulse 118, weak, and occasionally intermittent. Urine, 22 oz. July 21s^. — Last night had a rigor, and to-day at 2 p.m. he is found in a state of high fever, the face flushed, of a deep purple, and the tongue covered ivith a thick yellow fur, dry, cracked, and fissured. Pulse 130, very weak and intermittGiit. Still no appetite. Has no pain except when pressure is made over the left groin. Is very * Reported by Mr. John Wylie, Clinical Clerk. DISEASES OF VEINS AND LYMPHATICS. 635 restless. No pulsation can be felt in the left groin, but there is induration and tender- ness on pressure. His bowels are opened regularlj^ every second day by castor-oil. July 22c?. — Lies on his back ; his eyes fixed and glazed ; his eyelids half closed. The tongue is still covered with the dry yellowish fur, and is protruded with great difficulty Answers when spoken to and says he has very little pain, but has some uneasiness about the epigastric region. Pulse 140, weak and intermittent. Pain and restlessness at night. H Chlorodyne TT xv. ; 8p. ^Ih. Cldorici 3 ss ; 3fist. Camph. 3 vi. M. To he taken at hed-time. July 23c?. — Last night was very restless, complaining of pain in the lower part of the back. Got the draught at 11 o’clock and became easier, but after midnight he was observed again to become restless, and at 4 o’clock this morning he died. Sectio Cadaveris . — Thirty-five hours after death. Body greatly emaciated, and very slightly jaundiced. Thorax. — The pericardium contains a considerable quantity of yellow serum. Heart. — Aortic valves competent. Mitral valve somewhat atheromatous. Lungs contain a few soft cancerous nodules of the size of marbles, dispersed in their substance. Abdomen. — Intestines greatly distended with flatus. Liver. — On making sections through the organ, it is found to contain a few cancerous masses, varying in size from a marble to a hen’s egg. Stomach. — On opening into the stomach, its cardiac orifice as well as three inches of the lower part of the oesophagus, is found to be surrounded by hard scirrhous matter which is ulcerated on its internal surface. Pancreas healthy. In the Mesentery., especially near its root, there are a few scirrhous masses of the size of marbles. The left external iliac vein was greatly distended, and felt like a thick cord. On being opened, it was found to be occluded by a clot to the extent of four inches. The walls were one-eighth of an inch thick over this portion, and adherent to the clot. This was generally of a brick-red color, firm externally, but soft and pultaceousin the centre, where here and there it was of a fawn color. The smaller veins communicating with the altered vessel were also obstructed by clots. Other organs healthy. Microscopic Examination. — The harder part of the clot was composed of dense amorphous matter, and broken-down blood globules. The soft portions were composed of diffluent molecular fibrin, with a few colorless cells, resembling those of pus. Commentary. — In this man, who was weak and emaciated in con- sequence of cancer with stricture of the cardia, there occurs, without any obvious cause, intense fever followed by severe pain in the left groin, and oedema of the left inferior extremity. From this attack he never rallies, and dies ten days afterwards. On dissection, inflammation of the left iliac vein is found, its coats thickened and adherent to a clot which obstructed the vessel. The case offers another illustration of severe local inflammation occurring in weak emaciated subjects, which proves fatal from the want of vital power necessary for accommodating the system to the injury. Phlebitis, whenever it occurs, tends to cause obstruction of the vessels involved, and as a result of .this, dropsy occurs. The object of treatment should be to support the strength until time has been giveii to establish a collateral circulation, which, if the patient be strong, apd the case uncomplicated, frequently happens. But where, as in the instance before us, the strength is gone, from the results of gastric cancer, it could only hurry on the fatal termination. Case CXXYIII.'^ — Anyio-Leucitis^ supervening on Rupia — Recovery. History. — John Mercer, aet. 32, draper — admitted February 19th, 1859, with rupia, which followed primary and secondary syphihs that had been long treated with mercury. He has been of dissipated habits, and was in the house for delirium tremens. The whole skin is scattered over with prominent imbricated dark-brown scabs, varying in size from a small pea to that of a sixpence at the base. Other functions are normal. * Reported by Mr. R. T. Land, Clinical Clerk. 636 DISEASES OF THE CIRCULATORY SYSTEM. Five grs. of Iodide of Potassium to he taken three times daily. To have an alkaline hath. Progress op the Case. — Feh. Toth. — Last evening complained of pain on the flexor surfaces of both arms, extending from the wrist to the axilla. To day the pain is in- creased, and bright red lines, following the course of the lymphatics, may be seen ex- tending from the wrist, up the flexor surfaces, to the middle of both arms. The skin between them is erythematous. The tongue is furred ; there is no appetite ; consider- able thirst, but no rigor. Pulse 80, of good strength. Gloths steeped in warm water to he applied to both arms, and kept moist with gutta-percha sheeting. Feb. 26^4. — Felt much relieved from the moist applications. Flexor surfaces of both arms were much indurated, but otherwise the same. Feh. 29i!A. — Last night at 12 o’clock had severe shivering which lasted till 2 a. m., with pain in the head, and general feverish symptoms. Both forearms are to-day m )re swollen and painful, the bright red lines feel like cords, and the erythematous redness is intensified and somewhat elevated above the surface of the skin. It may now be regarded as erysipelatous. Warm moist ap- plications to be continued. March 2(7. — Yesterday the pain and swelling had greatly diminished, and to-day the whole has disappeared. The rupia also has greatly bene- fited from the moist applications, the scales have separated, and most of the ulcers have healed. April 2d. — Since last report has continued to do well, the rupia having nearly disappeared. Last night complained of pain on the inner side of the left knee, with slight erythema and swelling. Warm moist applications to he made to the part. This gave him great relief. The erythema, pain, and swelling continued, however, four days, and then diminished, without having especially affected the lymphatics. The rupia, also, is well, nothing remaining but the round and oval cicatrices. Dismissed April 11th. Commentary .- — It is very possible that the irritation produced by the adherent crusts of rupia and the ulceration existing at their bases, may have been the exciting cause of the inflamed lymphatics in this case. No relation, however, could be observed between particular rupia crusts and the aftected vessels. The general pain and local symptoms were very intense at one time, but yielded to warm moisture, applied locally, which caused great relief to the pain, while the disease ran its natural course. It is very rare that such a disease appears in the medical wards. The most remarkable case I ever saw of lymphatic disease, is one which has been recorded by Dr. A. Buchanan of Glasgow.* On examin- ing the affected thigh last September with that gentleman, the lymphatics appeared to me to be varicose, with vesicles scattered on the skin here and there, which, on being punctured, yielded an opaque milky fluid. Subsequently I received nearly half a pint of the chylous fluid from Dr. Buchanan, discharged from the lymphatics on the thigh of this woman, which, on microscopical examination, was composed of a mole- cular basis, with a few chyle corpuscles. * Med. Chir. Trans, of London, vol. xlvi. SECTION VII. DISEASES OF THE RESPIRATORY SYSTEM. In this, as in the preceding section, it will be well to introduce the study of individual diseases by a short enumeration of the general rules established for the diagnosis of lesions of the Kespiratory System. They are — 1. A friction murmur heard over the pulmonary organs indicates pleuritic exudation. 2. Moist or dry rales, without dulness on percussion, or increased vocal resonance, indicate bronchitis, with or without fluid in the bronchi. 3. Dry rales accompanying prolonged expiration, with unusual reso- nance on percussion indicate emphysema. 4. A moist rale at the base of the lung, with dulness on percussion and increased vocal resonance indicates pneumonia. 6. Harshness of the inspiratory murmur, prolonged expiration, and increased vocal resonance confined to the apex of the lung, indicate in- cipient phthisis. 6. Moist rales, with dulness on percussion, and increased vocal reso- nance at the apex of the lung, indicate either advanced phthisis or pneu- monia. The latter lesion commencing at or confined to the apex is rare, and hence these signs are diagnostic of phthisis. 7. Circumscribed bronchophony or pectoriloquy, with cavernous dry or moist rale, indicates a cavity. This maybe dependent on tubercular ulceration, a gangrenous abscess, or a bronchial dilatation. The first is generally at the apex, and the two last about the centre of the lung. 8. Total absence of respiration indicates a collection of fluid or of air in the pleural cavity. In the former case there is diffused dulness, and in the latter diffused resonance on percussion. 9. Marked permanent dulness, with increased vocal resonance, and diminution or absence of respiration, may depend on chronic pleurisy, on thoracic aneurism, or on a cancerous tumor of the lung. The diag- nosis between these lesions must be determined by a careful consideration of the concomitant signs and symptoms. The general diagnostic indications, now noticed as being derivable from physical signs, admit of several exceptions, which, however, it would be difficult to systematize, and which can only be known from a careful study of individual cases. It is important also to remember that 638 DISEASES OF THE EESPIRATORY SYSTEM. these signs should never he relied on alone, hut he invariably comhined with a minute ohservation of all the concomitant symptoms. Thus the signs indicative of incipient phthisis may he induced hy a chronic pleurisy confined to the apex, or hy retrograde tubercle. In either case the pre- vious history, age, etc., may enable you to determine the nature of the lesion. Again, it may be impossible at the moment of examination to distinguish between two diseases. For instance there may be general fever, more or less embarrassment of the respiration, and pain in the side, accompanied with no dulness on percussion, but with a decided ab- nonnal murmur, difficult to characterise, as being a fine moist rattle, or a gentle friction sound. Under such circumstances, the progress of the case also will soon relieve you from any doubt as to whether a pleurisy or a pneumonia be present. The alterations which occur in the physical signs during the progress of the case also will indicate to the pathologist the changes which occur in the physical conditions and morbid lesions of the lungs. Thus the fugitive dry or mucous rales heard during a bronchitis, point out the occasional constrictions and obstructions in the bronchial tubes. The fine crepitation of incipient pneumonia, passing into absence of respiration, and this again into crepitation, will satisfy him as to effusion, solid coagulation, and subsequent softening of the ex- udation. In the same way, by an accurate appreciation of physical signs, and a thorough knowledge of morbid anatomy, the practised physician can tell the abnormal conditions produced by phthisis, pleurisy, etc., and judge from the symptoms the effect of these upon the constitution, with a degree of accuracy that to the tyro must appear to be marvellous. All such knowledge can only be acquired by constant examination of the patient on the one hand, and by a careful study of morbid anatomy in the pathological theatre on the other. DISEASES OF THE LAEYNX. Case CXXIX .* — Acute Laryngitis — Treatso hj Topical Applications — . Recovery. History. — Alexander Flint, aet. 27, a salesman — admitted February 17, 1851, suffering from extensive lupus of the face, severe diarrhoea, Bright’s disease, and scro- fulous caries of the left knee-joint. Under appropriate treatment the diarrhoea ceased, the lupus was cured, and the disease of the kidney much alleviated. Symptoms op the Attack. — On the 24th of May, about three months after admis- sion, he first complained of dry cough and slight pain in the throat, with difficulty of deglutition. These symptoms were increased on the following day; and on examina- tion the mouth and fauces were unusually red, with minute florid elevations scattered over tiie mucous surface. Notwithstanding the application of leeches, and sponging the fauces with a solution of the nitrate of silver, the laryngitis progressed. Progress of the Case. — On the 14th of June the pain and difficulty of deglu- tition had increased, and his voice had become indistinct and hoarse. The cough also continued, but was now attended with a difficult expectoration of muco-purulent matter. On the 30th of June, notwithstanding the assiduous use of astringent gargles, occasional sponging of the fauces with solution of nitrate of silver, and the aiiplication of leeches, he was evidently worse, and he could only speak in a whisper. Jidtj Uh. — To-day Dr. Horace Green, of New York, who went round the wards with * Reported by Mr. W. M. Calder, Clinical Clerk. DISEASES OF THE LARYJS-X. 639 Dr. Bennett, stated that this was a remarkably good example of what he had named follicular disease, affecting the larynx. He passed the sponge, saturated with a solu- tion of nitrate of silver (3ij to | i of water), through the larynx into the trachea. The patient could not take a breath for some seconds afterwards, and described the sensation as like that produced by a piece of food “ passing down the wrong way, and causing choking.” The immediate effect of the operation was decided improvement of the voice, and more ease in deglutition. From this time his symptoms gradually left him. On the 10th, the sponge was again passed into the larynx by Dr. Bennett, and produced the same sense of temporary suffocation ; but immediately afterwards he spoke with perfect clearness of voice. The application was made every second day until the 16th, when all the laryngeal symptoms had disappeared, the voice was nor- mal, and there was no cough, expectoration, pain, or difficulty of deglutition. He now left the house ; the disease in the joint had made considerable progress, but the renal disorder was much alleviated. Case CXXX.* — Chronic La/ryngitis — Topical Applications — Recovery. History. — Helen Guthrie, set. 24, married, a fisherwoman — admitted July 4th, 1851. Four months ago was seized with a cough, attended with hoarseness of the voice, dryness of the throat, painful deglutition, and pain in the larynx, which symp- toms have continued with greater or less intensity up to the period of admission. Lat- terly, there has been considerable expectoration of purulent matter, often tinged with blood. Symptoms on Admission. — On admission, she complains of cough coming on in paroxysms, dryness in the throat, and pain in the larynx, voice cracked and occa- sionally absent. There is no difficulty in swallowing, but copious expectoration of frothy mucus. Can inspire without difficulty. Percussion over chest elicits nothing abnormal. On auscultation, the inspiratory murmur is harsh over superior tliird of chest on both sides. Over larynx and trachea there is heard a dry snoring sound. On examining the fauces, red patches were observable here and there, with slight erosion on the left side. The fauces and epiglottis were sponged with a solution oi nitrate of silver ( Dj to % j of vvater). Progress of the Case. — The application was repeated on the following day, and the voice was evidently improved. On the 6th, the sponge, saturated with the solu- tion, was passed into the larynx by Dr. Hoi’ace Green, of New York, and produced no feeling of suffocation whatever. It was passed afterwards every day by Dr. Ben- nett till the 14th, when she left the house, all the laryngeal symptoms having disap- peared, and the voice nearly restored to its proper tone. Commentary. — The two cases above recorded point out to you in a very marked manner the great advantage to be derived from the method of local application to the larynx, introduced by Dr. Horace Green, of New York. This practice consists in the direct application of a solution of nitrate of silver to the interior of the larynx and trachea, by means of a bent whalebone probe, with a piece of sponge fastened to its extremity. Numerous attempts had been made, with more or less success, by Sir C. Bell, Mr. Vance, Mr. Cusack, and MM. Trousseau and Belloc, to carry this practice into effect, and the results obtained, even by their imperfect efforts, exhibited the great advantages which were to be derived from it in the treatment of laryngeal diseases. Now, thanks to Dr. Green, we can wnth safety apply various solutions directly to the parts affected, and the two cases you have observed must convince you of the benefit which patients so treated may obtain. In Case CXXIX. you have observed the progress of a tolerably acute case of laryngitis from its commencement to its termination — the distressing symptoms produced, and the loss of voice occasioned. You have re- marked, I trust, the gradual increase of the disorder, from its commence- * Reported by Mr. D. 0. Hoile, Clinical Clerk. 640 DISEASES OF THE EESPIRATORT SYSTEM. ment on tlie 24tli of May until the 6th of July, when you saw Pr Green himself pass the sponge into the larynx, and the immediate effect it occasioned. Lastly, from that moment you saw the case get better, and terminate in perfect cure eight days afterwards. No stronger evidence could be offered you in any single case of the benefit to be derived from a local application, especially when it is considered that the usual treatment had been actively employed, consisting of leeches externally, gargles, and the application of a strong solution of nitrate of silver to the fauces, pharynx, and epiglottis without any benefit. It was only when the application was made directly to the part affected that good was obtained. The second case, though more chronic, and though she went out before a perfect cure was obtained, is also calculated to impress upon you the value of this treatment. The instruments to be employed are, first, a tongue depressor, with a bent handle, such as I now show you (Figs. 4 and 5), by means of which the tongue can be firmly pressed down, so as to expose the whole of the fauces, and the upper edge of the epiglottis. In doing this, some patients experience no inconvenience, whilst in others there is such excessive irritability, that spasmodic cough or even vomiting is occasioned, which prevents the possibility of seeing the epiglottis. Secondly, a whalebone probang, about ten inches long, having at its extremity a round piece of the finest sponge, about the size o? a gun or pistol bullet. The probang, towards the extremity, must be bent in a curve, which, according to Dr. Green, ought to form the arc of one quarter of a circle whose diameter is four inches. Sometimes the curve must be altered to suit particular cases ; and when it is thought necessary to pass it into the trachea, the curve must be considerably less. It is important that the sponge be fine, and capable of imbibing a considerable quantity of fluid ; that it be 8ewn firmly to the extremity of the whalebone, and that this last should not be cut in the form of a bulb, but tapered as much as consistent with firmness. The solutions of the nitrate of silver which will be found most use- ful are of two strengths. One is formed of 3ij and the other 3 j of the crystallized salt to an ounce of distilled water. On some occasions a solution of the sulphate of copper has been found beneficial, and it is very possible that as our experience of this kind of treatment extends, the application of other substances in solution may be found capable of meeting parti- cular indications. Some have used Tr. of Iodine, others solutions of various salts, and Dr. Scott Alison, in cases of great irritability, has re- commended olive oil. The method of introducing the sponge which I have found most successful is as follows : — The patient being seated in a chair and exposed to a good light, you should stand on his right side, and depress the tongue with the depressor held in the left hand. Holding the probang in the right hand, the sponge having been saturated in the solution, you pass it carefully over the upper surface of the instrument, exactly in the median plane^ until it is above or immediately behind the epiglottis. You now tell the patient to inspire, and as he does so, you drag the tongue slightly forwards with the depressor, and thrust the probang down- wards and forwards by a movement which causes you to elevate the right DISEASES OF THE LAEYXX. 641 arm, and brings your hand almost in contact with the patient’s face. This operation requires more dexterity than may at first be supposed. The rima glottidis is narrow, and unless the sponge come fairly down upon it, it readily slips into the oesophagus. Its passage into the proper channel may be determined by the sensation of overcoming a constric- tion, which you yourself experience when the sponge is momentarily em- braced by the rima, as well as by the momentary spasm it occasions in the patient, or the harsh expiration which follows, — symptoms which are more marked according to the sensibility of the parts. If the probang be properly prepared, and the operation well per- formed, the actions which take place are as follows : — 1st, The sponge, saturated with the solution, is rapidly thrust through the rima into the larynx, and frequently into the trachea ; for if the distance of the pro- bang be measured from that portion of it which comes in contact with the lips, the extent it has been thrust downwards can be pretty accu- rately determined. I am persuaded that on many occasions I have pass- ed it pretty deep into the trachea, not only from the length of the pro- bang which has disappeared, but also from the sensations of the patient, although this may be thought hy some a fallacious method of determin- ing the point. In the first part of the operation, the rima glottidis is, as it were, taken by surprise, and the sponge enters, if the right direc- tion be given to it, without difficulty. But 2d, The rima glottidis im- mediately contracts by reflex action, so that on withdrawing the instru- ment you feel the constriction. This also squeezes out the solution, which is diffused over the laryngeal and tracheal mucous membrane. Now, if the sponge be a fine one, it will be found capable of holding about 3 ss of fluid, the effect of which upon the secretions and mucous surface almost always produces temporary relief to the symptoms, and strengthens the tone of the voice — results at once apparent after the momentary spasm has abated. 3d, The action of the nitrate of silver solution is not that of a stimulant, but rather that of a calmative or sedative. It acts chemically on the mucus, pus, or other albuminous fluids it comes in contact with, throws down a copious white precipitate, in the form of a molecular membrane, which defends for a time the ten- der mucous surface or irritable ulcer, and leaves the passage free for the acts of respiration. Hence arises the feeling of relief almost always occasioned, with that diminution of irritability in the parts which is so favorable to cure, and why it is that strong solutions of the salt are more efficacious than weak ones. It may be easily conceived that such good effects must be more or less advantageous in almost all the diseases that affect parts so sensitive, from whatever cause they may arise ; and that this treatment is not only adapted to one of the diseases of the larynx, but, like all important remedies, meets a general indication of which the judicious practitioner will know how to avail himself. The mucous membrane of the larynx consists of ciliated epithelium externally, a basement layer below this, and areolar tissue internally, richly supplied with blood-vessels. Scattered over its surface are numerous follicles, which secrete mucus. It is liable to the same structural alterations as all other similar membranes, which may be 41 642 DISEASES OF THE EESPIRATOKY SYSTEM. divided into — 1st, Exudation, into the areolar tissue between the base- ment membrane and epithelium, or upon the external surface ; 2d, Abrasions or desquamations of the epithelial layer ; 3d, Ulcerations ex- tending more or less deep into the areolar tissue ; and 4th, Obstruction, swelling, and subsequent ulceration of the mucous follicles, a lesion particularly described by Dr. Horace Green, and denominated by him “ follicular disease of the air passages.” These different lesions may be more or less complicated with each other, and will vary in intensity" ac- cording to the rapidity of their progress, and the extent to which the mucous membrane is implicated. Sometimes the exudation is thrown out quickly and infiltrates the textures, as in oedema glottidis, or in malignant angina. At other times it is poured out on the surface as in croup. More frequently it is partial, occasioning subsequent abrasion or ulceration, and the acute disease becomes chronic. Perhaps the most common form it assumes is when it is chronic from the commencement, sometimes dependent on atmospheric changes, at other times on re- peated attacks of “cold;” in a third class dependent on too much straining of voice, as occurs in public speakers, clergymen, singers, etc., and occasionally it is connected with a general constitutional disorder, as syphilis, tuberculosis, or some form of cancer. All these forms of laryngeal disease may be further associated with similar lesions of the fauces, tonsils, uvula, and pharynx. The symptoms will of course vary according to these different cir- cumstances. The acute forms are accompanied with general fever, con- siderable local pain, more or less obstruction to deglutition and respira- tion, and loss or alteration in the character of the voice. As a general rule, it may be said that lesions of the fauces, tonsils, and neighboring parts, are indicated by greater or less difficulty or uneasiness in swallow- ing, whilst the laryngeal disorder is evinced by changes in the character or power of sustaining the voice. Then, as a general result of the local irritation, spasmodic action is evinced, and we have cough, at first dry, but afterwards attended with mucous or purulent expectoration, and not unfrequently with discharge of blood. Elongation of the uvula may produce these effects. It has been lately supposed that hooping-cough is only an obscure form of laryngeal disease. In the more acute and ex- tensive cases of exudative laryngitis, the spasms are more violent and prolonged, and the greatest caution is necessary in watching persons so affected, lest, from sudden and continued closure of the glottis, fatal asphyxia be induced. The following case is very instructive in this point of view. Case CXXXI.'^ — Acute (Edema of the Glottis — Chronic Pharyngitis and Laryngitis — Sudden Death. History. — Frances Nichol, set. 25, a shoe-binder, married — was admitted in the evening of February 2V, 1851, complaining of sore throat, but breathing easily, and otherwise presenting no urgent symptoms. She has suffered from cough upwards of four years, had secondary syphilis, and ulcerations in the throat for twelve months. Symptoms on Admission. — At the visit I found her breathing to be laborious and noisy ; cough frequent ; expectoration difficult, with frothy sputum tinged with blood ; * Reported by Mr. Henry Thom, Clinical Clerk. DISEASES OF THE LARYNX. 643 countenance anxious ; lips livid; pulse 130, small and soft; cannot speak, nor can any oujc give any account of her. On examining the mouth and fauces, the mucous membrane was seen to be covered with tenacious muco-purulent matter. The sott pa- late is perforated by ulcerations the size of a pea in three places ; there is another ulcer the size of a fourpenuy piece on the roof of the mouth. The tonsils and mucous mnnbrane surrounding tlie glottis were somewhat swollen, but not unusually red. On percussing the chest, no dulness could anywhere be detected. Respiratory mur- murs over the large air-tubes loud and harsh, with occasional mucous rale, but their character masked by the loud snoring noise in the larynx. To have 3 ss of wine every half-hour ; an antispasmodic mixture of sulphuric ether ^ ammonia^ and opium ; the ulcers and mucous membrane of the fauces to he sponged with a weak solution of nitrate of silver^ and the steam inhaler to he used assiduously. Progress of the Case. — These remedies alleviated all her symptoms, so that in the evening she gave a history of her case. Seeing that she was so much better at the evening visit of the house-clerk, the intensity of the disease was supposed to have abated, but in the morning she was found dead in bed. Sectio Cadaveris. — Fifty hours after death. Pharynx, Larynx, and Trachea. — The opening of the fauces was considerably contracted ; and the mucous membrane of the tonsils, soft palate, and from this to the root of the tongue, presented numerous ulcerations, extending to the submucous tis- sue, and undermining to some extent the mucous membrane. The ulcers were mostly rounded in form, of exceedingly various size, up to a diameter of three-eighths of an inch ; the edges not at all elevated, and for the most part smooth, as though scooped out by a punch. The floors of the ulcers consiste 1 of the submucous tissue, perfectly clean and pale, without the least trace of granulations or pus. The neighboring mu- cous membrane was scarcely at any point more vascular th in natural. The aryteno- epiglottidean folds were hypertrophied, — that of the right side being thickened and cedematous, that of the left being flaccid and relaxed. They could be made to lie in apposition, so as almost to close the opening of the glottic. The mucous membrane of the entire larynx was somewhat rose-colored ; and the submucous tissue of the epiglottis, the chordae vocales, and the ventricles, considerably infiltrated with fluid. Throughout the trachea, the membrane was of a rose color, becoming deeper towards the bronchi, and was everywhere covered with a thick mucus, whic’n lay in semi-trans- parent drops, the size of a very small pin’s head, on the opening of the follicles. Thorax. — The tissue of the lungs was for the most part healthy, but here and there a few small portions of its substance were collapsed. The mucous membrane of the larger bronchi was congested, and the smaller ones on the right side yielded drops of purulent mucus, on compressing the cut surface of the lung. Abdomen. — There were several small cancerous nodules in the liver, but all the organs were healthy. Commentary. — In this case I think there can be little doubt that during the night some obstruction occurred to the breathing, dependent on the local disease, which caused asphyxia and death. Neither can we have any hesitation in thinking, that had tracheotomy been performed in time, life would have been saved, inasmuch as the tissue of the lungs was healthy, and the only lesion found in those organs was a trifling bronchitis. No doubt the amelioration of the symptoms which was observed at the evening visit removed the idea of urgency, but this is just the reason I have cited the case, as a lesson to all of us, with regard to the watchfulness which is necessary in the treatment of such disorders. In another case, occurring in a man who entered the clinical ward shortly afterwards, laboring under symptoms so similar that I need not detail them, I ordered tracheotomy to be performed at once, and the result was the preservation of life and restoration to health, although the ulceration destroyed the vocal chords, and the aphonia was complete. The following case presents the most rapid progress of acute laryngitis I ever saw, and points out strongly the necessity of great watchfulness in this disease. C44 DISEASES OF THE EESPIKATORY SYSTEM. Case CXXXII.^' — Acute Laryngitis supervening on Ascites^ and Cirrhosis of Liver — Sudden Death from Asphyxia. History, — William Corbett, set. 40, seaman — admitted October 4th, 1860 with enlarged liver and ascites. Symptoms on Admission. — The liver, on percussion, measures six inches vertically, and the abdomen is greatly distended. Urine passed daily only 19 oz. The treatment was directed, by means of diuretics, to increase the flow of urine, and Tr. of Iodine was ordered to be painted over, the liepatic region. Progress of the Case. — Odober 29^/n — Has been taking half-drachm doses of the bitartrate of potass, with the effect of increasing the flow of urine to 40 and 45 oz. daily. To-day complains of pain in swallowing, and says he has had cough for the last two nights. The fauces on examination are somewhat congested. The throat to he fomented., and a xmrm poultice to he applied at night. October 81s^. — Has experienced much relief from the warm applications, and swallows without much inconvenience. He expectorates, however, after coughing, a frothy, slightly viscous mucus. November 1st. — Cough very troublesome during the night. Expectoiated about 6 oz. of frothy mucus since yesterday. Tongue covered with a brown fur. Pulse accelerated, but no fever. Abdominal symptoms and signs unchanged. Passes 45 oz. of urine daily. H Chlor'odyne 3 ss ; 3Iist. Carnph. 3 ij. Half to he taken at hed-time, arid repeated in the night if the cough he troublesome. Wai'm poultices to the throat to he continued. November ‘Id. — Cough and expectoration very troublesome last night, preventing sleep, notwithstanding the anodyne, Sputum frothy, slightly purulent. Voice slightly hoarse. On examining throat, fauces seem to be very red, and tonsils swollen. Other symptoms the same. To use an astringent alum gargle. Continue fomentations and poultices to the throat. November Zd. — According to the reports of the night nurse, he became restless, constantly requiring attention about the middle of the night, with difficulty of breathing. She did not observe anything very urgent, however, un- til 6 A.M. this morning, when she went for the house physician. No sooner had she left his bedside, than he rose, fell down, and on being raised by two neighboring pa^ tients, gave one gasp and expired. Sectio Cadaveris. — Thirty hours after death. Considerable lividity of lips, face, and neck. Fauces and Larynx. — Fauces everywhere greatly congested. Left tonsil much swollen, and the circumvallate vilii at the base of the tongue numerous, enlarged, and prominent. The epiglottis thickened, indurated, and erect, of deep purple color, con- ical form, with its external edges curved inwards. The neighboring mucous mem- brane thickened and infiltrated with exudation. On opening the trachea and larynx from behind, the mucous membrane was seen to be oi a deep mahogany unitbim color from congestion ; both vocal chords, true and false, on each side were infiltrated with exudation. The right ventricle was occupied by, and distended wdth, a straw-colored mass of coagulated exudation | of an inch long, and \ of an inch broad at its widest part, bulging inwards tow'ards the rima glottidis. The mucous membrane surround ing left ventricle, oedematous, indurated, and an oval mass of coagulated exudation 4 of an ineh long, blocking up the left ventricle, bulging inwards and obstructing the rima glottidis. Chest. — About an ounce of serum in the pericardium, none in the pleural cavities. Heart healthy, cavities empty. No congestion of right side of heart. Lungs of dark mahogany color throughout ; bronchial lining membrane also of dark mahogany color, and towards bases of both lungs posteriorly the bronchi contained a slight amount of frothy mucus. Abdomen. — Liver enlarged, weighing 6 lb. 2 oz., of a pale fawn color, considerably indurated, in the second stage of cirrhosis. Abdomen contained two gallons and a half of amber-colored serum. Other organs healthy. Microscopic Examination. — The lymph filling up the ventricles of the larynx was entirely composed of molecular fibres, included in a mass of coagulated molecular exudation. Commentary . — This man, while laboring under enlarged liver with ascites, was apparently seized with an ordinary sore throat, having caught cold, as it was afterwards ascertained, when visiting the water-closet. * Recorded by Mr. James Pettigrew, Clinical Clerk. DISEASES OF THE LARYXX. 645 There were no severe symptoms, however, farther than cough, expectora- tion, and slight difficulty of deglutition, which latter symptom yielded to warm fomentations and poultices applied to the throat. On the morning before his death, the voice was somewhat hoarse, which was the first symptom indicating that the larynx was alfected. Neither at the visit, Fig. 448. nor in the evening when seen by the house physician, nor by the nurse, were any urgent symptoms observed, until about the middle of the night. Then suddenly respiration became affected, he was restless, and dyspnoea came on so rapidly, that before medical assistance could be procured, he expired on making the exertion of rising from bed. I have previously pointed out how insidiously fatal laryngitis may come on, and how rapid Fig. 448. Appearances described in the case of Corbett — Natural size. 646 DISEASES OF THE EESPIRATORT SYSTEM. its effects occasionally are. It is certain that no acute symptoms indi- cated danger at the morning or evening visit, the man speaking on both occasions, and that day for the first time somewhat hoarsely. There can therefore be little doubt that it was in the middle of the night that the exudation must have occurred into the ventricles of the larynx, which, bv closing the glottis, caused the fatal asphyxia. The appearances observed were so striking that they are represented Fig. 448. Case CXXXIII.*- — Chronic Laryngitis and Pharyngitis — Tracheotomy — Recovery. History. — Hugh Martin, set. 36, laborer — admitted December 28th, 1849. Says, that six years ago, he had gonorrhoea, without any other form of venereal affection. Twelve months since, he was treated with calomel for some swellings below his jaw, and shortly after, having caught cold, was affected with sore throat. Subsequently he was again treated with mercury in the Glasgow infirmary, and having again caught cold, his throat became worse. Symptoms on Admission. — His general appearance is cachectic and emaciated. His speech is almost inaudible, and the upper part of a large ulcer is seen deep down in the pharynx. Respiration is evidently impeded and accompanied by hoarse tubular breathing, heard on placing a stethoscope over the larynx. Pulmonary sounds feeble, and resonance good everywhere on percussion over the lungs. Has slight cough with muco-purulent expectoration, not so copious, he says, as it has been. Has pain in deglutition, which often excites violent cough. Pulse 82, of natural strength. Other functions well performed. The urine contains hexagonal plates of cystine, mingled with crystals of uric acid. Progress of the Case. — Pcc€inh(r ZOfh. — Topical applications of a weak solution of nitrate of silver internally, and warm fomentations to the throat externally, have failed to cause relief. Breathing still impeded and difficult; voice extinct. Tracheo- tomy teas performed, a^nd a hthe inserted. January \lth. — Since the operation, he has breathed freely through the tube, and feels much easier. The ulcer in the pharynx has been touched occasionally with nitrate of silver, and is now healed. Has con- siderable difficulty in expectorating mucus through the tube. To have steak diet. Pec. 20/A. — A solution of nitrate of silver (2 gr. to of water) to he applied to the inside of the trachea every other day, by means of a sponge attached to a slip of bent whedebone. Pec. 28c?. — Has been greatly relieved by the topical application to the trachea. Strength of solution to he increased to Argent. Nit. gr. v. to § j water, and applied daily. Pecember 2f)/A. — Strength of solution further increased to gr. x. of the salt /o 3 j of water. From this time, the muco-purulent expectoration gradually subsided. B Potass, loelid. 3 ss ; Tr. Gent. c. 3 j ; Pif. Gent. c. § v. M. j to be taken three times a day. February 10/A. — The tube was removed. The voice returned, although it re- mained very hoarse, and there was every reason to believe tfiat the ulcer in the larynx, if not perfectly cicatrized, was nearly so, when he went out, February 20th Commentary. — In this case tracheotomy was performed, not so much with the view of relieving urgent symptoms, as to secure rest and immobility to the larynx, so that the ulcerations might cicatrize. This object was effected, and the man slowly got well. First, the ulcer in the pharynx healed, and subsequently that in the larynx, although, when the tube was removed from the trachea, it was apparent that the vocal chords had been partially destroyed. At the time this case was treated, the mode of application by means of sponges to the interior of the larynx was unknown. The record shows, however, that in 1849 I applied a nitrate of silver solution directly to the trachea, through the aperture made for the tube, which was from time to time removed for that pur- pose. I then found its use very beneficial in checking the amount of muco-purulent secretion, and increased the strength of the solution from * Reported by Mr. Hugh M. Balfour, Clinical Clerk. DISEASES OF THE LARYNX. 647 two to ten grains of the salt to an ounce of water. The man complained of no pain or inconvenience of any kind from these applications. He had undergone two courses of mercury, and so far as his own statements are to be relied on, without any other form of venereal disease than that of gonorrhoea, and swellings below the jaw. Even supposing that these latter were originally venereal, it is certain that the mercury produced no benefit, but, on the contrary, while the local disease was making pro- gress, it so affected his general health, as to occasion emaciation and general cachexia. We have seen that the ulcers healed under a non- mercurial treatment, and that his health improved under tonics and good diet. The diagnosis of laryngitis is most important, and must be derived — 1st, From the general symptoms; 2d, From the results obtained by careful examination of the air-tubes and lungs by auscultation and per- cussion ; and 3d, From an inspection of the parts. With regard to the general symptoms, I have already alluded to the relative value to be attached to difficulties of deglutition and of speech. Concerning the difficulties of respiration, the nature of the expectoration, and the cough, we cannot with certainty refer them to the larynx, without a careful study of the condition of the pulmonary organs. Indeed, the attention which has been lately directed to the fauces and larynx, in consequence of the writings of Dr. Horace Green, has demonstrated the important fact, that many of those disorders which have been sometimes called “ chronic bronchitis,” and others which have not unfrequently been sup- posed to indicate in young persons incipient phthisis, are really a chronic form of laryngitis, altogether local, and readily removed by topical ap- plications. The distinction between them, however, often demands the greatest care in examination, but when a good auscultator fails to detect the signs characteristic of bronchitis or phthisis pulmonalis, whilst, on the other hand, there is unusual hoarseness or shrillness of the laryngeal murmur, dryness of the throat, and hacking cough, sometimes accom- panied by muco-purulent expectoration, or even occasional spitting of blood, then his suspicions may be directed to laryngeal rather than to pulmonary disorder. It is the more important to notice this, because a good authority has lately stated, — “ Expectoration of blood in persons laboring under chronic bronchitis, with or without emphysema, but without notable disease of the heart, justifies in itself a suspicion of the existence of latent tubercles.” — (Walshe.) In making this diagnosis, however, I must recommend to you the exercise of the greatest caution, and especially not to confound the natural hoarseness heard in the larynx of some individuals with the coarse sounds heard in others only when the organ is diseased. The examination of the throat and upper edge of the epiglottis will do much to remove any difficulty you may experience, because in many cases alterations in the mucous membrane of the larynx follow and accompany similar changes in the mucous membrane of the fauces and pharynx. Indeed, it may be accepted as a general law, which admits of but few exceptions, that morbid changes in the mucous membranes of the pharynx and larynx proceed from above downwards, as is well ob- 648 DISEASES OF THE KESPIEATORY SYSTEM. served in scarlatiea. Lesions often attack the fauces or tonsils and spare the larynx; but if long continued, the latter is affected consecutively. Hence why chronic, syphilitic, and mercurial ulcerations of the throat, have such a tendency to attack the larynx. Again, when the larynx is first attacked, as occurs among clergymen, and in the ordinary croup of children, the follicular disease in the one, and the coagulated exudation in the other, tend to pass down the trachea, and not upwards into the fauces. It follows, that when hoarseness of the voice, cough, and other laryngeal symptoms are accompanied by abrasions or ulcerations in the mucous membrane of the soft palate or uvula, by thickening or irregu- larity in the epiglottis, and especially by the follicular disease formerly alluded to — presenting elevated pimples more or less numerous scattered over the parts — there is every reason to believe that the larynx is simi- larly affected. The tongue-depressor previously alluded to will enable you to examine these parts with the greatest ease, and in most cases the upper edge of the epiglottis will with its aid be brought into view. In this manner we receive exact information as to the state of the fauces, uvula, tonsils, and back of the pharynx, but valuable as such informa- niation is, we cannot determine by it the condition of the glottis. Occa- sionally, under such circumstances, the finger will assist us and enable us to feel swelling, induration, or irregularity in the epiglottis. But to derive information in this manner, tact and habit are necessary. The introduction of the laryngoscope has been too recent, and the cases which have presented themselves during the limited period I have been on duty, have been too few, to enable me to say much as to the advan- tage of the instrument as a means of diagnosis. I consider, however, that its employment should be vigorously prosecuted, although in acute cases I have found the pain and irritability of the parts oppose an in- vincible obstacle to my bringing the organ into view. In no case ought you to depend upon examination of the parts alone ; it should be con- joined with the knowledge derived from a careful study of the symptoms, and of the physical signs furnished by the air-tubes and lungs. Two other diseases, by causing obstruction of the larynx, are justly regarded with great apprehension; these are tracheitis or croup, and diphtheria. In both these diseases an exudation is thrown out on the mucous membrane, which, coagulating and blocking up the chink of the glottis, proves fatal. Neither of these diseases are common in the clinical wards. Indeed, I have only seen one case of diphtheria here, and that was in a man called Carrall, who died in November 1860, affected with small-pox, violent fever, and a sore throat, which was covered with a dirty grey exudation. In the foundling and chil- dren’s hospitals of Paris I have frequently seen it, where it presents a tough, adherent membrane, in which vegetable parasitic growths are abun- dant. (See Fig. 53.) All these various affections pass insensibly into one another; so that, with that natural exaggeration so common to anxious relatives, slight interruption of the respiration, owing to enlarged tonsils, is frequently regarded as croup, whilst almost every severe case of sore throat is now denominated diphtheria. In true cases of croup and diphtheria, however, with febrile symp- toms and the unequivocal formation of a false membrane on the mucous DISEASES OF THE LARYNX. 649 membrane invading tlie glottis, tbe greatest danger is to be apprehended. In croup, emetics are useful; and occasionally a few leeches applied over the sternum, I have seen act like a charm. Observe that when applied, they must be placed carefully over the bone, so that the hemorrhage may afterwards be commanded by slight pressure ; for if placed on the throat or soft parts, as has occasionally been done through inadvertence, the danger and inconvenience afterwards is very great. If suffocation be threatened, the sooner tracheotomy be performed the better, for although that operation is far from being always successful, and is not unattended with danger, the risk from the disease I hold to be much greater. Dr. J. Buchanan of Glasgow has recently published an account of twenty-one cases of diphtheria, all of which were on the point of suffocation when the operation was performed, with the result of causing recovery in seven. In all these cases I regard the mode of applying topical remedies introduced by Dr. Green as a most valuable addition to our other means of cure. The experience of that physician indicates, that the earlier it is applied the greater the chance of success, especially in acute cases of scarlatina and croup. It was first applied in hooping-cough by Dr. E. Watson of Glasgow, and has subsequently been tried in laryngismus stridulus, hay fever, and other diseases hitherto considered spasmodic, and with such success, as to lead to the conclusion that these disorders are essentially connected with local irritations or an obscure form of catarrh. In various kinds of laryngeal disease occurring in the adult, whether primary or secondary, I have employed it very extensively, in many instances with permanent good results, and in a large number with temporary alleviation. Indeed, nothing is more remarkable than the immediate effect it has in clearing the throat and improving the tone of the voice, and hence, in many cases which do not admit of cure, it may be employed as a palliative. As such, I have successfully used it in old cases of chronic laryngitis and bronchitis, clergyman’s sore throat, spasmodic asthma with accumulation of mucus in the trachea, and so on. In syphilitic and confirmed tubercular laryngitis, though not so bene- ficial, it is still in some cases decidedly useful. I have, however, met with several instances where it has been very injudiciously employed, and others where the sponge had been passed by unskilful hands re- peatedly down the oesophagus without any good effect, the patient having been persuaded for a considerable period that it had been applied to the larynx. Circumstances of this kind may bring the practice into dis- repute with some, but I trust you will discriminate, and neither lightly abandon it from a few failures, nor be led into the opposite error, of supposing, from one or two favorable cases, that it is capable of being invariably successful. Case CXXXIY."* — Pertussis — Violent Paroxysms — Bronchitis — Collapse of the Lungs — Recovery. History. — William Campbell, aet. 4^ — admitted 18th June 1864. The mother first noticed a cough in this child two weeks ago, which was accompanied by a distinct whoop. • About the same time he vomited a good deal of mucus at the close of cough- * Reported by Mr. H. S. Pavson, Clinical Clerk. 650 DISEASES OF THE RESPIRATORY SYSTEM. ing, which seemed to give him great relief. She knows no cause for the disease, except that, for a tew tine days previous to the commencement of the cough, the child played out of doors without shoes. Symptoms on Admission. — A strong, vigorous child. Respirations 68 per minute. Inspiration hurried. Percussion anteriorly normal. Sibilant and sonorous rales heard on both sides of chest. Posteriorly percussion normal. Sibilant and sonorous rales heard, with mucous rales over both bases of lung, with inspiration and expiration. Expectoration copious, nummular. Pulse 144, regular, but feeble. Tongue covered with a slight white fur — oedematous. Bowels regular. Stools natural. Skin moist. Patient emaciated. Other functions normal. Progress of the Case. — June 19/A. — Slept well last night, but had two or three fits of coughing. Expectorates large quantities of mucus. Took his breakfast this morning. Had several paroxysms of coughing at the visit, with the w^hoop so loud as to be heard not only over the ward, but in the neighboring passages. The congestion and lividity of the face, scalp, and neck, were well marked. He generally feels hungry after each paroxysm, and asks for something to eat. Dyspnoea continues. Pulse 150. Skin hot and dry. Had three stools to-day. Urine amber-colored ; sp. gr. 1022 ; acid reaction ; otherwise normal. Acid. Nit. DU. 3 j ; Tr. Cardam. Co. 3 ss ; Syrupi 3 ivss. M. Sig a dessertspoonful to be given every four hours. ^Ath . — Has continued the same, but on examining the chest anteriorly slight comparative dulness on right side inferiorly ; breathing tubular and harsh, with a few mucous rales. On left side, loud vesicular breathing, wdth abundant mucous rales. Posteriorly, dulness on percussion in lower third of right, and in lower fourth of left back. Percussion otherwise normal. At right base, breathing tubular, with clicking mucous rales ; higher up, breathing feebly tubular, mixed Avith vesicular breathing. On left side, breath sounds normal. Urine deposits lithates. 25/A. — Cough increased. Takes food as usual. Tongue clean. Bowels regular. Vomited after tea, in consequence of a tit of coughing. Pulmonary signs as yesterday. Sputum as on admission, only not nummular. Ordered a linseed poultice, with mustard on it, to be applied to the right side of the chest for ten minutes. Urine still loaded wdth lithates. Continues to take the acid mixture. 26/A. — No change. The acid mixture has been taken regularly, but appears to produce no effect on the disease. Ordered Linimentum Terebinthince Ace- ticum (PA. P.), to be rubbed over back and front of the chest twice a day^ especially over right side. 28/A. — Pulse 180, regular. Respirations 80 per minute. Tongue clean. Bow'els regular. Breathing rather troublesome. Skin warm and moist. T 0 discon- tinue Acid Mixture., and to have Sherry wine 3 ii daily. 29/A. — Slept pretty well last night. Took some bread and milk for breakfast. Had several paroxysms of cough during the night, but did not vomit. Vespere. — Was asleep at visit, but had a loud wheezing noise in his chest. Respirations hurried (68 per minute). Took some broth and meat for dinner. R Acidi Hydrocyan. DU. TT^xvi ; Syrupi Simplicis 3 ss ; Aquee Menthce Pip. 3 iiiss. M. Fiat mistura. A teaspoonful to be taken every second hour. He now slowly recovered, and was dismissed July 29th, the w'hoop and severe paroxysms of cough having disappeared, but with considerable w'heezing in the chest and occasional cough. Commentary. — Cases of hooping- cougli vary considerably as to the intensity of inflammatory and of spasmodic symptoms present, some- times one and sometimes the other being predominant. In the present case both were well marked. The bronchitis was intense, while con- densation of both lungs, from collapse, was present for a considerable time. The spasms, dyspnoea, constriction of the larynx, and attendant whoop, were also well marked. Having tried all kinds of remedies in this aff’ection, without deriving much benefit from any of them, my notice was directed by the class to the strong statements of Dr. Gibb as to the value of nitric acid taken internally in this disease. According to him, it is as effectual as quinine in intermittent fever, and it was therefore carefully given, and its use prolonged from the 19th to the 28th of June, but manifestly without the slightest benefit. Good nourishment, See Dr. Gibb on Hooping Cough, p. 335. BEONCHITIS. 651 and latterly a little wine, enabled the patient ultimately to struggle tlirougli the disease, which was very severe. I consider that hooping-cough is one of those disorders that runs through a certain course, and is very little affected by remedial measures. Our efforts should be directed to keeping the surface warm, preventing exposure to cold winds and alternations of temperature, and supporting the strength by good diet and a little wine. When the disorder becomes chronic, there can be no doubt that change of air often acts in at once removing the disease, much in the same way that it is frequently seen to relieve asthma. Analogous to the nervous phenomena observed in hooping-cough is the laryngismus stridulus, or crowing inspiration of children, which, as pointed oat by Dr. Ley, may often depend upon enlarged glands in the neck, and may originate in any cause irritating the recurrent nerve, di- rectly or indirectly, by diastaltic action, as ably pointed out by Dr. Marshall Hall. It is not an uncommon symptom, for instance, in aneurismal swellings affecting the throat and root of the neck. BRONCHITIS. Case CXXXY.* — Acute Bronchitis. Histoky. — Martin Conolly, aet. 25, a robust laborer — admitted May 16th, 1857. On the 7th of May, after working some days standing in water, he had a rigor, with great heat of skin, followed by profuse perspiration, but no headache. He continued at his work till 10th May, when he was confined to bed, the pain having got worse. Cough commenced the previous day, accompanied with a thick yellow sputum, and these symptoms, with dyspnoea, have gradually increased in severity up to his ad- mission. Symptoms on Admission, — Form of chest unusually rounded and well developed. Anteriorly, percussion is clear on both sides. On auscultation, inspiration is short- ened ; expiration prolonged, and accompanied by long sibilant and sonorous rales. Vocal resonance weak, but equal on both sides. Posteriorly there is clear resonance on percussion on both sides. On auscultation, the same sibilant and sonorous rales accompany expiration, and are occasionally but rarely heard with inspiration, which at the right base is accompanied by moist rales. Cough and dyspnoea urgent. Re- spirations 36 per minute. Expectoration gelatinous and muco-purulent. Cardiac sounds somewhat masked, but normal. Pulse 122, strong, full, and regular. Skin hot, but otherwise normal. Tongue moist and clean. Appetite much impaired. Thirst great. Bowels regular. Urine high colored, otherwise normal. Venesection to 14 oz. was performed by Dr. Bennett without any immediate relief, and § ss of the following mixture ordered to be taken every four hours. R . A quae Acetatis Ammo- nice 3 iss ; Spirit. ./Ether. Nitrici 3 ij ; Vin. Antimonial. 3 ij ; Aquam ad § vj. In the evening, dyspiima had much diminished. Respirations 24 per minute. Pulse 108, still regular, full, and stroi.g. Heat of skin less. Progress op the Case. — Next day improvement was found to continue. Pulse 116, full, but softer than yesterday. Sibilations no longer audible with expiration. The moist sounds are fainter and less abundant than at last examination. May \%th. — Sibilant and cooing rales accompany both respiratory acts posteriorly. Anteriorly these sounds are less intense, but are accompanied by fine crepitus. Under the left nipple, crepitus is mixed with a certain harshness, both on expiration and inspiration (friction?) Urine rendered turbid by the presence of urates. Pulse 116, of the same character as yesterday. May \2th (twelfth day of the disease). Patient was found bathed in profuse perspiration. The moist sounds are diminishing in amount. Crepi- * Reported by Mr. W. H, Davies, Clinical Clerk. 652 DISEASES OF THE EESPIEATOEY SYSTEM. tation still audible under left nipple. Patient still complains of pain in that region, but there is no friction. Cough continues, but is less severe. Sputum still copious and muco-purulent. Pulse 102, soft. Appetite improving. Skin moist. Urine throws down a copious sediment of urates. May 21s< (fourteenth day). — Patient still per- spires profusely. Crepitation with fine sibilus still heard anteriorly, most distinctly under left nipple. Pain in left side continues, being most severe on deep inspiration. Sputum diminished in quantity, muco-purulent. Pulse 100, soft and full. On the 26th, moist rattle had nearly. disappeared. On the 29th, sibilations were very faint, the cough was trifling, and sputum nearly gone. June Ath . — He was discharged quite well. Commentary . — This was a case of violent acute bronchitis of both lungs, in a strong vigorous man. On admission, so great was his dyspnoea, that I bled him with a view of determining whether the re- medy would relieve that symptom. I satisfied myself that it had no im- mediate effect, and the disease subsequently ran its natural course, ter- minating in perfect recovery on the twenty-first day. Bronchitis, like laryngitis, consists of an exudation infiltrated into the various tissues forming the bronchi, or coagulated upon their mucous surface. It terminates in the transformation of this exudation — accord- ing to laws previously explained, p. 166 et seq . — into matters which permit of being either absorbed into the blood or expectorated. At first the lesion causes increased dryness, narrowing, and rigidity, and subsequent- ly moisture, dilatation, and relaxation of the tubes. Owing to these changes, the vibrating sounds caused by the passage of air through the bronchi undergo variations, which indicate pretty clearly the dry or moist nature of the disease, or, as some term it, dry or moist catarrh. Acute bronchitis may differ in intensity, from an affection very tri- fling and scarcely regarded, to one which very nearly approaches in se- verity a decided attack of pneumonia. It may be epidemic, and con- stitute what is called influenza. It may follow or precede a similar lesion in the lining membrane of the nasal passages, that is, coryza. These affections are so common as to be . generally treated by domestic medi- cines only, or, it may be, totally disregarded. But there can be no doubt that a disposition to attacks of this kind, though they may often occur for a long time with impunity, frequently leads to the incurable and distressing change of pulmonary texture known as emphysema.^ with its fearful accompaniment of spasmodic asthma and consecutive disease of the heart. Bronchitis, therefore, is an affection which, if not check- ed early, should be carefully assisted through its natural progress. To check the progress of an incipient bronchitis or coryza, when slight, Dr. Christison recommends a full dose of morphia on the first, or at latest second night, on going to bed. In the morning the patient should breakfast in bed, and keep himself warm at home during the day. Should the disease progress, patience is perhaps the best remedy, as the disease will run its course. But if the bronchi become clogged, sudori- fics and expectorants, especially ipecacuanha, may be useful, and a sina- pism or blister will sometimes dissipate any lingering trace of the dis- ease. The chief caution to be given should be to get perfectly rid of the disorder before any exposure to cold air be allowed. It is the dis- regard of this point, and the getting “ cold upon cold,” which serves so much to keep up the affection, and at length induces the chronic form of the disease. BEONCHITIS. 653 Case CXXXVL"^ — Chronic Bronchitis — Acute Peritonitis — Collapse of the Lung. History. — MaryNichol, aet. 21, a servant — admittedJuly 8th, 1851. She has suf- fered more or less from cough for the last two years. Occasionally it has been very troublesome, but not accompanied by much expectoration. Seven weeks ago experi- enced severe pain in the epigastrium, and since then the breathing has become short and hurried. Symptoms on Admission. — Anteriorly the lungs are everywhere resonant on per- cussion. On auscultation, the inspiratory murmur is harsh, and towards its termina- tion fine sibilant rales are heard. Posteriorly, the right side is more dull on percus- sion than the left. This is more marked towards the apex. At this point there is harsh inspiration and increased vocal resonance. There are also, over the whole right back, sibilant rales during inspiration. Cough, with trilling mucous expectora- tion ; respirations short and hurried ; great tenderness over the epigastrium, increased on taking a deep inspiration ; appetite tolerably good ; no nausea or vomiting, and, with the exception of constipation, digestive system healthy ; pulse 80, soft ; heart sounds natural ; catamenia regular ; urine voided with pain, and in small quan- tity, otherwise healthy. Progress op the Case. — The dry rales accompanying the inspiration continued for some days; but on the 21st they became moist, and coarse crepitation was audi- ble over the inferior third of right back. The cough became more loose also, and the expectoration increased. On the 24th, the moist rattles were converted into deep sonorous murmurs, and great variations were heard from day to day, evidently in con- sequence of the greater or less amount of fiuid in the bronchi. The cough and ex- pectoration also varied greatly in intensity. Her principal complaint, however, was the epigastric pain, which, notwithstanding the application of leeches, warm fomenta- tions, opiates, and counter-irritants, continued to increase. On the 28th there was diffuse swelling of the abdomen, general tenderness of the surface, and all the symp- toms of peritonitis from intestinal perforation. Latterly there was dulness and ab- sence of respiration over the lower thh-d of right lung. She died August 10th, 1851 ; but unfortunately no dissection could be procured. Gommentanj. — This girl labored under a chronic bronchitis of some standing, which presented, during the progress of the case, most of the physical signs characteristic of the disease. Her chief complaint, how- ever, was a fixed pain in the epigastric region, which proved in no way amenable to treatment, and which, as the event proved, was evidently connected with an ulcer either in the stomach or neighboring intestinal viscera, probably the former, considering the frequent occurrence of ulcers in that viscus among- servant girls. But in the absence of the facts which a dissection only could have afforded, all speculation on such a point is evidently useless. The dulness on percussion at the apex of the right lung, the harsh inspiration and increased vocal resonance, point to the existence of some condition of the organ at that point, giving it increased density. They constitute the signs of incipient or of cretaceous tubercle. But percussion over the whole of right back was impaired ; and towards the close of life, as weakness appeared, there was dulness and absence of respiration over the lower third of right lung. These physical signs indicate collapse of the organ in this situa- tion, or a condition which has been variously called by pathologists “ condensation ” — infarction ” — “ hypostatic pneumonia ” — “ peri-pneu- monie des agonisans,” etc. etc. In a series of observations on bronchitis, by Br. W. T. Grairdner,f he points out, as one of the most common results of the disease, more or less collapse of the vesicular tissue, dependent on obstruction to the * Reported by Mr. C. D. Phillips, Clinical Clerk, f Papers in Monthly Journal for 1850. 654 DISEASES OF THE RESPIRATORY SYSTEM. passage of air during inspiration, by glutinous or inspissated mucus. This collapse is often confined to individual lobules, which are condensed, comparatively heavy, indurated to the feel, of dark color, and present the usual characters of the unexpanded portions of lung in the newly- born infant iateleciasis). Doubtless, also, such collapsed lobules have often been mistaken for lobular pneumonia, or pulmonary apoplexy in children. Dr. Gairdner has further recorded facts, which render it highly probable that this collapse becomes more diffused in chronic cases of bronchitis, when a large bronchus is obstructed, as represented Fig. 449, and when, from the weak- ness of the individual, from abdominal disease, or want of resistance in the thoracic walls, the pa- tient is unable to clear the air-passages by a strong expiratory effort. Hence why this lesion is com- mon in fever, in bronchitis accompanying perito- nitis or ascites, and in young children. The case recorded is evidently one where, from the physical signs and other symptoms, we can have little doubt that collapse in the right lung occurred to a considerable extent. Case CXXXVII .^ — Chronic Bronchitis — Emphysema — Acute Laryngitis, History. — Edward Jackson, ast. 22, a robust negro, cook to a vessel — admitted February 14, 1851. He says that three months ago, when at sea, he first began to suffer from cough, expectoration, and shortness of breath, which symptoms, notwith- standing various remedies given him by his captain, have continued to increase up to the present time. Symptoms on Admission. — Anteriorly the thorax is unusually arched from above downwards. On percussion, there is everywhere loud resonance, especially in front. On auscultation, the expiration is much prolonged, and accompanied by sibilant and sonorous rales, louder and more general on the right side. There is frequent and pro- longed cough, accompanied by copious frothy mucous expectoration, gi’cat dyspnoea on making an exertion, and occasionally coming on in paroxysms without any obvious cause. Cardiac sounds normal. Pulse 80, strong. Frequently vomits after a severe fit of coughing ; but the digestive and other systems are otherwise healthy. Progress of the Case. — In addition to the dry rales heard when he ivas first ex- amined, it was soon ascertained that copious coarse moist rales appeared posteriorly and inferiorly, especially on the right, but also on the left side. These rales were oc- casionally absent, but continued tolerably constant. The dry rales also underwent from time to time several variations in tone, intensity, and situation. During February, May, and June, he was tortured by severe and prolonged attacks of dyspnoea, during which he gasped for breath, and appeared on the point of suffocation. The attack generally terminated by violent cough, expectoration, and vomiting, after which he always felt relieved. These attacks came on every second or third night, and were sometimes occasioned by an unusually full meal. In May there was noticed, in addition to the other physical signs, a coarse moist tracheal rattle, so loud as to mask the pulmonary sounds. On one occasion, during this month, the attack of dyspnoea lasted four hours, producing partial asphyxia, delirium, and stupor. On the 24th of May, he was attacked with sore throat, and difficulty in deglutition, followed on the 39th by laryn- gitis and partial aphonia, which greatly aggravated the asthmatic attacks. During all this time, expectorants, antispasmodics, anodynes, counter-irritants, with occasional * Reported by Mr. W. M. Calder, Clinical Clerk. Fig. 449. Plug of mucus or coagulated blood, so placed that, while it admits of partial expiration, it prevents inspiration and causes collapse of the pulmonary tissue, to which the smaller bronchi are distributed. — ( Gairdner.) BRONCHITIS. 655 emetics, and cupping, were employed, with temporary but no permanent benefit. In April and May the smoking of stramonium evidently alTorded him considerable ease. He also experienced marked relief from a draught containing 3 iss each of Tr. Lobe- li£e and of Ether. Towards the end of June, a sponge, saturated with a strong solu- tion of nitrate of silver, was passed into the larynx several times, with marked bene- fit ; indeed, so much so, that, on the 11th of July, his condition was greatly im- proved, the attacks of dyspnoea ceased, and the cough, expectoration, and other symptoms, were much abated. On the 16th, he was dismissed at his own recpiest, to resume his occupation as cook on board ship. The sore throat and laryngitis had then disappeared, but the chest was still unusually resonant on percussion ; there was loud tracheal breathing, prolonged expiration, and occasional sibilant rale. Kespira- tion, however, was comparatively easy, and he considered himself, as he certainly was, greatly relieved. Commentary . — This man presented all the physical signs and symp- toms indicative of extensive emphysema dependent on chronic bronchitis, accompanied with the most severe asthmatic attacks. These attacks were of a spasmodic character, referable to irritation of the inci- dent filaments of the pneumo-gastric nerve, and to reflex action by means of the excident ones, whereby the bronchial tubes were contract- ed, the glottis clqsed, and the muscles of inspiration rendered incapable of dilating the chest. Violent cough and vomiting were always induced towards the close of the attack, followed by relief. The dyspnoea dur- ing the course of the disease was alleviated by antispasmodics, and the laryngitis by topical applications, of which I have previously spoken. I consider, however, that his recovery was mainly due to the advance of summer and a change of temperature — circumstances whicli should never be overlooked in estimating the effects of treatment in such cases. Of all the causes which excite asthmatic paroxysms in individuals laboring under emphysema, the effect of certain seasons and changes of temperature is the most unequivocal, and yet the most mysterious. Thus some persons who are martyrs to the disease in winter are perfect- ly well in summer, and vice versa. Some are immediately affected by the foggy air of Loudon, and are well in the country ; others arc at- tacked when the wind blows from a particular quarter, especially the east. However difficult it may be to explain such idiosyncrasies, there can be no doubt that a knowledge of these circumstances will enable those who can change their residence, to alleviate their sufferings in no small degree. Emphysema is characterised anatomically by a permanent enlarge- ment of the air-vesicles of the lung. These may frequently be seen through the pleura, with an ordinary lens, like groups of minute pearls. Two or more of them may break into each other, and produce others of larger dimensions, say the size of a millet seed, and this process may go on, until, by the breaking down of the intervening partitions, every size of emphysematous cavity may be formed, up to that of a large orange. The walls of such cavities remain permanently open, having lost their elasticity. The tissues which form them also are evidently atrophied, and their paleness proves that the capillaries have been so compressed as to be either obliterated or impervious to the passage of blood. In order to account for emphysema, numerous theories have been advanced, of which I shall allude to only the first and last. Laennec 656 DISEASES OF THE EESPIEATORY SYSTEM. supposed that the fine bronchial tubes became rigid and more or less im- pervious from swelling of their lining membranes or impaction of mucus. He conceived that inspiration was a more powerful action than expira- tion, so that while air could be drawn through the obstructions, it could not be breathed out. In consequence, it accumulated in the ultimate pulmonary vesicles, became expanded by heat, and so acted mechanical- ly as a dilator, distending them from within, and causing them to en- large more and more according to the duration of the disease, and ex- tent of the respiratory efforts. Dr. Gairdner, however, has pointed out that expiration is a much more powerful act than inspiration, and that there is never any difiiculty in causing expulsion of air. It is the in- spiration which is laborious in all bronchitic cases, and, as has been previously stated, when the tubes are obstructed, so far are the air-cells beyond them from being dilated that they are in truth collapsed. Em- physema, then, does not occur in the vesicles connected with obstructed tubes, but in those healthy ones which are adjacent. When the lungs are in a normal state, the column of air presses equally on the tubes and vesicles, but when one portion connected with any obstruction is col- lapsed or otherwise diminished in bulk, then the neighboring portion is over-expanded, so as to occupy the space previously filled by the former. Hence why em.physema occurs not only as a result of bronchitis, but of chronic phthisis, or any other disease which causes contraction and hypertrophy of the pulmonary fibrous tissue. Dr. Jenner also says,* “ The atmospheric air moved by the inspiratory effort can exert com- paratively little pressure on the inner surface of the air-cells situated at the extreme margin of the base, the root of the lower lobe {i. e., that part immediately next the spine and below the primary bronchus), or at the part of the apex situa ted in the furrow posterior to the trachea on the right side. While violent expiration, being chiefly performed or greatly aided by the abdominal muscles forcing upwards the liver, etc., drives the air (in consequence of the highly arched form of the dia- phragm in violent expiration) from the central part of the lung, not only through the bronchi towards the larynx, but also towards the circumfer- ence of the lungs, i. e., towards those parts which are the least com- pressed during expiration.” This view is confirmed by al Ithat we know of the usual seat of emphysema, and by the effects of expiration as made visible under particular circumstances. In the case of M. Groux, in whom the sternum was deficient, it could be demonstrated that it was only by a forced expiration that the lungs so expanded, as to protrude through the aperture.f The treatment of chronic bronchitis must be directed to facilitate expectoration by means of various expectorants, and to allay the irrita- bility of the bronchial passages by means of anodynes. I have already alluded to the circumstance, that chronic pharyngitis, tonsillitis, elonga- tion of the uvula, and follicular disease of the epiglottis, keep up a cough, often mistaken for chronic bronchitis ; and it is in these disorders that demulcents, lozenges of various kinds, astringent and stimulating gargles, etc., are found temporarily beneficial. In such cases the employment of * Medico-Chir. Trans, of London, vol. xl. \ Edin. Med. Journal, vol. iii., p. 853. 1868. BRONCHITIS. 657 the spon^’e, saturated in a solution of nitrate of silver, is, as we have seen in Case CXXXVII., of the greatest advantage. Perhaps there is no disease in which blisters and counter irritations are more useful than in bronchitis. When chronic bronchitis is associated with emphysema, and accom- panied by spasmodic attacks of dyspnoea, the various kinds of antispas- modics are most serviceable. Sulphuric and chloric ether often act like magic ; and the smoking of stramonium, with or without opium, and other remedies of this class, though they seldom cure, produce great relief. The idiosyncrasy of the asthma should also be studied, and a change of temperature or locality advised, according to the peculiarities of the case. In very severe and chronic cases this may be regarded as the only curative procedure. Case CXXXVIII.* — Chronic Bronchitis — Emphysema — Injection of the Bronchi with a solution of the Nitrate of Silver. History. — Eliza Dawson, set. 24, a servant — admitted 2Vth May 1857. — About fourteen months ago, after exposure to damp and cold, she was seized vvith a severe pain in the chest accompanied by cough. The pain in the chest disappeared in a few days, but the cough persisted, though it was not very troublesome, till twelve months ago, when again it became very severe, the house in which she was living being damp. The pain in the chest at the same time returned. In the middle of last January the pain and cough increased in severity, and were accompanied by consider- able dyspnoea. She derived no benefit from treatment, and was at length compelled to apply for admission, because her weakness was such as to prevent her continuing at work. Symptoms. — On percussion over the chest, resonance is very loud both anteriorly and posteriorly. On auscultation, expiration is everywhere prolonged. Sibilant and snoring sounds accompany inspiration and expiration on both sides, anteriorly and posteriorly. Vocal resonance everywhere diminished. Cough and dyspnoea paroxys- mal ; the respiration being labored even in the intervals. Expectoration in moderate quantity, consisting of frothy fluid floating over tough gelatinous mucus. Apex of heart cannot be felt. Cardiac sounds normal, but masked by the pulmonary sounds. Pulse 74, of moderate strength. Tongue clean, but somewhat dry. Appetite impaired. Feels pain in the epigastrium after taking food. Dowels generally constipated, requiring the occasional use of aperients. Other functions normal. Spirit. JEther. Nitric. I iij ; Spirit. Ammon. Aromatic. 3 iv ; Aquarn ad 3 vi. A table-spoonful to he taken thrice a-day. The chest to he dry-cupped anteriorly and posteriorly. Progress of the Case. — She has experienced great relief from the treatment, and on 1st June the snoring sounds are reported to have disappeared. On that day, how- ever, the dyspnoea again became distressing, and on 3d June, the sibilant and sonor- ous rales had returned. Was ordered Spirit. uEther. Sulphuric. 3 ij. ; Sol. Mur. Morph. 3 iss ; Decoct. Senegce ad §vi. A tahle-spoonfd to he taken thrice a-day. A blister (3 by 4) to he applied over the chest. This was followed by great relief; sibilus continued audible, but the sputum diminished in quantity, becoming altogether mucous. On the 13th, cough and dyspnoea again became severe, with pain in the chest. A blister (3 by 4) was again applied with benefit. 27^A June. — The dyspnoea has re- turned during the last few days, the paroxysms occurring chiefly during the night. During the fit she sits up in bed; the whole chest heaves; the head is thrown back during inspiration ; the face is unusually pale and moist with perspiration ; lips pallid ; aiticulation slow and measured; respiration accelerated with prolongation of expira- tion. A drachm of sulphuric ether., and half a drachm of Sol. Mur. Morph, in a draught., gave immediate relief. The fits now became less frequent, diminishing at the same time in severity and duration. On 13th July, after the previous application for a few days of the sponge to the throat. Dr. Bennett injected, by means of a catheter introduced into the trachea, 3 ij of a solution containing half a drachm of nitrate of silver to § j of water. The operation was repeated next day. There was no return of dyspnoea till 15th July, when she had two paroxysms, both followed * Reported by Mr. Stephen Scott, Clinical Clerk. 42 658 DISEASES OF THE EESPIRATOEY SYSTEM. by vomiting. She had a third paroxysm next morning at 4 o’clock, vhich left her very weak ; respiration at 2 p.m. being still considerably embarrassed. On 1 7th July, 3 ij of the solution of nitrate of silver were again injected into the trachea. No difficulty is experienced in passing the tube, nor is any inconvenience felt by the patient. The presence of the catheter in the trachea was demonstrated by tlie propul- sion of 2 01 3 drops from the external orifice to a distance of 3 feet during a forcible expiration. After the operation, she passed a much better night ; the cough and ex- pectoration being very much less, and the respiration perfectly easy. On 22d July the operation was repeated ; she vomited in an hour and a half after it, but remained com- paratively free from cough and dyspnoea till 30th July, when a re-accession occurred. On 1st August, 3 ij of the solution were again injected, and on 4th August she left the Infirmary to obtain change of air. Commentary . — This also was a case of chronic bronchitis, with em- physema and severe paroxysms of asthma, in which various remedies were tried with the elfect of temporarily alleviating the dyspnoea. Dur- ing her residence in the house, much of the bronc.hitis gradually disap- peared, but the emphysema and asthma continued and underwent little change. It appeared to me a favorable opportunity for trying the new practice introduced by Dr. Horace Grreen of New York, of bronchial in- jections with a solution of nitrate of silver. We were singularly favored in this case by the high position of the epiglottis, and the com- parative insensibility of the larynx. The sponge saturated with the nitrate of silver solution, apparently caused no irritation whatever, and on passing the catheter through the rirna glottidis little uneasiness was manifested. Two drachms of a solution ( 3 ss of the salt to 3 j of water) were injected into the trachea several times, producing only a feeling of warmth in the chest, but, as she frequently declared, greatly diminish- ing the cough and expectoration from one to two days afterwards. This woman, with the catheter deep in the trachea, closed her mouth round the tube, respired through it, and could blow so as to render the ex- pelled air quite sensible to the finger. No one could doubt that the tube was in the trachea, and that the solution had passed into the lungs. After her dismissal, I continued to see her, and subsequently increased both the strength and quantity of the injection. Latterly I have thrown in 3 ss of the strength of 3 ij of the salt to 3 j of water. She emigrated to Australia, May 1858. On Injections into the Bronchi in Pulmonary Diseases. In a publication which I received from Dr. Horace Green of New j' ork in 1856, there is a table of 106 cases of pulmonary disease, which were treated by injections into the bronchi of a solution of nitrate of silver. A flexible catheter was introduced through the larynx, into the right or left division of the trachea, and, by means of a glass syringe, the injection thrown into the lung. This bold proceeding was described as producing great benefit in cases of pulmonary tuberculosis, bronchitis, and asthma. Whilst tuberculosis is at first a constitutional disease, its localization in any part reacts more or less on the general health ; and the opinion I have long entertained, that any means which could enable the physician to act directly on the tissue of the lung or inflamed bronchi, would assist his efforts at cure — at once led me to take a favor- able view of this new mode of treatment. The nitrate of silver ought to act as beneficially on the mucous membrane of the trachea and bronchi BRONCHITIS. 659 as on that of any other hollow viscus, and we have seen previously that the- remedy may be applied to the traclieal mucous membrane by means of an artificial opening (see Case CXXXIII.), not only without injury but with decided benefit. The difficulty was obviously to get it there through the rima glottidis. I therefore wrote to Dr. Green, requesting him to send me the instruments he employed. In a letter which I re- ceived from him in reply, dated New York, January 30, 1857, he says : — “ 1 would, with much pleasure, send you the instruments I employ, but they are simple, and may be obtained at any surgical instrument maker’s shop. They consist of an ordinary flexible or gum catheter, and a small silver or a glass syringe. The catheter is Hutching’s gum- elastic catheter (Nos. 11 or 12), which is 12|- inches in length; and as the distance from the incisor teeth to the tracheal bifurcation is, ordi- narily, in the adult, about eight inches, if this instrument is introduced so as to leave only two inches of the catheter projecting from the mouth, its lower extremity must of course (if it enter the trachea) reach into one or the other of its divisions. I first prepare my patients by making applications with the sponge-probang, for a period of one or two weeks, to the opening of the glottis and the larynx, until the sensibility of the parts is greatly diminished. Then, having the tube slightly bent, I dip the instrument in cold water (which serves to stiffen it for the moment, and obviates the necessity of using a wire), and with the patient’s head thrown well back, and the tongue depressed, I place the bent extremity of the instrument on the laryngeal face of the epiglottis, and gliding it quickly through the rima glottidis, carry it down to or below the bifur- cation, as the case may require. It is necessary that the patient continue to respire, and the instrument is most readily passed during the act of inspiration. The tube being introduced, the point of the syringe is in- serted into its opening, and the solution injected. This latter part of the operation must be done as quickly as possible, or a spasm of the glottis is likely to occur. Indeed, if the natural sensibility of the aperture of the glottis is not well subdued by previous applications of the nitrate of silver solution, or if the tube in its introduction touches roughly the border or lips of the glottis, a spasm of the glottis is certain to follow, which will arrest the further progress of the operation. The epiglottis^ which is nearly insensille (and this you may prove on any person, by thrusting two fingers over the base of the tongue, and touching, or even scratching with the nail, that cartilage), should be our guide in perform- ing the operation. The strength of the solution for injecting is from 10 to 25 grains to the ounce of water. Commencing with 10 or 15 grains to the ounce, its strength is subsequently increased, and the amount I now employ is from \ to 1^ drachms of this solution. “ In cases of bronchitis, asthma, and in phthisis, even the employ- ment of the tube once or twice a week diminishes the cough and expec- torations with great certainty, especially in the two former diseases ; and many cases ha'^e recovered under the local treatment after other means have failed. The applications of the sponge-probang are continued in the intervals of the employment of the tube.” My period of attendance on the clinical wards having expired in January, it was not until May 1857 that I had an opportunity of making a series of observations on this subject. I was then fortunately assisted 660 DISEASES OF THE EESPIEATORY STSTESf. by Professor Barker of New York, wlio showed me the kind of catheter he had seen Dr. Green employ, and demonstrated the manner in which the operation was performed. Without entering into minute particulars, I have only to say that I have confirmed the statements made by Dr. Horace Green. I have now introduced the catheter publicly in the clinical wards of the Boyal Infirmary, in several patients affected with phthisis in various stages, in laryngitis, and in chronic bronchitis, with severe paroxysms of asthma. In other cases in which I attempted to pass the tube it was found to be impossible ; in some because the epiglottis could not be fairly exposed, and in others on account of the irritability of the fauces, and too ready excitation of cough from pressure of the spatula. I have been surprised at the circumstance of the injections not being followed by the slightest irritation whatever, but rather by a pleasant feeling of warmth in the chest (some have experienced a sensa- tion of coolness), followed by ease to the cough, and a check for a time to all expectoration. In making these injections, I have observed very great differences in the form of the epiglottis, as well as in the irritability of the fauces and root of the tongue in different individuals. In some persons the epiglottis is easily exposed, and on depression of the tongue may be seen standing erect, quite inseuvsible as stated by Dr. Green, so as easily to permit the passage of the catheter. In other cases, the top of the epiglottis can only be reached with the greatest difficulty, and in several is not to be seen at all. In such cases I have not as yet attempted to pass the catheter. Again, while some individuals can bear without difficulty forcible depres- sion of the tongue, and considerable freedom in touching the fauces and rima glottidis, others are thrown easily into violent spasms, or exhibit great irritation in the parts, from the mere pressure of the spatula. This appears to me to be more constitutional than dependent on local disease ; some persons being more irritable or easily excited than others, and I have observed the same difference in individuals who are in all respects perfectly well. On one occasion I put the sponge through the rima, and allowed it to remain some seconds, completely obstructing respiration, but without causing cough or any other inconvenience. In the case of Dawson (Case CXXXVIIL), very trifling irritation was occasioned by the pressure of the catheter. Whenever great irritability exists, the operation ought not to be performed. One phthisical gentleman who, with a desire to have the operation com- pleted, violently restrained all efforts to cough when I was in the act of injecting the solution, experienced great pain in the chest for several days. PLEURITIS. Case C XXXIX .* — Acute Pleurisy — Recovery. History. — Mary Harvey, set. 21, a robust servant girl, was admitted into the clinical ward, July 23, 1851. She enjoyed good health until seven days ago, when, after unusual exposure to cold and wet, whilst washing clothes, she was seized with difficulty of breathing, and a sharp cutting pain in the right side. She shortly afterwards experienced headache, general soreness, and the usual symptoms of fever * Reported by Mr. C. D. F. Phillips, Clinical Clerk. PLEURITIS. 661 but does not remember having had rigors. The dyspnoea and local pain have increased in intensity, although the febrile symptoms on admission had somewhat abated. • Symptoms on Admission. — On percussing the right lung anteriorly, there is com- plete dulness over its lower half, and, posteriorly, the dulness extends over the two lower thirds of the lung. On the left side, the lung is everywhere resonant on per- cussion. On listening over the dull portion of right side, there is complete absence of respiration, with loud pealing vocal resonance. In the centre of lung posteriorly mgophony. No friction or crepitating murmur can be distinguished. On the left side, respiration is puerile. Slight cough, but no expectoration ; dyspnoea, but not urgent ; sharp cutting pain in right side, increased on taking a deep inspiration. Considerable headache and general soreness; the skin of natural temperature, but dry. Pulse 100, of natui-al strengtli ; tongue furred ; face flushed ; no appetite ; great thirst ; func- tions of the body otherwise well performed. Progress op the Case. — On the following day the dyspnoea and pain had diminished. On the morning of the 25th there was considerable sweating, and next day a copious sediment of phosphates and lithates appeared in the urine, and it was observed that the febrile symptoms had disappeared. The pulse was 84, soft. On auscultation, a friction murmur could be heard at the upper margin of the dulness on the right side. On the 3d of August the pulse was 72, and weak. The pain still con- tinued, and the physical signs were the same. On the 6th, the extent of the dulness, the aegophony, and the vocal resonance, began to diminish, and the friction murmur to increase. On the 9th no friction could be heard, and the respiratory murmurs were audible in the primary dull portion of lung. On the 27th, with the exception of slight dulness, she was quite well, and was dismissed by her own desire. On admis- sion, twelve leeches were applied to the affected side, followed by warm fomentations. Two purgative pills were administered, and a third of a grain of tartrate of antimony, with 3 ss of solution of muriate of morphia, ordered to be taken every four hours. Subsequently a succession of blisters was applied to the right side. On the 3d of August she was ordered a pill of calomel and opium three times a day. All the six prescribed were not taken, and no physiological action of the drug resulted. Commentary. — This was a case of uncomplicated acute pleuritis, with all the characteristic symptoms and signs, as described by systematic authors. The fever terminated by crisis through the skin and kidneys on the tenth day. The physical signs commenced to disappear on the seventeenth day, but had not wholly vanished until the thirty-fifth day. On admission, there must have been a considerable amount of ex- udation, with serum subsequently separated from it compressing the lung, so as to destroy the respiratory murmurs inferiorly. At the upper margin of the dulness, however, aegophony was heard, a sign as often absent as present in pleurisy, and certainly not deserving the importance which Laennec attached to it. The diminished action in the compressed lung was evidently counterbalanced by increased action in other portions of the pulmonary organs, as determined by the puerile respiration on the opposite side. Lastly, it was very instructive to observe how, as the fluid became absorbed, and the pleural surfaces were thereby allowed to come into contact, friction sounds were developed, and then ultimately disappeared, when union between these surfaces may be supposed to have taken place. The treatment slightly diminished the pain in the side, but in other respects evidently had no effect whatever on the progress of the disease. Case CXL.^ — Acute Pleurisy loithout Functional Symptoms — Rapid Recovery. History. — Peter M‘Guire, aged 21, laborer — admitted September 12th, 1866. (States that in June last he was seized with pain in right side, hot skin, and slight * Reported by Mr. A. Turnbull, Clinical Clerk. 662 DISEASES OF THE RESPIEATOEY STSTEil. fever, for which he was bled, blistered, and confined to bed for a fortnight. He per- fectly recovered, but for the last five weeks he had been unable to carry on his usual employment, in consequence of pains in his right shoulder, arm, and side. On Tues- day last (tlie 9th), these pains were unusually severe, accompanied, as he says, by dyspnoea, thirst, and heat of skin. On the following day (10th), although not confined to bed, he could not go to his work ; and finding no improvement take place, he came to the hospital. Symptoms on Admission. — Percussion note over whole of the left side of thorax is resonant. Respiration is somewhat puerile. On the right side the lung is every- where resonant on percussion, except posteriorly, where there is slight dulness below the level of the angle of the scapula, and laterally, below the level of the sixth rib. On auscultation over the dull portion, respiration is faint, but there is no friction or crepi- tation to be heard. At the apex the respiration is harsh, and the vocal resonance is louder than on the other side. At the base near the spine there is an approach to mgophony. Cough slight, attended by little pain. Expectoration scanty and frothy. No pain in right side, nor uneasiness in taking a deep inspiration. Circulatory system normal, with the exception of the pulse, which is 96, full. Bowels constipated. Ap- petite bad. Considerable thirst. Urine clear; does not coagulate on being heated, nor on the addition of nitric acid. Chlorides abundant. R Pulv. Ipecac. Co. gr. xii to be taken at bed-time. Proorkss of the Case. — September l-ith. — Has not perspired much during the night. Complains of slight palpitation, but has no pain of any kind. Heart’s sounds normal. On percussion over the right side of chest, the line of dulness, which in the recumbent position is at the fifth intercostal space, rises as high as the third when he sits up in bed. lUh . — Line of dulness now extends up to the second rib anteriorly, and is the same in all positions. Vocal resonance above the right nip- ple is loud, but breathing faint. At the apex, the expiration harsh and very much prolonged. Was ordered one-twelfth of a grain of antimony every four hours. Had a blister applied last nighty which has risen well. Sept. ikth. — ^No pain in the side even on a deep inspiration. Has no fever ; appetite good ; expresses himself as much better. Pulse 100, small and weak. Dulness has become universal over the right side posteriorly, and anteriorly ascends to the second rib, above which a cracked- pot sound is audible. There is now no difference on percussion, when in the upright and when in the recumbent position. Respiratory murmurs posteriorly are feeble and distant, not healthy ; aegophony well marked. On the left side posteriorly, expiration is puerile. Anteriorly on right side, respiration exaggerated superiorly, feeble in- feriorly, and vocal resonance increased. No friction murmur anywhere audible. Sept. ISth. — Dulness has extended higher. Cracked-pot sound more limited, but increased in intensity under the clavicle. Posteriorly an occasional fr iction sound was detected ; ordered to have this part painted with iodine. Sept. \9th . — Dulness now clearly limited by a line, the convexity of which is downwards, its greatest distance being from the clavicle one and a quarter inch, and its smallest distance one quarter of an inch. Sej)t. IsiJ. — Cracked-pot sound — now limited to a spot below the sterno- clavicular articulation — is not so audible. Complains of dyspnoea when walking. Sept. ^ad . — Cracked-pot sound replaced by a somewhat metallic sound. Patient feels so much better, that he is anxious to leave the hospital to resume his labors. 23(/. — Very little expansion of right side of chest even on deep inspiration. A warm poultice to be applied over the whole right side of chest. 26^/i. — Patient complains that after walking quickly he experienced dyspnoea. Hot spongio-piline to be ap- plied to foment the whole side. Patient takes three ounces of wine daily. 21th. — The convex line of dulness anteriorly, which has for seven days been stationary at the line mentioned on the 19th, has now become lower, and not so clearly defined. No cough nor expectoration. Pulse 80 per minute, rather feeble. Appetite pretty good. Fomentations and wine continued. October 2d. — Resonance in front, and internal to the nipple, extends as far down as sixth intercostal space. Dulness to the right of the nipple still remains. The resonant portion at the anterior and upper part of right side may be bounded by a line drawn from the upper part of the axillary region to the nipple. Pulse gradually gaining strength. 4th. — The an- terior portion of right side has almost entirely regained its normal resonance. Lateral region of same side is also more clear on percussion. Anteriorly and laterally over fourth and fifth ribs, and posteriorly to a lesser degree, there is heard friction de retour. The palpitation has again returned, and on auscultation, a very soft murmur is heard with the first sound. 13^/t. — Percussion perfect over the whole of anterior PLETJRITIS. 663 surface of right side of thorax ; still a little clulness posteriorly. Friction d(. retour is only slightly marked during ordinary respiration, \%th . — Both sides of chest expand equally on deep inspiration. Anteriorly over both sides of chest, resonance equal. Laterally, external to nipple of right side, there is marked sense of resistance and slight diminution of tone on percussion when compared with opposite side. Poste^ riorly over whole of right side, percussion duller than over left, but still resonance is greatly increased to what previously existed. On auscultation posteriorly, respiratory murmurs equal on both sides ; no friction anywhere but on right side ; vocal reso- nance increased, especially laterally below the axilla. His general health has long been quite good, and he insisted on going out. Dismissed. Commentary. — Od the admission of this man, it was supposed, and I still think correctly, that the comparative dulness which existed on percussion over the right back depended on the pleurisy he had had in the previous June, and that the wandering pains and slight fever were owing to rheumatism. Two days afterwards, fresh exudation was evi- dently poured into the right pleural cavity, and it is a remarkable fact that it continued to increase until the whole of that cavity was occupied, and this without fever, pain in the side, or any of those symptoms which are thought the usual indications of acute pleurisy. In this state the exudation remained stationary for seven days, then began to be absorbed, and gradually disappeared. In short, we had the most distinct evidence from physical signs of the commencement, onward progress, and decline of an acute pleurisy, without any functional symptoms whatever, the man all the time maintaining he was in perfect health, and being with great difficulty retained in the house for the sake of observation. In this respect, the case proves that an acute pleurisy, like an acute pericarditis (Case C.), may be altogether latent, and at no period of its progress give rise to those symptoms with which systematic writers have made us so familiar. For another remarkable example of this fact, see Case CXXVII. It is unnecessary to comment in this place on the importance of such cases in reference to treatment, and to former views as to the good effects of blood-letting and antiphlogistic remedies. In the case of Stanbroke (Case XCVII.), we saw that a pericarditis required no such remedies to enable it to pass through its natural progress, and we have here another illustration of the same fact in reference to pleuritis. Local pain appears to be an accidental occurrence, and in no way essential to a true inflammation. Case CXLI.'^ — Chronic Pleurisy on both sides — Bronchitis. History. — John O’Neill, set. 40, a writer — admitted into the clinical ward November 28th, 1850. Three weeks before admission, he was suddenly seized with a severe pain in his left side, which impeded breathing. Three days afterwards feeling better, he returned to his employment, but in the evening he experienced distinct rigors, and the pain returned. Strong febrile symptoms followed, with cough and expectoration. He has been under medical treatment since then, and now, on admis- sion, is considerably better. Symptoms on Admission. — On percussion, there is complete dulness over the whole of left side, anteriorly and posteriorly, with the exception of the infraclavicular region, where the dulness is incomplete. Over the whole of right side there is unusual resonance. The expansion of the chest is greatly diminished on the left side with absence of vocal fremitus. On auscultation, the respiratory murmurs are inaudible over left side, except at the apex, where there is prolonged expiration accompanied with sibilant rale. On the right side anteriorly, loud sibilant rales, both with inspira- tion and expiration. Posteriorly the respiratory murmurs are puerile. Increased vocal resonance, amounting to bronchophony, heard over whole of left side, assuming * Keported by Messrs. Cunningham and Calder, Clinical Clerks. 664 DISEASES OF THE KESPIRATOET SYSTEM. an 00 gophonic character over scapular region. On right side vocal resonaace normal. Frequent and severe cough, followed by copious expectoration of frothy mucus. No pain in chest on taking a deep inspiration, but occasional “stitches ” in left side. No dyspnoea. The apex of heart beats in the epigastrium, immediately below ensiform cartilage, and its sounds (which are healthy in character) are heard most distinctly on right side of sternum interiorly. Pulse 68, small. Urine turbid, with deposit of lithates. Appetite good. Other symptoms normal. Progress op the Case. — On the ^th of December a. frietion sound was heard below the left clavicle, and the resonance on percussion was more diffused. On the 26^A, loud friction sounds had extended from above on the left side down to an inch below the nipple, and dulness on percussion was confined to the two lower thirds of the lung. The bronchitis, also, was diminished, and on the l^th of January the cough and ex- pectoration had ceased, and the bronchitic rales had disappeared. On the 23(i of February a eareful examination showed that there was complete dulness over left lung, from the nipple downwards, and that on auscultation there were loud double-frietion sounds with absence of respiration. He now complained of dull pain on the right side of chest inferiorly, and on the following day there was heard in that situation a double- friction sound, which, however, disappeared on the ^th of March. It returned every now and then, accompanied by “ stitches ” more or less severe. On the of April there was dulness over both sides of chest, anteriorly from the nipple downwards, to- gether with double-friction sounds on both sides. The expansion of both sides of chest is now equal — that on the left side having greatly inereased, and the respiration being audible over its two superior thirds. During the whole of April the physical signs underwent no change, and he suffered considerably from dyspnoea. In May the dul- ness was more circumscribed on the left, and more extended on the right side. The dyspnoea, however, was diminished, and his general health so improved that he was enabled to take walks in the green. During the months of June and* July he continued to improve, but complained of occasional pain in the chest, and cough, Avith slight ex- pectoration, originating apparently from imprudent exposure to cold. The respiration, however, insensibly extemled itself inferiorly on the left side, and towards the end of July tlie dulness was greatly diminished on the right side also. At this time he was so well that he was dismissed, August 4. The treatment consisted at first of expectorants and anodynes to mitigate the bronchitis, together with a course of the iodide of potassium, and frequent blisters applied to the pleuritic side. In February.^ pills of calomel and opium were ordered, which caused slight salivation for a period of ten days. On the appearance of pleurisy on the right side, it was combated by frequent applications of leeches, followed by counter- irritation. The latter remedy was continued from time to time during his subsequent residence in the house, together with occasional expectorants, anodynes, anti-spasmodics, and purgatives, according as his symptoms required them. Commentary . — In this case the disease ran a more chronic course, beginning on the left side, and subsequently attacking the right. As the one declined, the other increased, and in both the physical signs deter- mined with great exactitude the extent of the fluid exudation, its subse- quent absorption, the rubbing of the diseased surfaces against each other, and, lastly, their subsequent adhesion. These changes occupied a period of upwards of eight months. Seeing the slow progress of the case, and the indisposition of the exudation exhibited to be absorbed, mercury was tried, and salivation maintained for ten days. At this time, such was the state of discomfort it produced, so thoroughly did it destroy the appetite and thereby diminish the vital powers, that it was discontinued. So far from causing absorption, the action of the drug not only failed to do so, but pleurisy on the opposite side actually developed itself while the system was under its influence. Surely facts of this kind ought to disabuse medical men of the notion, still very prevalent, of the power of this drug in causing absorption of an exudation. (See Pericarditis.) Pathology., Diagnosis, and Treatment of Pleuritis. The physical signs of pleurisy can scarcely be understood without an accurate acquaintance with the appearances which the exudation assumes PLEURTTIS. 665 on the pleural surface. This is essentially the same as has been previ- ously described in the case of Pericarditis, pp. .174 and 175. In very acute cases of pleuritis, which have proved rapidly fatal, I have repeatedly observed the following appearances ; — On elevating the sternum, care having been taken not to disturb the body for some hours, the pleural cavity on the side affected has been found full of an appar- ently clear fluid of a yellowish or greenish tint. On removing this by means of a small shallow cup, the first portions seem perfectly clear and transparent. On continuing to empty out the fluid, it has been ob- served that the deeper we descend the more turbid it becomes, until at length nothing but a semifluid mass is removed. It will frequently be found that large portions of this mass, although tolerably consistent, are semi-transparent, resembling a light-colored calf’s-foot jelly, whilst other portions present the usual opaque appearance. Sometimes, when the body has been undisturbed for twenty-four hours, the whole exudation is separated into two distinct portions, — the upper, fluid and perfectly transparent, whilst the lower is composed of a pultaceous mass, re- sembling a bread-and-water or oatmeal poultice. In all such cases, the fibrinous portions, from their superior specific gravity, have sunk to the bottom, whilst the supernatant serum remains clear. The semi- transparent lymph is the portion most recently exuded, in which very few of the plastic corpuscles formerly described, p. 165 have been developed. When the progress of the exudation is less rapid, the coagulated fibrin or lymph assumes a more consistent appearance, and forms, over the part inflamed, flocculi of different sizes, or a distinct lining, varying in thickness from half a line to an inch. This is always villous, but sometimes it presents a honey-combed appearance, or hangs in the serum in loose flakes of a dendritic character. A serous membrane, when in- flamed, resembles a mucous surface, and, in point of fact, performs the functions of or.e for a time, and is very active in absorbing the serum. Occasionally also it assumes a lamellar arrangement, attributable prob- ably to repeated exudations of blood-plasma at different times. This may be frequently observed on the pleura, and layer after layer may be readily dissected off. Sometimes there is more or less blood extravasated with exudation, causing it to assume various tints of red, mahogany, purple, etc., according to the amount thrown out, and the period which has elapsed before examination. When the inflammation has been less acute, or is of longer standing, we find, after death, that the coagulated blood-plasma or lymph has become more consistent. It assumes a more distinctly fibrous appear- ance, often extending between opposed serous surfaces in the form of bands, which have considerable tenacity and strength. These bands have a great disposition to contract, and ultimately become shorter and shorter, and assist in forming a dense substance, which at length firmly unites together the serous surfaces. This uniting substance becomes more and more dense, and not unfrequently resembles ligament in toughness and general aspect. In this form it may frequently be seen in phthisical cases, uniting together the lobes of the lung and pleura] surfaces. Occasionally it assumes even a cartilaginous hardness, resem 666 DISEASES OF THE KESPIKATOET SYSTEM. bling the fibro-cartilage of the intervertebral substance. In this state it may frequently be observed on the pleurae, and I have seen it thus half an inch thick, intimately uniting the lungs to the ribs. When it has been very slowly developed, it produces white indurated patches, of a glistening cartilaginous appearance, varying in extent, the surface of which has assumed the character of a serous membrane, and in no way interferes with the movements of neighboring organs. Such patches are exceedingly common on the sur- face of parenchymatous organs, as the lungs, heart, liver, spleen, and kidneys. Occasionally encysted ab- scesses of the pleura are resolved, and their walls contracting assume a cartilaginous hardness. Dr, Mark- ham has recorded a remarkable ex- ample where the pyogenic walls in this manner formed a tube sur- rounded by puckering of the pleura pulrnonalis, the lung itself being quite healthy.* (Fig. 450). The hardish gritty particles scraped from its roughened inner surface consisted chiefly of cholesterine and granular matter. Lastly, false mem- branes on the pleural surfaces, but Fig. 450. especially on the costal one, may assume a stony hardness, from the deposition of calcareous matter ; and patches of this character may be scattered over the serous membrane, or may exist in disseminated points. The minute structure ot the coagulated exudation, composed of plas- tic or pyoid corpuscles and molecular fibres, has been previously de- scribed and figured, p. 165. These fibres are more and more aggregated together the more dense the lymph becomes, and, in cases of calcareous deposition, are associated with molecules and irregular masses of earthy salts, mingled with crystals of cholesterine, and, it may be, numerous fatty molecules and granules. It results from our knowledge of the morbid anatomy of pleuritis, conjoined with careful observation at the bedside, that, if a large quantity of fluid be interposed between the pleurae, the respiratory murmurs will be lost, while the vocal resonance is diminished. If the amount of fluid be small, the murmurs are obscure, and the vocal resonance assumes a peculiar vibrating character, said to resemble the bleating of a goat. This is cegophony. If strings or bands of chronic lymph exist, which are stretched during the movements of the chest, then the rubbing sound will assume a leathery or creaking character ; and if there be calcareous deposition, a filing or grating noise may be produced, although this is ^ Patholog. Soc. Trans., vol. ix. p. 61. Fig. 450. Remains of a pleural abscess. — {Markham), PLEUEITIS. 6G7 very rarely heard over the pleurae. Not unfrequently dense adhesions, with thickening of the fibrous tissues uniting the pleurae, may occasion partial dulness, and increase of the vocal resonance, a result not uncom- mon at the apices of the lung, but which must be carefully distinguished from the condensation from tubercle. With regard to the treatment, it is essentially the same as that of other acute infiammations. It is rare that a case enters an hospital in its incipient stage, that is, when the serous membrane is unusually dry, and before much exudation has occurred. But in private practice such cases are more common, and occasionally they may come on in the ward of an hospital. At this early period, a general bleeding was formerly recommended, with a view of cutting short the inflammation, the possibility of which we have discussed at p. 306. When, however, exudation has been poured out to any extent, and has coagulated, bleeding is injurious, and we must endeavor to favor the development, absorption, and excretion of the exudation, by means of warm, topical applications, sudorifics, and diuretics. The urine especially should be carefull}" watched, as the sediments it contains will serve as an index to the amount of exuded matter excreted. Care should also be taken, at this period, not to allow the general strength to sink, for it is only by keeping up the nutritive functions that we can assist the vital powers in making those transformations which are essential in procuring the disappearance of the fluid, and adhesion of the solid exudation. By some, calomel is considered to be directly indicated as a means of favoring absorption from the serous cavity. It was fairly tried in Case CXLI., but was more productive of harm than of good; and although I have frequently seen the drug employed for this purpose, I have not met with a single instance where its good effects have been unequivocal. If there be much local pain, warm applications at first, and subsequently blisters, tend to remove it. On some occasions, when the exudation has been very abundant in the pleural cavity, and the vital powers of the economy are constitution- ally low, and have been depressed by injudicious antiphlogistic treatment or want of rest, the changes described do not occur. The exudation, in such cases, passes into pus, although some of the fibrous element attaches itself to and lines the membrane. This termination of pleuritis is denominated empyema. Case CXLII."^' — Empyema., with Fistulous Openings between the Lung and Pleural Cavity., and between the Pleural Cavity and External Surface. History. — George Fair, set. 30, a ploughman — admitted December 10th, 1850, in a very exhausted state. Fourteen months ago had acute pleuritis, on account of which he was confined to bed for eight weeks, and was bled several times. Three months afterwards he still felt occasional pain in the right side, which gradually became more constant and severe, and at length was accompanied by cough and ex- pectoration. He now perceived a small swelling below the right nipple, which, at the end of last July, was the size of a hen’s egg. It was then opened by incision, and a quart of purulent matter extracted. About the end of August, two other apertures formed spontaneously in the neighborhood of the previous one. As soon as matter ^ Keported by Mr. J. M. Cunningham, Clinical Clerk. 6G8 DISEASES OF THE RESPIRATORY SYSTEM. was discharged from the external opening, the amount of expectoration was di minished. Sympi'Oms on Admission. — Thoracic walls much depressed under right clavicle ; right side of chest motionless on taking a full inspiration ; three apertures still exist in the thoracic walls ; the upper one (that made by the incision) is between the sixth and seventh ribs, immediately below the right nipple, the two others a little lower down, and somewhat smaller ; from all three there is a copious purulent discharge. Circumfereuce of the thorax, on a level with the right nipple, measures thirty-five inches ; from the spinous processes of the vertebrae to the sternum, on the right side, measures sixteen and a half inches, and on the left, nineteen inches. On percussion, the left side is resonant throughout ; on the right side there is a dulness everywhere, but most marked in the inferior two-thirds ; posteriorly, the dulness is not so marked as in front. On auscultation, the respiratory murmurs on the left side are puerile ; under the right clavicle the respiratory murmurs are harsh, and the vocal resonance increased ; a little lower down the respiratory murmurs become more feeble, and there is crepitation with the inspiration ; in the remaining lower two-thirds of the right front, the respiratory sounds are inaudible ; over the whole right back, the respiratory murmurs are feeble ; the vocal resonance increased and segophonic ; in the lower third crepitation is audible. Pain over the sternum and under right . clavicle ; cough neither frequent nor severe ; expectoration scanty, partly white and frothy, partly tenacious and muco-purulent. Apex of heart beats feebly half an inch to the left of its natural position. Pulse 92, slightly jerking, but compressible ; general strength much reduced. Progress of the Case. — In the beginning of January, he was attacked with vomiting and diarrhoea, accompanied with febrile symptoms, which greatly diminished his strength ; his countenance assumed a hectic appearance, and the opening in the thorax became painful and larger, their margins were inflamed and ulcei-ating, and the discharge continued. On the l^ih, it was ascertained, by means of the probe, that of the three openings the middle one alone enters directly into the pleural cavity, and ad- mits with ease a No. 8 catheter ; the other two communicate with the central one underneath the integument. On the 29^/i, diarrhoea and purulent discharge from the chest had diminished, his appetite and general health were also improved, but he was removed from the house by his friends. The treatment consisted at first of good diet and tonics ; and when the vomiting and diarrhoea appeared, various remedies to check these symptoms. On the 18/A of January, a small canulaand No. 8 catheter were in- troduced side by side into the opening into the pleura. By means of a Bead’s syringe attached to the former, about a pint and a half of distilled water, at the temperature of 90°, was injected into the pleural cavity. The fluid escaped through the flexible catheter, but did not equal in amount what was thrown in, and was at length discharged clear and unmixed with pus. During the half hour immediately following the operation, a quantity of clear water oozed from the wound. Commentary. — When this man entered the house, his general strength was much reduced ; and it was apparent, from a careful study of the physical signs and symptoms, that a communication existed be- tween the lungs and pleural cavity, in addition to the external fistulous opening into the latter. The pleuro-pulmonary fistula had evidently formed before the opening through the thorax was made artificially, as evinced by the marked diminution of expectoration on the evacuation of pus externally. That it continued to exist, I was satisfied, by observing that the sputum was increased when the external discharge diminished, and vice versa. Two errors had been made in the previous treatment. These consisted, — 1st, In the “ frequent bleedings,” which had so dimin- ished the general powers of the system, as to have checked those changes in the exudation necessary for recovery ; 2d, In making a free incision, instead of a small puncture, to draw olf the purulent matter. Of these two errors, the first, however, was the greatest ; indeed it was irremedi- able. The second was probably undertaken with the idea formerly so prevalent, that pus is injurious to the economy, and wlien known to exist should be let out as soon and as freely as possible. We now know PLEURITIS, 669 ^hat there is nothing to be feared from the mere presence of piis, either in the lung or pleural cavity ; and that the most natural method for its disappearance is by absorption and elimination. Still, when large in amount, and either pointing externally, or displacing the heart internally, no danger can arise from making a puncture with a small canula, and allowing the matter to flow out, while we prevent air from passing in. Indeed there is every chance of producing benefit, for we thereby save the vital powers a considerable amount of unnecessary work, and so facilitate the disappearance of the exudation and return of expansion in the compressed lung. With regard to the operation of paracentesis thoracis, and the good effects attending it, I refer you to some excel- lent papers by Dr. Hughes,* and a lecture by Dr. Alison.f (See also p. 675.) In the case before us, the difficulty experienced was to rally the general strength, especially after it had been so much reduced by diarrhoea, and this was to some extent accomplished. My attention was then directed to the cure of the thoracic disease ; and it occurred to me that if the pus could be replaced by water, there would be less labor thrown upon the weakened absorbing surfaces. The pleural cavity, therefore, was washed out with distilled water, heated to 90° as di- rected ; and this would have been repeated at intervals, had he not left the house, and thus put an end to every effort undertaken for his benefit. Case CXLIII.lj; — Chronic Pleuritis and Pneumo-Thorax^ without Symp- toms — Articular Rheumatism — Pericarditis — Recovery. History. — William Dow, get. 33, boot, -maker — admitted 26th of January, 1857. States that he has always been a temperate man up to his present illness, and has had pretty good health. On the 12th of last December, after exposure to cold and damp during the day, he was seized with articular pains, which affected most of the joints, and have continued to wander from one to the other up to the present time. On the evening of the 7th of January, independent of any exertion, the patient was suddenly seized with acute pain in the umbilical region, attended with difficulty of breathing ; these symptoms were at once removed on taking a powder, which caused the expulsion of much wind. He denies ever having had cough, pain in the side, or any pulmonary symptoms whatever. Symptoms on Admission. — On inspection of the chest, there is less expansion on the right than on the left side anteriorly ; posteriorly, the right side bulges consider- ably below the level of the third rib ; the measurement of th e corresponding sides is slightly different ; the girth of the left side being fifteen and a half, that of the right sixteen inches. The movement of inspiration on the right side is very slight ; on the left the girth is increased half an inch on a full inspiration. Percussion note ever the right side, anteriorly, is tympanitic from apex to base, being flatter at the apex. It likewise extends on a level with the nipple over the left side to about half an inch beyond the sternum. On auscultation, there is a slight harshness of re- spiratory murmurs at the apex of left lung, the sounds of which are otherwise nor- mal. On the right side, the vesicular murmur is supplanted by loud amphoric breathing, more distinct towards the base. Expiration is much prolonged. In the recumbent posture, both inspiration and expiration are accompanied by a clear pro- longed metallic note, exactly like the distant blast of a trumpet, somewhat louder with expiration. Vocal resonance over the middle third is of a loud brazen metallic character. Posteriorly on this side, percussion superiorly is tympanitic, but below second dorsal spine, dulness commences, becoming more intense as it extends to the * Guy’s Hospital Reports, vol. ii. Second Series, f Monthly Journal, August 1860 \ Reported by Mr. T. J. Walker, Clinical Clerk. 670 DISEASES OF THE RESPIRATOEY SYSTEM. base of the lung. Laterally its extent is bounded by a line drawn vertically fron. the posterior fold of the axilla. At the apex, inspiration is blowing, with prolonged expiration, and at the close of inspiration a moist click is heard. Towards the bass, the respiratory sounds are scarcely audible, and inspiration is accompanied with an obscure crepitation (?). Vocal resonance at apex and base is aegophonic, but over the middle third it is normal. No cough, expectoration, dyspnoea, pain, or other pul- monary symptoms. Impulse of heart’s apex felt in the usual position. Transverse dulness and sounds normal. Pulse 108, feeble. Patient is somewhat deaf ; has still pain in both knee and ankle joints, and in the right shoulder and carpo-phalangeal joints. Tongue dry and furred, otherwise normal. Copious deposit of lithatesin the urine. He is much emaciated, and for the last seven weeks has perspired very freely. Habeat Pulv. Doveri gr. xij. hord somni snmenda. Progress of the Case. — January 28^7i. — Pain in the joints is now so much re- lieved, that he can move the limbs with comparative freedom. He slept well last night. Potass. Nitrat. ; Potass. Bicarb, ail 3 ij : Aquam ad § vj. 31. Capiat § ss ter indies. Jan. 297/i. — On examining the patient to-day. Dr. Bennett found that, while lying on his left side, percussion note was duller over the sternum than when he lay on his back, and the slightly dull tone over the right lateral region became clear. When also the patient is placed in a sitting or recumbent posture, dulness extends from the back forwards to the centre of the right lateral region, and upon being laid on his left side, the posterior part of the lateral region becomes resonant. Jan. 31s7. — Physical signs over right side of chest continue as before. Apex of cardiac organ beats with a visible impulse somewhat to the inner side of a line, vertical from the nipple between the fifth and sixth ribs. At the margin of sternum a double rumbling sound is audible, not qnite synchronous with the systolic or diastolic movements. Transverse dulness of heart on percussion still two inches. Pulse 100, small, rather hard. Respirations twenty-two. Feb. 2(7. — Friction murmurs at the base of the car- diac organ more audible ; the patient has no pain over pericardium, nor uneasiness, except after cough, over the chest generally ; feels very slight tenderness on percus- sion over the sternum at the level of fifth and sixth ribs. To have spongio-piline^ sa- turated with warm water., applied over the prcecordial region. Feb. ^th. — Patient so well as to get up in the morning, and from this time he rapidly regained his strength. The pulmonary signs have undergone no change. The friction murmurs over the heart gradually diminished, and disappeared on the 12th, while a blowing murmur was gradually established, heard loudest with the first sound over the apex. He was dismissed March 11th. June 22(7. — He was re-admitted to-day, having in the interval again lost strength in consequence of his work being too fatiguing, and his appetite having failed him. The amphoric respiration, metallic notes, and brazen resonance of voice, have now disappeared from the right side, which is didl on percussion, immovable during inspi- ration, with slight trace of respiratory murmur, and great increase in the vocal reson- ance. Left lung healthy, with puerile respiration. Still a blowing murmur with the first sound of the heart, loudest at the apex. To have nutrients., with § iv of wine daily. July 2.%th. — Since last report his general health has been iirproving, and he now looks fat and well nourished, and says he is much stronger. Has no pain, cough, dyspinna, or inconvenience of any kind. There is now decided flattening anteriorly over the upper third of the right chest. On deep inspiration it expands much more than formerly. It is still everywhere dull on percussion, with great increase of vocal resonance amounting to bronchophony anteriorly, and pectoriloquy posteriorly and superiorly. Resjiiratory murmurs are absent over upper third of lung, but inferiorly and anteriorly inspiration is audible but feeble, and posteriorly is much stronger. Discharged. Commentary. — It is no uncommon thing for men who have pre^ viously had pleurisy, to be seen walking about the streets with one side of the chest more or less dull on percussion and incapable of action, although complaining of nothing. But this, so far as I am aware, is the only instance on record where a pleurisy has come on and proceeded to the formation of extensive pneumo-thorax, not only without symptoms, but without the cognizance of the patient. Yet such is the case before •as. For when I demonstrated to the clinical class at the bed-side the PLEUEITIS. en tympanitic sound over the right chest on percussion, the absence of healthy respiration, the metallic notes with the respiratory murmurs, and the-brazen amphoric vocal resonance, he himself denied that there was anything wrong with his chest, and smiled at the trouble we gave our- selves in examining it. In his case, as in Case CXL., after the acute rheumatism subsided, we had the greatest difficulty in keeping him in the house for the purpose of observation. On his going out, however, he himself at length became satisfied that his breathing was not so good as it ought to be, and on his re-admission subsequently we had the pleasure, under the influence of nutrients, to see the morbid murmurs disappear, the chest gradually contract, and his general health re-establish itself. V>'"hat might have been the consequences, if by means of physical signs we had not detected this morbid condition, but had dismissed him from the house as soon as ho 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 CXLIV.^ — Empyema^ following Chronic Phthisis — Paracentesis Thoracis — Pneumo-Thorax — Singular mode of Death from Enor- mous Distention of the Stomach and Emphysema of its Coats — Tubercular Pleuritis — Adherent P ericardium — Waxy Spleen — Tubercle in the Kidneys. History. — Allan Brown,- aet. 2-6, a gilder — admitted November 26, 1856. States that about twelve months ago, he suddenly at night, experienced pains 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 pre- ceding 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 sweatings, which have since gradually declined. His appetite, at no time great, has become yet more defec- tive, especially during the last few months. His thirst has always been considerable. Symptoms on 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 infe- riorly, 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 ten- derness on pressure, with redness and increase of temperature. The chest measures — 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 no corresponding 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 reson- ance, 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 the level of the third rib, also laterally and posteriorly, the respiratory mur- Level of Pour inches Left side Eight side Nipple. lower. 18 17 18 i 16 i * Reported by Mr. H. N. Maclaurin, Clinical Clerk. 672 DISEASES OF THE KESPIRATORY SYSTEM. murs are dry and somewhat blowing in character and intensified in tone. On thg left side ao respiration is audible, except near the sternal end of the clavicle ante- riorly, 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, then 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 exami- nation the patient became much troubled with spasmodic cough, so that further inter- rogation was considered unadvisable. To have ^ iij of wine, steak diet, extra milk and an ecig for breakfast. Progress of the Case. — On the %th and dth November 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 may be felt on applying the hand. No particular pain exists on 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 posteriorly, laterally as high as the eighth rib, and anteriorly only at the base. Vocal fremitus unimpaired. Pulse 120; small, weak and somewhat hard. Nov. Will. — Fi’iction 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. \Wi. The operation of paracentesis thoracis was performed by Mr. Sjaiie in the following manner : A free incision was made in the lower part of the left back at the spot where the tumor was pointing, A con- siderable 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 dirty-yellow sanious pus were withdrawn, passing with force at each expiration. In the evening, forty ounces more of pus escaped. Breathing was easier than before the operation ; cough not so readily excited ; patient lies more on the back than before. Pulse 96, weak and soft. Nov. \%th. — Percussion is now tympanitic over the left side anteriorly ; laterally and posteriorly, where the integument is oedematous, ppT- cussion gives great sense of resistance, with deep amphoric resonance. Vocal reson- ance posteriorly and anteriorly on the same side is amphoric, with whispering pecto- riloquy. 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 faint in comparison with the right side. On the right side, harsh inspiration pnd prolonged expiration continue to be heard, and vocal reson- ance is loud ; friction murmui s have disappeared from the anterior and lateral regions. Cardiac apex beats two inches to the left and one inch below the right nipple. Pulse 108, soft and feeble. Tongue dry and bright red ; appetite defective ; occasional thirst ; bowels regular. Great weakness, and considerable general uneasiness, but no local pain ; occasional rigors. Nov. \Mh. — At the left apex, and over left infra- mammary region, metallic tinkling was heard at the close of inspiration, and vocal resonance was loudly metallic in character. Nov. l%th . — The following measurements were taken at the same levels as those mentioned when he was admitted : — At this time the pulse varied from 120 to 130 ; it was small and feeble. The patient complained much of the heat and foetor of the discharge. Small granulations were seen on the edges of the W'ound. Nov. 2Qth . — 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 with a sound superficial, and rough, resembling coarse crepitation. Two and Level of Four inchco Ripple. lower. Left side Eight side 15| 15i Hi 17 PLEURITIS. 673 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 I'espiratory murmurs are harsh and loud. These observations were made while patient lay on his left side : his weakness precluded an examination of the back. His eyes were sunk ; there is a cold clammy sweat on the face ; occasional feeling of chilliness, JS^ov. 2,Mh . — No change since last report. To-day his appetite has im- proved to such ail extent that he was able to take two eggs for breakfast. Loud metallic tinkling still audible over the left chest. Nov. ZOth. — Metallic tinkling is now no longer audible. Dec. 4:th. — The following measurements w^ere taken : — ■ Level of Four inches. Nipple. lower. Left side ....... 15 15 Right side 16 15^ The second level was that of the ensiform cartilage. Dec. Zth. — A sore of the size of a fourpenny 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 fell to 96. Dec. lZtJt . — 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. Dec. lf>th. — Three discolored spots were found over the sacrum, with a very small ulcer, which, 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 distention from tympanitis over the whole left flank. Pulse 96, feeble, soft. Dec. \%th. — He was greatly relieved, and he con- tinued 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.m., when it ceased ; the matters vomited were partly fluid and partly solid, and evidently consisted of alimentary substances. Tenderness on pressure in the region of the recti muscles ; bowels opened this morning ; dejections natural. Respirations 30, somewhat labored. Pulse 120, small, somewhat hard, but quite compressible; consciousness perfect; skin hot and dry; cheek flushed. Dec. 19,ogress of the Case. — Nov. l?>tk. — Passed a sleepless night. Cough incessant, and dyspnoea urgent ; face livid. Pulse 112, full and strong; sputum very copious, rusty and gelatinous. In addition to physical signs formerly reported, there was faint crepitation all over right back posteriorly (most distinct at apex), but no great increase of vocal resonance ; friction over left side anteriorly below nipple, both with expiration and inspiration, but loudest with former, and posteriorly marked dulness over inferioi two-thirds, with loud crepitation and bronchophony. Ordered to be cupped to over region of pain on left side., and to take only one table-spoonful of the mixture., to which is to be added Sp. .^th. Nitr. 3 ij. To have strong beef -tea and milk. Nov. \4:th. — Patient says he felt relieved by the cupping for 3 or 4 hours, but the pain returned af- terwards as bad as before. There is still great dyspnoea and lividity of face ; expec- torates about 18 oz. of purulent, gelatinous, frothy matter, tinged with rusty-colored blood, during the 24 hours. Pulse 98, soft and irregular. To have a table-spoon fxd of wine every hour. Omit mixture. Nov. \bth. — Dyspnoea and pain in side much di- minished. Sputum less rusty. Pulse 100, strong and regular. Very coarse crepita- tion (amounting to mucous rattles) heard over left side anteriorly. Respiratory mur- murs harsh and dry over right side anteriorly. There is still marked comparative dul- ness over left back, and also in upper third of right back. Tubular breathing over up- per fourth of right back, harsh interiorly. Crepitation over left back, but more feeble than before. Vocal resonance the same. Urine quite clear, and no deposit. Chlo- rides have been increasing since the 13th, but are not yet in normal proportion. Still thirsty and feverish. B Sp. jNth. Nitr. 3 iij ; Potass. Acet. §ss. Aquarn ad ^vj ; Ft. mist. To be taken as before. To continue the milk., wine., etc.., and to have 6 oz. of beef-steak. Nov. \%th. — Patient says he feels very much better. All crepitation gone, but there is slightly increased vocal resonance on left side. Urine loaded with urates. Convalescent, but steak to be increased to 8 oz., and wine to he diminished to | iv daily. Nov. 2Uh. — Has been gradually getting stronger since last report. Yesterday he got up for some time, walked about the ward, and exposed himself to draughts in the pas- sages. This led to an attack of acute rheumatism, for which he was again confined to bed, and ordered Potass. Bicarb. 3j three times a day. He gradually got better, and was quite free from muscular pains on Dec. 4th ; he got up on the 'I'th, and with the exception of slight weakness, felt quite well. 2 oz. extra beef-steak were ordered on the 11th, and he left the Infirmary on the 13th in perfect health. Commentary. — This is what some former writers would have called an “ ex(]^uisite ” case of pneumonia, occurring in a man who, with some emphysema, was accustomed to have attacks of bronchitis and bloody expectoration every winter. It presented all the symptoms of the disease, including pain in the side, great dyspnoea, lividity of the face, strong and full pulse, with copious rusty sputa. Physical signs also proved it to consist of hepatization of the two inferior thirds of tho PNEUMONIA. 681 left lung, and of the superior half of the right lung. Occurring in the year 1858, it disposes of two theoretical statements which have of late been much discussed, viz. — 1st, TJiat such cases are now not to be met with ; and, 2 d, that if they should occur, bleeding would again be re- quired for their treatment. In this respect the case resembles that of Koderick M^Farlane, Case CXLVII. ; and in severity that of Peter Robertson, Case CXLIX. In consequence of the dyspnoea and evident engorgement of the right side of the heart, he was cupped, and 3 v of blood extracted, with the effect of relieving his symptoms, but for a time only, as they returned with equal intensity in a few hours. This is the result which usually followed large venesections, and which misled practitioners as to its utility. I have no doubt that a large bleeding in this case, if it had not proved fatal, would have seriously prolonged his recovery, which took place under an opposite treatment on the ninth day. The case inculcates another caution — viz., the necessity of avoid- ing exposure to cold during convalescence, as in the debilitated condition which then exists there is very likely to be a relapse, or some other form of febrile disease, again proving that these are the results of weak- ness rather than of strength. Case CXLIX.* — Bouhle Pneumonia — Great Pyspnoea — No Heeding — Local warmth and Stimidants — Rapid Recovery. History. — Peter Kobertson, set. 51, a tolerably robust man, house-painter — admit- ted May 11, 1857. On Tuesday last, the 5th instant, when washing the outside of a house, he got wet through from the dripping of water. In the evening had a rigor, which continued more or less all night. On the following morning had a short cough, and a thick yellow sputum. These symptoms continued the two following days, with pain in the left breast anteriorly ; but he continued at his work, although feeling very weak. On the 9th he was obliged to go to bed, and observed his sputum to be tinged with blood. Yesterday again had rigors, with cramps in the arms and elbows. Symptoms op Admission. — On percussion there is marked dulness over the lower two-thirds of the left lung posteriorly, with tubular breathing and coarse mucous rale on inspiration. The vocal resonance is aegophonic inferiorly, and bronchophonic over the middle third. Right side and anterior surfaces normal. Sputum copious and viscid, mixed with dark blood. Pulse 100, small and weak. Respirations 36 per minnte. Skin moist. Other functions normal. R Liq. Ammon. Acet. yEther. Nitric. I ss ; Vhi. Antim. §jss: Aquam ad § vj. M. One table- spoonf id to be taken every three hours. Progress op the Case. — May W.h. — Dulness on percussion over lower third of right back, in addition to that on the left, with tubular breathing and increased vocal resonance. Physical signs otherwise the same. Respirations are 40 in the minute, laborious and catching. Sputum gelatinous and rusty. Pulse 120, weak. Face livid, and expressive of great anxiety. Urine high colored, scanty, and deficient in chlorides. Warm fomentations to be applied over left side., and to have § iv wine. May \2>th. — Much better. Respiration easy. No lividity or anxiety of countenance. Cough diminished. Pulse 80, soft, but of good strength. Omitt. mist. May lAth. — Less dulness and crepitation on left side ; on right side crepitation fully established. Chlorides present to a slight degree in urine, and urates abundant. Pulse 74, regular. Appetite returning. Tongue clean. May \<6th. — Is now convalescent. Urine natural. Percussion resonant over both backs ; inspiratory murmurs heard, but no moist rales. Cough painless. Still gelatinous sputum without blood. Has been’ out of bed, and feels tolerably strong. Steak diet. ALay l^th. — Has been up all day, and says he is quite well. May ^Oth. — Dismissed. Commentary. — This was a severe case of double pneumonia, with great dyspnoea, impending suffocation, and great weakness on the seventli * Reported by Mr. W. H. Davies, Clinical Clerk. 682 DISEASES OF THE EESPIEATOEY SYSTElf. day, when wine was liberally administered. On the following day he was better, and continued to improve, so that on the fifth day after admis- sion he was fully convalescent, and on the ninth was quite well, and re- turned to his work. I never saw a case in which the symptoms were more urgent than in this man the day after his admission, and in which the livid and anxious countenance, the intense dyspnoea, the bloody sputum and feeble pulse, gave stronger evidence of impending dissolution. A question arises whether, if this man had been bled, he would have been relieved. I think this is very probable. But it appeared to me at the time, that the practice would have been fatal. Certain it is, that by following an opposite treatment of warm fomentations locally, and wine internally, these symptoms quickly subsided, and next day he was found breathing easily, and from that moment, though both lungs were alfected, speedily recovered. In a similar case, recently published by Dr. Mark- ham, a bleeding of 3 xvj caused marked and immediate relief, and on this ground the practice of bleeding is again inculcated. Now, everything in such a case depends upon the character of the pulse and amount of exhaustion — two points not referred to by Dr. Markham. It is to be observed, however, that whilst the above case, with the same impending dissolution from asphyxia and double pneumonia, was convalescent in five days after entering the house, and left the hospital quite well on the ninth day. Dr. Markham’s case, though relieved by bleeding, had a long convalescence, with pericarditis and pleuritic abscess.* Case CL.f — Pneumonia on the Right Side — Early Bleeding — Slow Recovery. History. — James M‘Quair, tailor, aet. 29 — admitted June 4th, 1855. This man has been of intemperate habits during the last five years. On the 28th of May, after severe drinking and exertion, followed by exposure to the night air, he was attacked early in the morning with rigor, chilliness, a feeling of weight over his whole body, and a dull heavy pain in the right chest. He drank several glasses of whisky and water to allay his thirst, and kept his bed, occasionally vomiting, and going out of doors to stool, until the 30th. He now felt very feverish, weak, and unwell, and a soup-})lateful of blood was extracted from the arm ( 3 xxiv). Venesection to the same amount was made on the following day ; but the pains in the side, with sanguineous cough and expectoration continuing, he came to the Infirmary. Symptoms on Admission. — On admission, the patient has an anxious and flushed appearance, and feels very weak. The respiration is hurried, 42 in a minute, and the lower part of the right lung expands little. Cough is short, frequent, and suppressed ; the expectoration scanty, consisting of gelatinous mucus, slightly tinged Avith blood. Oil percussion, there is marked comparative dulness over the inferior half of the right lung, but the upper half anteriorly, especially at the apex, though flat in tone, gives out a tympanitic and somewhat intestinal note. On auscultation, crepitation is audible all over the right lung, both anteriorly and posteriorly, and the vocal resonance is much increased over the dull portion. The left lung is normal. The pulse is 100, hard and incompressible. Heart normal. Tongue dry, and covered with a dark brown fur, and the teeth surrounded by sordes. Appetite gone; great thirst; the vomiting, which existed at the commencement of the attack, has noiv ceased. Abdo- mina' viscera normal ; bowels regular. Skin dry and hot to the feel. Urine high- colored and diminished in quantity, clear and without sediment. No trace of chlo- rides; no albumen. Nervous system normal. Antim. Tart. gr. iij ; Aquae § vj ; 8olv^ One ounce to he taken every three hours. Pko^res.s of the Case. — June bth. — Says he feels better ; pulse 90, full and * British Med. Journal, Feb. 4, 1865. f Reported by Mr. Robert Byers, Clinical Clerk. PNEUMONIA. 683 compressible, but in the evening it fell to 80, and became soft. June Uh. — Pulse 78, soft, breathing more easy. On percussion, the lower half of right lung is dull, but the upper half is resonant, with distinct cracked-pot sound. Fine crepitation audible over the whole of right chest. June Sth . — The whole of the right lung in front has become resonant on percussion ; otherwise the same. Faint trace of chlorides in the urine. Jmie ^th. — Chlorides abundant in the urine. June 10th . — Percussion re- sonant and equal over both sides of chest anteriorly. Under right clavicle, cracked- pot sound still audible. Crepitation much less inferiorly, but continues at the apex, with increase of vocal resonance. Posteriorly, percussion over right lung dull inferiorly, with loud crepitation, and segophonic resonance of voice. The patient feels much better, though weak. Respiration free. Pulse 72, soft and regular. Con- siderable diaphoresis. Urine deposits on cooling a large amount of lithates. R An- tim. Tart. gr. ij ; Tinct. Camph. co. 3 ij ; Decoct. Serpent. § xij. M. ^ j. to he taken every three hours. June lAth. — Physical signs of right lung, with the exception of cracked-pot sound, much diminished. lias been taking, during the last three days, good diet, with § ivof wine. From this time he improved slowly, the crepitation and dulness posteriorly gradually disappeared, but the cracked-pot sound continued with great intensity up to the 29th of June, His strength was not sufficient to admit of his discharge until the 3d of July. Commeyitartj . — This was a case io which nearly the whole of the right lung became pneumonic, and where we had an opportunity of convincing ourselves that full and repeated bleeding, although practised so early as the second and third days, had no beneficial influence on the progress of the disease. It should also be remarked, that these bleedings were practised in accordance with the rules laid down in systematic writings, that is to say, not only early, but when the pulse was accelerated, hard and incompressible, with all the characteristic symptoms of the disease. Surely, if bleeding could cut short or diminish the duration of a pneumonia, it might have been expected in this case. Yet so far from proving beneficial, they appear to me to have assisted in prolonging the case, and preventing resolution and recovery. For although the critical diaphoresis, and discharge of lithates by urine, occurred on the fourteenth day, the subsequent weak- ness was considerable. On his admission into the house, the Sth day of the disease, the chlorides were observed to be absent from the urine. This fluid was tested daily for these salts, which returned in small quantity on the twelfth, and were abundani on the thirteenth day of the disease. If, as we shall subsequently see, it is probable their reappearance indicates a cessation of fresh exudation, then it was observable that on the day following, excretion of the morbid products commenced by the skin and kidneys. The interval between the return of chlorides to the urine and the critical period, varies considerably in different cases ; but the careful estimate of these facts in future will, I think, furnish us with valuable hints as to the vital pow^ of the exudation. If, for instance, it should ultimately be shown that the return of chlorides indicates stoppage of exudation, and the presence of lithates or other critical discharge, the commencement of excretion of the exudation, then we shall possess evidence not previously discovered, as to when the pathological lesion is checked, and when the reparative changes in the economy commence. Another fact, which excited considerable attention in this case, was the characteristic cracked-pot sound under the right clavicle. The physical signs sufficiently proved that the pneumonic condensation com- menced at the base of the lung, and proceeded upwards, where, poste- 684 DISEASES OF THE RESPIRATORY SA'STEM. riorly and anteriorly, a considerable amount of air was retained in the air vesicles, so that percussion was never dull, although crepitation and increased vocal resonance existed. This presence of condensed lung covered with or surrounded by air, or of a cavity containing air, sur- rounded by condensed tissue, seems to constitute the condition under which this peculiar noise is elicited when the mouth is open. Hence the occurrence of the cracked-pot sound {Iruit de pot feU) is common in pneumonia, and in a variety of diseases which present similar physical conditions.^ Case CLT.f — Double Pneumonia — Treatment by Mercury^ which caused Profuse Salivation before Admission — Prolonged Recovery. History, — Robert Jude, set. 36, a bricklayer — admitted 10th December, 1855. On the 1st instant, while engaged building bricks round a boiler, the weather being very cold and windy, he suddenly felt a pain in the chest, deep-seated, half way between the ensiform cartilage and umbilicus. The pain rapidly grew worse, and caused nausea, but he could not vomit. He immediately went home, took some gruel, and went to bed. On the 4th, a medical man gave him some pills, one of which he took every third hour. On the Gth his teeth were loose, the gums very tender, and the tongue swollen to twice its natural size, so that he could not spit out the excessive amount of saliva that was secreted, and which consequently flowed from his mouth. He also had pain in the loins. Symptoms on Admission. — On admission, the excessive salivation has much di- mini.shed, but there is still tenderness and redness of the gums, with 'considerable dis- charge from the mouth. The breath foetid, the tongue covered with a dense, dirty white coating. Tlie bowels, while taking the pills, were open from six to seven times a day ; they are now regular. His diet has been confined to farinaceous articles. On percussing the chest anteriorly, it is everywhere resonant, but posteriorly it is dull on both sides, most so on left side. On auscultation anteriorly nothing abnormal, but pos- teriorly respiratory murmurs are harsh and shrill, with occasional sibilation. At the base on rigid side, there is crepitation on inspiration; on the left side respiration is tubular. Vocal resonance equal superiorly and anteriorly, but posteriorly everywhere increased, on the left side amounting to bronchophony. Pulse, 96, weak ; heai-t sounds normal ; skin hot, moderately dry, but there has been profuse perspiration ; there is dull pain in lumbar regions ; urine opaque from the existence of a reddish cloud ; sp. gr. 1024, not coagulable, but clears on the addition of heat ; chlorides diminished in quantity. 1^ Sp. uEther. Nit. 3 iij ; Potass. Acet. 3 ij ; Aquam ad §yj. M. One table-spoonful to he taken every four hours. R Liquor. Sodae. Chlor | j ; Sp. Vini Gallic. § ss ; Inf us. Rosar. c. ad § yj. M. Ft. garyarisma. Progress of the Case. — December \lth. — Crepitation more diffused over right back. On left side respirations still dry and harsh. Cldorides absent from urine. Dec. 12 Dr. T. Pea-i 2,760 “ 1842 “ 1843 41 26 0 15 ) cock. 7,204* » 1843 » 1844' 31 16 4 11 1 3,252 3,638 c: 1844 u “ 1845 “ 1845; 1846 50 61 33 40 4 6 13 15 1 1 Dr. Hughes I Bennett. 7,435* » 1846 “ 1847 93 47 5 41 7,44-6* “ 1847 “ 1848 103 52 6 45 J 3,724t “ 1848 “ 1849 1 1 88 66 5 17 i Ir. M'Dougall. 46,965 i 1 648 388 38 222 *At these periods there were great epidemics of fever. I At this period considerable changes took place among the medical staff of the Infirmary. PNEUMONIA. 693 My former clerk, Dr. Thorburn, was kind enough, at my request, to go over ’208 case-books of the Infirmary, dated between the years 1812 and 1837, and belonging to twelve physicians, all of whom practised an antiphlogistic treatment. He found that of 103 cases of pneumonia, 55 were cured, 41 died, and 7 were relieved — that is, 1 death in 2|- cases. Dr. Thorburn then carefully read over these 103 cases, and rejected all those that were incomplete, or which presented no evidence of having been pneumonia The remainder were tabulated, and it may safely be said that they were all cases of pneumonia, or of acute inflammations of the chest closely allied to that disease, and the result was ; — Number of cases, 50 ; died, 19 ; cured or relieved, 31 — that is, more than 1 death in 3 cases. The total number of cases, recorded by M. Louis, was 107."^ Of these 32 died, or 1 in 3i. In 78 of those cases, which occurred at La Gharite, bleeding was performed from the first to the ninth day, and the deaths were 28, or 1 in 3|. The duration of the disease in the cases which recovered was 15i days. Of the remaining 29 cases, which occurred at La Pitie, the bleeding was performed earlier, that is, during the first 4 days, and of these only 4 died, that is 1 in 7{. The dura- tion of the disease, however, in the cases that recovered, was 18i days. This diminished mortality, but greater length of recovery, M. Louis at- tributes to the bleedings not having been so large, and the greate amount of tartar emetic employed. Hence, the proposition he sought to estab- lish, that although bleeding has a very limited influence on pneumonia, it should be practised early. With regard to M. Louis’s results, it should be remembered that all these patients enjoyed excellent health when they were attacked, that the cases were uncomplicated, and that the duration of the disease was estimated from the occurrence of febrile symptoms, up to the time when light food could be taken, which was generally three days after the fever had ceased. M. Grisolle f advocated more moderate bleedings than those so fre- quently had recourse to, his conscience preventing the abandonment of venesection altogether (p. 561). He analyses the 75 cases of Bouillaud, pointing out that only 49 were treated by the coup sur coup mode of bleeding, of which 6 died, or 1 in 8 cases, a favorable result, which he attributes to the youth of the patients treated. Of his own cases, one group of 50 cases were bled only in the first stage of the disease ; of these 5 died, or 1 in 10. Those cases that died were bled most, each losing about 4 lb. 4 oz. of blood in successive bleedings. All the cases in this group were uncomplicated, and of the average age of 40 years. Of the 45 who recovered, convalescence commenced on the 10th day, and they resumed their occupations on the 21st day, as an average. Of 182 cases that were bled in the second stage, 32 died, or more than 1 in 6. Here also those who died were bled most — the bleedings varying in amount from 8 or 12 oz. to 8 lbs. The average quantity lost was 3 lbs. All the cases in this group were uncomplicated, and of the average age of 35 years. Of the 150 cases that recovered, convalescence commenced on the 17th day, and they resumed their occupations on the 22d day — as an average. He admits that the pneumonia can never be jugulated by * Recherches sur les efFets de la Saignee. Paris, 1836. •j- Traite pratique de la Pneumonie. Paris, 1841. 694 DISEASES OF THE RESPIRATORY SA'STEil. bleeding. Of the whole 232 cases, 37 died, that is, about 1 in 6^ , as the general result of M. Grisolle’s hospital practice, a mortality only one-half that of M. Louis’s cases, although the circumstances under which they occurred were the same, with the exception of not being so heroically treated. Laennec also, who only bled moderately at the com- mencement of the disease, regarded the mortality to be 1 death in 6 or 8 cases."^ In 1864 M. Grisolle published another edition of his work, in which these old statistics are repeated without any change whatever, and this notwithstanding his acquaintance with the author’s researches, and the immense improvements which have taken place in the art and science of medicine during the long interval of 23 years. What seems very sur- prising is, that he wishes to have it believed that his antiphlogistic treat- ment, with a mortality of 1 in 6 cases, is still the best. Dietl treated 85 cases by large bleedings, of whom 17 died, that is, 1 in 5. Dr. Glen, my former resident clerk, was so good as to tabulate for me all the cases of pneumonia given in the army returns, and reported by Colonel Tulloch.f These returns give us no information as to the mode in which the diagnosis was determined, or what was the treatment. The favorable mortality of 1 death in 13 cases, which, according to Dr. Glen, is the general result, is supposed to result from the bleedings having been performed early, and in young vigorous subjects. Yon Wahl treated, in St. Petersburg, by bleeding and antiphlogistics, 354 cases, of whom 84 died, or 1 in 4f cases.| Treatment hy large doses of Tartar Emetic. — Rasori, § in the great hospital of Milan, treated 648 cases by large doses of tartar emetic, of which 555 were cured, and 143 died, that is, 1 in 4i. In publishing this statement, Rasori gives the result as one more favorable than the practice of blood-letting, which of course he would not have done unless the latter treatment was then well known to have been attended with a greater mortality than that by tartar emetic, or 1 death in 4i cases. M. Grisolle treated 154 cases with large doses of tartar emetic, of which 29 died, that is, 1 in 5i, and Dietl treated 106 cases, of which 22 died, that is, a little more than 1 in 5. Treatment hy Diet. — This treatment essentially consists in allowing the disease to go through its natural course. During the stage of fever diet is light, or withheld altogether, and cold water allowed for drink ; subsequently better diet is allowed, and occasionally wine, according to the nature of the symptoms. Sometimes a dietetic is converted into an expectant treatment., when remedies are given to meet occasional symp- toms, as in the practice of Skoda, in the Charity Hospital of Vienna. * Forbes’ Translation. Fourth Edition, p. 237. f Government Statistical Reports on Mortality among the Troops. 1853. \ Petersburg Med. Zeit., i. 6. 1861. ^From an Analysis of Rasori’s Practice — Annales de Therapeutique, Jan^der 1847. PNEUMONIA. 695 An account of this has been given to us by Dr. George Balfour, who found from the books of the hospital, that during a period of three years and five months, commencing 1843, 392 patients were treated, of whom 54 died, or 1 in 7^. Occasionally opium was given in small doses if there was much pain. Venesection was also practised early if there was much dyspnoea, and emetics given if the expectoration con- sisted of tough mucus. Dr. G. Balfour has also given some statistics of the Homoeopathic Hospital of Vienna, accompanied, however, with statements which ren- der it doubtful whether every case that applied was admitted, and con- sequently not fairly comparable with other hospital statistics. There can be no doubt, however, that many severe cases of pneumonia recovered under a system of treatment, which, it appears to me, most medical men must consider to be essentially a dietetic one. Dr. Dietl published, in 1848, an account of 189 cases treated by diet only, of which 14 died, that is, 1 in I3i-. The following is his table of 380 cases, exhibiting the result of the three kinds of treatment: — - f!iired Vene- Bection. 68 Tartar Emetic. 84 Diet. 175 Dipd 17 22 14 85 106 189 Per cent 20.4 20.7 Deaths 1 in 5.22 1 in 134 It was further observable that of the 85 cases treated by blood-letting, 7 of the fatal cases were uncomplicated; whilst of the 189 cases treated by diet, not one of the deaths was an uncomplicated one. In 1852 he gave the result of 750 cases, treated dietetically, of which 69 died, or one in 10.9. Mixed treatment . — In recent times cases of pneumonia have been treated after a mixed fashion, according to* the nature of the symptoms, but with no very marked beneficial result. As examples of this system, I may refer to the results given by Huss, Bamberger, and Flint. The most important memoir recently published is that of Professor Huss of Stockholm,* who employed bleeding and heroic remedies in the early stage, and in the later ones antimony, mercury, and various reme- dies — among the rest, turpentine, morphia, and quinine. The number of cases given is 2616, of which 281 died; that is, 1 in 9^ cases. The un- complicated cases were 1657, of whom 96 died, or 1 in 17 cases. The complicated cases were 959, of whom 185 died, or 1 in 5 cases. The treatment employed was adapted, as it was thought, to the emergencies of the case, and may be called a modified antiphlogistic practice, many cases not having been bled at all. Its superiority over the rigid system, and even over that of Grisolle, therefore, is marked. Dr. Bambergerf treated 186 cases without general blood-letting. * Die Behandlung der Lungen-entzundung, etc. Leipsig, 1861. f Wiener Wochenschrift, No. 50, 1857; and Canstatto Jahnuberricht, 1858, iii. p. 284. ] 696 DISEASES OF THE RESPIRATORY SYSTEM. Only a few leeches and fomentations were applied in some cases, and inf. digitalis given internally. Occasionally, also, expectorants, emetics and other remedies were employed. Nothiug is said of diet or wine. Of these cases, 21 died, or 1 in 9. Number of complicated cases not stated. Dr. Flint has given the result of 133 cases he treated, of whom 35 died — more than 1 in 4. Among the uncomplicated cases were 19 deaths, and among the complicated 16 — a strange result. The treat- ments varied according to the case ; 12 were bled.* The Author's Treatmenthy Restoratives^ directed to further the natural progress of the disease, and supporting the vital strength. — A study of the pathology of the disease, which I have previously explained many years ago, forced upon my mind the conviction that blood-letting and antiphlogistics must be injurious. Pus-cells must be regarded as living growths, and as such require an excess of blood, good nutrition, and exalted vital force to hurry on their development and carry them success- fully through the natural stages of their existence. If the resolution of a pneumonia simply consisted of a retrograde process, of a so-called necrosis of the exudation, a previous antiphlogistic practice, by favoring it, might be expected to relieve the lung rapidly and cure the disease. But my conviction that such removal was dependent upon vital pro- cesses of growth, led me to an opposite treatment, viz., never to attempt cutting the disease short, or to weaken the pulse and vital powers, but, on the contrary, to further the necessary changes which the exudation must undergo in order to be fully excreted from the economy. To this end, during the period of febrile excitement I content myself with giv- ing salines in small doses, with a view of diminishing the viscosity of the blood. At the commencement of the treatment I order as much beef-tea as can be taken, and, as soon as the pulse becomes soft, nutri- ents, and from 4 to 8 oz. of wine daily. As the period of crisis ap- proaches 1 give a diuretic, consisting of half a drachm of nitric ether, and sometimes ten minims of colchicum wine, three times daily, to favor excretion of urates. But if crisis occurs by sweat or stool, I take care not to check it in any way. The object of this practice has been greatly misunderstood, and by none more so than by M. Grisolle, who calls it an expectant treatment. It seems to me to differ entirely from it in the care which is taken to nourish the weakened frame from the beginning^ and thus, according to the pathological views formerly explained, assist the vital powers to change the coagulated exudation, first into a new morbid growth (pus), and then into a fluid capable of absorption. I cannot call it a dietetic treat- ment, because this term has been applied on the Continent to with- holding diet rather than giving it — the “ diete absolue ” of the French meaning starvation — a fact which explains the fatal result of this practice, and especially the ill success of M. Grisolle, when he tried expectancy — or, as he understands by that practice, withholding all nourishment — while at the same time the bowels are acted on by injections and castor-oil (p. 559, 2d edit.) My pathology, in his * American Journal of Medical Sciences, 1861. PNEUMONIA. 097 opinion, appears strange, and useless to refer to (Idem^ p. 568) ; but as it has led me to cure every case of single and double uncomplicated pneumonia, whereas among M. Grisolle’s cases there is a mortality of one in every six, I may be permitted to think my theory better founded on observation, while my practice supports its correctness. In order, however, that there may be no farther misapprehension as to the facts which demonstrate the success of the restorative practice fol- lowed in my clinical wards, I give, in a tabular form, all the cases which have entered since the year 1848. The following Table includes all the cases of acute pneumonia which have been admitted into the clinical wards of the Royal Infirmary under m}’^ care since the 1st of October 1848 to the 31st of January 1865. During this period my term of service was at first four months in the year, and then, on alternate years, six months and three months. I find that, altogether, I have treated cases in the wards for 75 months, or a com- puted period of 6^ years. The Table presents the leading facts presented by the cases, so as to enable the reader to judge of the effects of the treat- ment employed. The columns indicate — 1st, The number of the case ; 2d, The name of the patient — D marks a double case, and Uns. one un- satisfactory as to the duration of the disease; 3d, The age; 4th, The previous health, whether good or bad, or in any way particularly affected ; 5th, The day of admission, counting from the rigor, which indicates the commencement of the disease ; 6th, The duration of the disease, or the commencement of the convalescent state, counting in days from the period when the rigor occurred; 7th, The number of days in the hospital after admission, or, should the disease have commenced in the hospital, count- ing from the rigor — this is a very uncertain period, which ought to re- present the duration of the convalescence, but which in many cases was lengthened by a variety of circumstances having no relation to the pneumonia ; 8th, The frequency and character of the pulse on admis- sion ; 9th, The number and character of the respirations on admission ; 10th, The side of the chest, and extent of pulmonary tissue involved ; llth. If complicated with other diseases it is marked by a X ; 12th, The treatment; 13th, General remarks; and llth. The volume and page where the case may still be found. It must be remembered that the cases were not recorded in reference to any statistical inquiry, but are those drawn up by the clerks in the Clinical Wards, at the bed-side, in obedience to long-established usage. They vary greatly, therefore, in value, and in a few the information on certain points required is defec- tive. This is indicated in the Table by a note of -interrogation. This Table was commenced by my former able resident physician. Dr. Glen, whose early death, as medical superintendent in the Dundee Infirmary, in 1863, deprived the profession of a singularly well-informed and highly-educated physician. It was continued by Drs. Smart, Duck- worth, and Macdonald, also my resident physicians in the Infirmary during the years 1863, 1864, and 1865, to whom I am greatly indebted for the pains they bestowed upon it. The fact that the table has been carefully revised by each of these four gentlemen in succession, affords the most convincing proof of the accuracy of its details. Tabular View of all th-e Cases of Acute Pneumonia treated in the Clinical Wards of the Royal Infirmary by the Author, from 1st October 1848 to 31st January 1865, while on service for 76 months, or a computed period of 6|^ years. — Average number of Beds, 40. MALE CASES. 698 o _ 5 o !z; S O H « SW fi ^ X M o =« 1.-^ ® Pi S ~ o 0.2 B ■2 o S I -2 §io « PI o;^cc ^ > i « Pi 2 a n o o r o III ^.sl .t; rt <0 |S jn o'Ti « O Q O O 0) ^ ^ »— H C o rh .9 - <1 CSX5 1.2 B a aif “.9 § . O W o ^ Cl O H o o §2 9 g” 8 ^ |«l 2 2®! .5 ^ t>» aiq3 13 •1^ Q a* 1^' O P. ® 9 os73 I'lig g g,§ p . p p c3 oj.Q P « •2-2 § •§.a8 2 5-^ S 8 a ® 9 g "" .52 '2 -9 13 =(-i >1 ^ o j ,P4 “ PI .S3 « 9 9* cj .M ® PI P ^ .2 '9 9 ill 5 > p S) o S fi ^ 2 o P 'H c:» P ^ ^ ^ w ^ «pi c5 o c« ^ M U •g ^ p 3 pop +J rP P '73 P 3 . . P?' I- .2 >-> a 'p S', ' O &0 pi 0 ^ a® ^ P 3 K5<1^ ^ g-s la P^ I ® g-s » Ip® m H g w ci S -r! § ®-p rP P >7 g l> _fl «3 T: >71=1 i.i^ f "is ip9? §.prt 2 . rP PL CL ® Q S-^ &9 il a *p 7“ . >7,- O g Sc s 9 rP -P •42SPI P^.-P -P 3. ^.fli 'P.S Pll I ,?2 siiS'K b a- 1^.9 «l II 5 ;A P g ■p ? 9 N''^ . *.*43 rs «3 O o'a 2 2 ?3 m >7.9 ■r P a a cq ’Sell'S 9 p^ 1"1 P 7? ® &1.P -to>'S P •uaxYOiUKOO 1 Extent, and Side involved. VCQ 0 cq" p qq 0 QQ .2P8 .SPh .2h^ «Hr Ho «t» -- CO ^ 14 14 2 2 8 Previous Health. Winter cough for 3 years Good Good Good Good Weak Good ? Vigorous •rxn-w 1 ® 0 TH 0 •J V 1 CO Tf< iO rt< 52 18 53 38 19 N J. Aikencross B. King J. Foreman J. Kell J. M ‘Intyre R. Hogg D 1 F. Farrell W. Hamilton |J. 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S. s (» ^ 3 oPn «)» f lower onl both sidesj Easy Dys- pnoea d w 26, diffi- cult Dys- pnoea Dys- pnoea 32, diffi- cult 46, hur- ried Hurried Dys pncea 1h o rd o CO 56 1 R « 8 R R( 120, weak :44, diffi-' cult j 106, strong 72, natural 100, full and strong 76,natural 100, strong 100, full and strong 100, small and soft 106, good strength 106, full 128, good streng-th 130, full 148, full and strong 112, good strength i CO Tt< CO CO C5 00 * (M Tj4 GO O CO 00 (M e- 1 -t C^ a< Tt< (M CO - lO lO CO i? 'R 3 ® §) O (.< .g|^| ^ 8 g? o m d g R R % -s ci o M i o .S' I R ^ao 0 1 u d s >> R c '3 R t§ § o CO 2 d o ft 8 m • 4 ^ bt) >cs <7 ® ^ «c1 § OT ^ r^ n o O C ,5 cj ^ ■B^ ■rt'Bl ®-B § ® 2 Sr® Ph fee j „ ce u o ^ o ^ 'S’rf ga oi to O O) ;aa B 03 II 0 3 Cfi fH c^ o '® >d i1 8 C3 g ® (ri n '^‘rt 'S ® tA. CJQ !h 73 " rt • O Cjra O 03 P t>>s ® ® ® •5 5 & fl M a 8 >.a 03 O o § ra 'Ti ■r) a, • c^ w 3 ”.r^ O 1^7 ^ fcB a §•§ 8 a^j -ajr- o O 03 •p p O O 03 r!:3 rt fl "2 S3 1 Cs p.iii p p g p- PrP ® 2-t? B- gB3 r3 ® g '3'^' o ® P'S -d 2 in a „s l>> ? S g o r*> -- cS o ® do OS'! I'i la 2-^ |o 'S -3 ti lll| ^ 1 6 p. d d B o ® a gs 0) , a . d ^ •-< dP? Is® ^ B-*^ ® d ra 03 P . dti P(CS a ^ M'B . Nod p ® d;B O "d S£ S o .c>-^ o I § ” S-H- P o o ®.B ® .,’d B o bo 2 cp p,^ >> . d J2 1 1 d -3 §A2 rB B 03 Sh -ri d j 3 =2 d B 3 B B ^ B s a I" 4) £ BB? d II 2 o id d t> o< X 2 M 'cJ P gNo _a y. . P c bo a 3 .^-d d ” I CO a-s a ci 'd o io M d +0 , O P SiS >^B d^ 2 d 1 3 "B ra d'S ro ■/■‘ bb B d ® t® a^ s -0? C?S 00 eco . 2 ft g 2 § •■§ bog « p •o B p tih •2 B 3 s ® s 4 3 h 'e '53 j:; S) o « g Sb 7 a ‘Is B ►002 d '« 'di •si ® c P -B ^p i.2 .a QiB eg X •^1 « d •aaxvanjivroQ Extent, and Side involved. ■f lower L. S. 1'^' -ll« 1 lower L. S., apex, R. S. f lower both sides Whole of 11, S. dCO dec ^ p . -l« H« Whole of R. S. ^ lower both sides. i middle L. S., i lower R.S. 4-5thslow- er R. S. ft® . P.H»(M .*o7[i'i4 •i^TtotntBOJX JO juoraoououuaoo jn suoiXBJidsa^ 1 d ^8 fl ft (M CO 32, diffi- cult - Tran- quil 24 42, hur- ried t>> W C5 d O ^ CO CM o Pulse. •jnoxn -jnaax .P jnouioouara -uioo JY 84, soft i 104, strong 112, soft 100, full and strong 80, good strength ? 92, strong 1 100, full bB to ►M d d 8 2 2 ^ m CO* cT o O O il o"'® BJi •lujtdsoH ui 1 1 o . 00 fcO TJ1 (M 00 s 00 03 ■rs lO uaas jsjix; | (5 B a >> 1 a ^ d U 05 cg^ .2 "cl n a '8 >• -d B » c£a .B 3^ o ^ ^ o is s>4 rd d fcc^ 5 w s bo^ 1 T) cB O O 1 B »t 3 -tj o o o §) mh P 03 >"-d «u o 2 0‘S o w o’S p? o o a ■ M O o o •aov 1 CO O CO t— C5 O CO o CO C f- _ ci CD i. ^ 'So f-l <=> eS ^ & ~ ^ M Pt ^ pH O "p > . > . ■':S- ^• "H ^ p s'-^ s i5 ^ " S pf ^ ^§1 0 a d) '-‘p! p <='3^.3 t S , PI 1 - ^ rt « H-S S H p 85g^ ^.sl g|.a o ^ feg'B s oj g tij g=M'p a >S > "S-S s-1 g t3 ^ I'c ° -L ;3. ' w ^ ' ^ o ) ^ 0 2 0 o a^j=i • ^•2 g -ssi :S w"?. A 2 2 -i A *=l »£3 ' i-5 ^ E\ c3 '= S-S3 W .g;x-S gg'l^g.A g o-2'g g-g •Sgi-^g pi +; o laa^|2 '3 P^ oc ts g li ■Sr^.2 «&: g ^ ^ . g o o ■*^ te ^igg ^ ^.3 I i A’-^ H-a 2'g ^ •SlS g-2 c . g p3 < .2 ippS Si'S all g o o o o gpq ^ o g ^ a^ “’-2 ^ g ^ o rt M > - Oi o S.2 2 g S'! g a "S g o o po ^>»g ®-a r2 -^1 g go pj c3 0 gg II 1 a .a § gi 'S g.2 I s igj ph2 a 2 Sfg *g .2 .2 ng V.P n ^O; 2 CJU yj cc o ^ >. '“'S g^ .3,2 i 'I § 2 ^ is 2a d o " p,o p,g g< ^S d|:2 d O rt !> no n 0.15 n >-i H ai r-i I. £1 3t3 I 8 “ 2 o g g a g o •poQ || 'gg acf . 2-2 |l !^ P •S ^ s ^ ,„• PI ;i3.2 O C WO I 'si P3 ■| . w •Sg . 3-2 -a-S is CQ ^ O C3 O O g g-g i|o|2 ^ »• S^g g H-d g ^ o g p o a-gll^.| u3 b^'p'cg w g g ^ S'**! g g g o s -+g SSs/f-a g g -g g g,^-^ d tg a ■sf Pi:*^*-- 5 S,«.2 g-g ^ C3 C ^ ^ O 9 ^ 2 o o g t>'B o ^ "g ^ Fl^ & P'u -2 2 g< 3 Pf- ■§|rg CO o 'd pg > 2 o NOt© "g 5R .1 a « .a g .2 ■>l ^■'!2; VI w I -sll X X OCQ •*s 1 lower R. S., A lower L. S. ^ lower B. S. |2 «i» 1 lower L. S. AVhole of B. S. i lower L. S. 1 lower of L. S. and iofB. S. apex. Fh . gw . .2^ 1 lower L. S. 1 A upper both sides. • ft® -d« P 1 g 5 ^p2 |d«w ‘>^>=x Pp -1 *1 g i 8 2 P 1. 1 Much, dys- . pncea 36, tran- quil 1 - 40, diffi- cult 1 ?lahor- ed ? great dys- pnoja 'd g t-. p< 0 120, weak,! Itheii hard and bounding 100, weak 95, weak 110, small and weak 108, small and weak 100, soft 90, good strength 95, full and strong 98, weak 72, small and weak 112, weak 120 , weak 100, full and strong 1 a> CM CD C-. 00 f-< CO iO CO c^ .-t fH CO 10 cq d fH 0 TJ1 t-H ^ m uO e-* Oi cq rH t-H 5 d w S S. . ^ o w S !< o & « ■ > t> -i13§ f^i Ph Ph I ai '2'^ s P ‘ •- > hn 1 "I § 5 P55 >> ■^•JS g ^P?i 2 bej ^ §) 02 S.P ^ §1 •=^:aP Pf|-S be H cS p S.'S «:S H . P u '2 fp-P d to 53 . tp be ptd o o P be P d ci s be o§ .-a ".§ S 'Us p ^ ^ a Ca c !l a a p §3^ >> p 2 §)t^ p< ® a ^ > o o i® P rt ^ £ Cfi O ‘rn.a g P P to-^ ptp B •'^ rO U ^ NO^ P O ^ o ^ -Y 'PPP.S P .*3 o .- 00 -d :-|is| i“i” u- cS .S . ^ 2 rp ^ 52-a^p ^ 3 ^ tj >■ d to ?-l MO “ o p;*" 3 In'^ § « .a CO O o o ^ Sq.^ 3^ t» ^ P I 2 NO 2 0) © d IS I :S3 > .£ i "p ■r3-2 id d .^P .. ..-p S •a .a ® •aaxvon;jwoo Extent, and Side involved. I lower both sides 1 lower R. S., i lower L. S. 5 upper and lower R. S., i lower L.S. Whole of R. S. f lower L. S. , Slower R. S. Whole of R. S. Whole of R. S., # lower L.S. f lower R. S. , .J. lower L. S. Whole of R. S. i middle R. S. 1 upper R. S. f lower L. S. •:^noni:)i??9.Tj, JO jnaniaououiuioD JB STIOrjC.Ildf30JI 28, op- pressed. 46, hur- ried 44 48, la- bored 52, op- pressed 56, short 56, urgent dys- pnoea 48 44, diffi- cult 24, tran- quil 32, hur- ried 56, dys- pnoea PXILSE. 1 •jnonr -jEOJx jo jnoraooTiotn -raoD JY 90, good streng-th 120, full and soft 90, weak 82, strong 100, fair streng-th 88, fair strength 104, fair strength 104, full and strong 104, weak 96, fair streng-th 72, good strength [104, good [strength •j'Bjidgojj nj Q if 1 COCO lO Of-» OCD O Cqr-lr-l i-Hr-lf-. r*H pH pH •io.§th; .Toyn | OOuaoso[nAno0 •joSt'a; .TOjjE 1 UOOS JSJtl^ 1 3 10 2 10 7 15 6 11 3 8 4 8 6 14 4 8 5 8 4 7 5 8 5 14 Previous Health. Good Good Good Good Good Good Bad ^Good Good Good Good Good 1 •aov 1 \ <0 i-» >^1^ 00 C5 pHir^t^o lOi-t CO C<o to >o o to 703 Q > O o C 3 S 3 8 '-5 .-5 ^ 1 ^ o *^53 d o t* S ;^8 M ^ (=^ O e^ 'o "o ;> !> 2 p< 9 3 d a w Ph® H ^ o 0 tS fcc8 S § 2 p 8 • d d > od d'S , 2? d d d S n 3d g > d rd §8 I “3 . ;3 O H ^ W a *s “:S5 I . rtn ^ ^ ^ » ^.2> 3 g S'd 3 ^ ^ ||o |i 8a d o H «+-« 3 2 Is.g H il I’X, 1 I d . t»d '“.a d « -2d 00 d d3 a i=! . “ ti) _ I §1 'I §lt« i1° I 2° P. 2" a as “®® O d3d 53.2 g ,.3 P rC pi rt ►*- 3 h 1 lower L. S. f lower K. S. Whole ol R. S. s g* 1 «i«aj o ^ 0) "’”P l,il Ph * ^ • OJ CQ «D 02 HlOl -Hl« d m |3 Hci d.2 |d^03 hICiCC ^ middle L. S. f lower R. S. ^ • 8.“ d?^ •4b 1 r^ 5w. Ph o CO 1* W CO d 1 CO d CO CO d g CO d g O d CO pH tC ■£ i cor3 d d CD 1 CO _^c3 ^ 8 sa fcjD a o p CO o C'f o ^d o' 8 o 43 I— 1 CO ce 0> ifT o G> ci o o 6 o -d .M ^ 1 cT ^ ^ CD fH CD 0? o O CM o5 Si rH VQ 'i o C5 'd 1 cT rq (T^ C ^ -g S'S ^ I 05 0 s tL I o fl M'S toO 5 d cjH .2 a ;> d p< C3 Ph S' > 8 ^ ^ I'S g 3 ^8 ft “ ts .O o 8 ? g ^ 15 'I .2 J T o^ i g ix) a g-l ^ P CS S p-U 2 ® § 1 ^ H p< «5 d CQ O « ci fc/D p . a 3J d'^ O >> PJ^ O S'dtS ■ P 1‘j" •&2 P^ |1 &.P p^ ® la 5g rP O spp I OQ -O . §"8 6Cd P « <] .9 'd ^ '3 rrS • • ^ g .2 2 ® « d !C O 111 . ® to «(-( to O ■'§1 22 §a p ^ -d p^ ^ g xg.9 ■p p I'fO M «.'2 oj *w O O P •*^ ® CO “ II •p . -B i»cSr^ M .9 .9 c3 o3 05 02 •aaxvanjKOQ | X Extent, and Side involved. 5 - lower L. S. f lower R. S. i lower E. S. i lower L. S. 1 lower L. S. f lower R. S. 4 lower 1 L. S. •:jnora;no.tx JO jnouioououiuioo jn snoij'BJTdsoji 30 40, dys- pnoea 24, no dys- pnoea 27 28 34 48, dys- pnoea p to P P Ph •jTiani -jnajx .;o juaraaonara -uioa JY 98, weak 98, weak 96, full, of good streng-tk 70, soft 108, strong 90, weak 96, fair strength X^Jidsou nj Days Days 25 8 13 14 10 14 15 •joi 0OUO3 •ao: na iiH: JaytJ fsa^nAHOQ 9 10 13 10 9 11 12 las '^s.iix II e- !>. 00 eo 0 to to • P W 0 H P w P M PhUI Not good Good Good Good Occasional Bronchitis Good Good •aoy 1 1 00 0 r-l CO ^ 10 00 00 00 00 00 00 Ph 1^ i-T "S ^ S.s - 2 9 -3 O O O P g k g “1 = a p 4a ^8 9 § g I .S3 S t>. 2 's^ .9 55 J c» s s ^ "p 9 "p -S > p _s P p P -g p 8 Q-^ d-S si p-P O o rP O H'P 1 “ rP Q ' ti -d ^atp U^’p gS) I lower L. S. S CQ ^ • ort Hoi P? 1 P .2 0 eH«a5‘ |J 5 lower R. S., i up- per L. S. 1 lower R. S. Dys- pnoea. Sup- pressed. Hurried 8 ^p H P 1 g 1 ,P 0 CO i 0 rH cT 0 23 23 00 CM 0 CO C5 0 0 to - 00 00 - 'g .2 -p.s S 2 1-^ PS p p a p^ g^ g 1 .a 9 s « 02 a HQ 70 S o o !> ;> S B -a CQ«M S3 O $-1 S o p; sil P e -2 !l B I i | 4 Cl' c «J .2 B O t», M P-l p 5 r! is o ^ a 'S « ^Ph ^ OJ o ..Th s « 2 ® ® fl t» O ^ “ rt CS p 4 > fe.S.'S O lo ti -2 PI ^p, '^1 §g ^• 2 - .2 ^ ^ §1 f .2 S -P P iS p o 8 -p o ^ o 2 ^'2 ^ Cu f 4 CS P»> ® h p^ pi| 2 ®^ -- as- ■ _c/j pi I n^ M P >n ® P gT 3 "S P O) o Pop ,“S"= n o .3 P — 1 il '§§a§ 2 | a ® -2 p I a. §; 8 s ftp a, P *^2 xl p "m "p< o - M rt P p 5 8 p ii P p^ S 'p p =" • r- O w o <18 rt‘S 6 Q .2 CP f-i *S § P.P §.S ■g a'“-p^ II 'p O Ph P p ft p p( l2 0-2 8 o cii 02 .S w^o-^-pSp ,P _0 0 _o rO" g.g 'S ,P ^ ^ P - .M P .2 .2' .a '^•■p, p ^ >* lip I i | pa p . -s a p >!•'-« r/) c;,-^ 'r^ u a 3 ^ p'S S 5 II -S§ w <1 o H ^ o-a .P'S.” ra P ^ C.O 'P O^.MO o ,P ® - =« 1 -.'§ " S £'2 ■p f&i "S ® 3 ho •- O-P'P > -2 . c P ~ S Pi o rd ^ . s «2 "2 <15 ^ ■*1 ■* 1 1 = CO d 3 p- O 2^3 o o P p p hbT p^P 2 -^ § 2 2 N^rP a P .2 g ^l ‘§-2 . o T- O ^|p .2 c^m.Q P ^ "o P I"- 2 » &-| ^ « .2 242 a'i ■s’i 2 -g .•P NO g ••■ P ••' !i O “ 73 a, P g 3 o ^ fe d _S <1- OT 3 CQ • g.2 O .*3 J 0'S w CO 3 p o •I 3 m .2 3 i5 «J rP 5:^ -g. O o y ^ o ^ 'P p a!- ■|.1 " -1 § . ®p.g •-P- 2 TO -.| n 4 S <1 § ho o^ > frt c; o a t>>a o^ lly < o'm oTO 1:2 -ft p»rO nf* O TO s 02 03 02 ofB |p 4 |h 2 oto' ooQ oTO OTO oTO owj ®l^ oPn ®i-l a G 3 83 I ca I Q a H m -p 2 o S P. -P ®'p 53 2 1=1 ?P 2:2 o'-P .P O-Peo « 2 ^P "Si o 'P §a § o P O 8 ^ p 8 ^ C^ 1 -H ^ , Cowan Uns. 7 — cS 0 P 0 % P 0 Ip feo (M w 'o d >» 05 Pi cp 'p p 0 p OT S) Ta 0 W ■p "p p 0 P Smith Uns. 8 0 'p m OT 0 Ph a TO ' g tc 8 0 0 >7 p W p p 0 P S ■p "p p 0 P pp d S d 45 8 leeches. 706 j d S O S O Q ci O CO 12 § w o w fc, ri ►-< to fe O ® S ^ 8 ? Sugg Iff I . Il ® &02 « '■<, g O 02 .2 ” W !,_, CO w o ^ ta "o o yi 23 oi 2h '* (i (i 3:3 ^ g.s§ « § ^ ^ H o ill KIb i|o a-S ^ a.s . 1 p a a si pi « <» 2 el « rrl ei^OC! « 0) . gH ^ CS r^ .23, g§ II ® »- ^ fl o'rrt ® p § g "1 ® “ Oj -£ d Pii =S 3 ^a 0 «tir£ 3 c 3 S O ^ H § g 3 ® P:g 2 a s .&§ a :ii £ a a rt to bo ® 9 S -s>. S 3 .® g 'S .2 m:? OQ F 2 2 ei P ..3 •P3 c3 to -tH .Q 3 % oi .2 9 p,.2 a -3 O 5} O ttS 2 pp? 3 3 i^.'i § 2 S 3 asg 3 3 5 I ‘S S|| ^ s’^1 ® E: p « . 2.2 I al •>2 ®Q o'!, « I fc* 0 to ® §B ® 2.9 g S=S to O W GQ |S^. I „ 8 I QD r /5 p^c* ^ a ^'t •|l ^ p O P, o II ® P3 § ^ Ilf Pr® g O e3 p3 “Pm H»oi P ^ g, o 3 Ci c/j iS l^-J 9 S ® 33 ^. 2 Sg 3 pg '3 -J i^cp ” a§|g Ifsl a P:S 3 e 3 c^ eg ."tS 'S «.p ^ fr1li §|g a g ®. 2 3 g '43 g S p H ^ .9 Ph p P-« • 3 g tK> .fh y 0> SI PS Pi P o 3 p-p £ 3 t=l c P ® g 3 p-^ cc fciD 23 -C 3 cd w Wr^ •aaxvonaKoo ■53 « ®023 p . ® 02 ® OQ p • p • ® 02 P 02 S 02 . P-5® ® a . ® 02 P 1 ® 0 p . ® M 0 ^02 ® p,j ® <0 33 ® p g p 1 ^’ |« . &■ . 3P3Ph . ^ • opn ° r3 ^ a ort Of4 -§h4 ^Hc.^ 3 f ^ op H» > Ho H5 P ^f^, ft ^p P P4 p4 •JHOTn bo p M a- 1 1 3 p'rf CC JO § ^ & (in jnoxaaouaui -raoo JY 3 P p 3 <»3 C5 M 92, sc and j ing i 105, < press cT I § s QJ =2 S cS += Pi S ft '3 cs c3 D w a .a •a ^ ‘P p .& p . KA*S -S 8 O PI ^ c3 ■e 8 O Pi c5 >» ff3 >2 ^ -^rp! ^ 8 i CD ^ lO 9 eo o< c.2 02 PPP2 -43 “ « ‘S) I § g§ a 0^0 it I © a> o t>. .2 w i a "p .2 -p S-'^ ts'9'p ® a Pi b a p m2?g O Pc P a^’c? §3'^ .3 O ftg.2 ^ p H ® p.2 «'ft== ft ® o ft ^ > ifli 111 a=«l o o 0 ^ o ^ © cj (W to P ® & III p c 6 2 O 2S c gs.2 P Mp^pP fcbg _C o ?c I i-i -.a 5 CO © o fi •ft .1 pp p >5 -P S2 a fe* ^ c3 ^ © 'C-C 'S 43 ts P »§ 9 S .9 - a " ft- 3 ® . o ■=:| cS ■§'« .2 9 III tl l:-i II ^‘3 2 . a . P o t 3 cp> o p d “co o |> d 2 raso So 2 > S §■ o » ^-S ■Ss ts ss H— HO cQ p p P ^ ■Q^Y I ® 202 «02‘ oa 2®«2 H • ? . te . o • pP? ^Ph oPh gpH -it« Ht« -H ^ CO CO ga 708 DISEASES OF THE EESPIRATORT SYSTEM. In addition to the four fatal cases here recorded, I have found in the pathological registers kept bj Drs. Gairdner, Haldane, and Grainger Stewart, thirteen other cases, in which, as the result of chronic, cerebral, spinal, cardiac, hepatic, renal, or other pulmonary disease (such as phthisis and chronic bronchitis), pneumonia appeared before death, adding a fatal complication to previously existing maladies. Not one of these can pro- perly be considered as a case of acute pneumonia, or indeed of pneumonia at all. They have all been entered by the clerks in the ward-books as softening of the brain or spinal cord, morbus cordis, phthisis, Bright’s disease, cirrhosis of the liver, or other lesion, for which the patients entered the Infirmary and were treated. In most of them it was the pneumonie des agonhans of the French, and in all must be regarded as the consecutive chronic or latent pneumonia of medical writers. These, then, are positively all the cases of acute pneumonia which have entered the clinical wards of the Infirmary, when under my care, during the last sixteen years, so far as I can discover them. Every case has been treated publicly, and is open for inspection in the ward- books, and the result is that the mortality of the acute pneumonias, in the practice of the clinical wards while under my care, is, up to February 1865, 1 in 32^ cases ; and that of all the cases of uncomplicated pneu- monia, 105 in number, not one has died, although many of them have been very severe, involving the whole of one lung in 15, and portions of both lungs in 26 cases. In the four fatal cases, death was evidently caused by complications independent of the pneumonia. They ought to be regarded as patho- logical accidents, for in not one of them could the pulmonary disease be properly regarded even as assisting the mortality. The Table shows that in many instances where weakness was much greater than existed in any of them, pneumonia rapidly passed through its natural progress. To arrive at true statistics with regard to treatment^ therefore, it becomes necessary to eliminate these four cases, as has been done by many other hospital physicians, and to fix our attention on the first 125 cases re- ported in the previous table. Sex. Of these 125 cases, 85 were males and 40 females. The latter have been enumerated after, and so separated from the former. Age. The average age of the males was 31^ years; the average age of the females 28^ years ; the average age of both 30^ years. Between the ages of 5 and 15 years was 1 case — a girl ; between 10 and 20 years, 29 cases — 12 females; between 20 and 30 years, 35 cases — 11 females ; between 30 and 40 years, 23 cases — 7 females ; between 40 and 50 years, 24 cases — 6 females; between 50 and 60 years, 11 cases — 1 female; between 60 and 70 years, 1 case — a female; and between 70 and 80 years, 1 case — a female. Simple or uncomplicated Fneumonia. — Of the 125 cases there were 105 simple or uncomplicated, and 20 complicated. Of the former there were 74 males and 31 females. 79 were single and 26 double cases. Of these I find that the clerk has omitted to state either the exact day of rigor or of convalescence in six, so that no conclusion can be derived from them as to the duration of the disease. Of the remaining 99 cases, 73 were single, and 26 double. PNEUMONIA. 709 The duration of the disease in the 73 cases of single uncomplicated pneumonia, counting from the occurrence of rigor to the commencement of convalescence, was as follows : — 2 cases recovered in five days; 4 cases in 7 days; 5 cases in 8 days; 2 cases in 9 days; 8 cases in 10 days; 7 cases in 11 days; 7 cases in 12 days; 4 cases in 13 days; 13 cases in 14 days; 2 cases in 15 days; 3 cases in 16 days; 3 cases in 17 days; 3 cases in 18 days; 1 case in 19 days; 2 cases in 20 days; 3 cases in 21 days; 1 case in 22 days; 2 cases in 23 days, and 1 case in 26 days. The average duration 13| days. The duration of the disease in the 26 cases of double uncomplicated pneumonia, counting from the occurrence of the rigor to the commence- ment of convalescence, was as follows : — 2 cases recovered in 8 days ; 1 case in 9 days; 2 cases in 10 days; 2 cases in 11 days; 1 case in 12 days; 1 case in 13 days; 4 cases in 14 days; 1 case in 15 days; 2 cases in 16 days; 2 cases in 18 days; 2 cases in 19 days; 1 case in 20 days; 3 cases in 21 days; 1 case in 27 days; 1 case in 55 days. The average duration 16f days.* Of the 105 simple or uncomplicated cases, there were 9 bled by venesection and subjected to an antiphlogistic treatment, before or im- mediately upon admission, before I saw them. The amount of blood ex- tracted varied from 12 to 30 oz., the latter in two bleediims. The dura- tion of one case is not stated. Of the remaining 8 cases, the duration was as follows: — One case recovered in 7 days; 2 cases in 14 days; 1 case in 16 days; 1 case in 17 days; 1 case in 20 days; 1 case in 27 days, and 1 case in 55 days. The average duration was 2^- days. The average duration of residence in hospital of the single uncompli- cated cases of pneumonia — excluding 2 cases in which tlie date of dismis- sion is omitted, making 77 cases — was 21| days. For the males (52) 18| days, and for the females (25) 27^ days. Of the 26 double uncom- plicated cases, the average duration of residence in hospital was 23^ days. Of the males (20) 23ii( days; of the females (6) 22| days.f The average duration of residence in hospital of 8 cases, bled early in the disease (the 9th case being excluded in consequence of the day of dismission not being entered in the case-book), was 32 days. The extent of pulmonary tissue involved in the pneumonia was care- fully determined by percussion and auscultation — from the amount of dulness, crepitation, tubular breathing, and increased vocal resonance present in each case. The average duration of the disease in the 95 single cases remaining after deduction of the 10 unsatisfactory ones, counting from the rigor to the commencement of convalescence, was as follows : — ^ of the lung (2 cases), average duration, days ; ^ the lung (12 cases), 12 days; \ the lung (25 cases), 15f days; f the lung * If the case of Hogg (No. 6), a weak young man, much reduced by bleeding and other antiphlogistic treatment before admission, and the duration of whose disease in consequence was 55 days, be subtracted, the average duration of these double cases would only be 14 days. f All these averages are far too high, as will be at once seen on referring to the Column of Observations in the Table, Nos. 14, 17, 18, 19, 27, 29, 50, 51, 100, 104, 105, 107, 109, in all which, detention in the house, for various reasons irrespective of the pneumonia, makes the period of residence on account of that disease much too long. 710 DISEASES OF THE EESPIRATOKY SYSTEM. (34 cases), 14 days; f the lung (6 cases), 14| days ; | the lung (1 case), 12 days; the whole lung (15 cases), lOf days. Of these 95 cases, the right lung was affected in 58, the left lung in 37. Among these 95 cases, also, the pneumonia was confined to the upper lobe in 11 cases, or nearly 1 in 9 of the whole; and the average dura- tion of the disease in these was 13 days, and of their residence in the hospital 14^ days. Complicated cases of Pneumonia . — Of the 20 complicated cases of pneumonia, 16 were single and 4 double. Of the 16 single complicated cases, the duration of the disease cannot be determined in 3. Of the remaining 13, the duration was as follows : — One case recovered in 7 days; 2 cases in 9 days; 1 case in 10 days; 1 case in 12 days; 2 cases in 14 days; 1 case in 15 days ; 2 cases in 16 days; 2 cases in 19 days; and 1 case in 48 days. The average duration, 16 days. Of the 4 double cases of complicated pneumonia, 1 case recovered in 9 days; 1 case in 14 days; 1 case in 15 days; and 1 case in 18 days. The average duration 14 days. A careful study of the preceding facts will, I think, tend to establish some new truths, and correct several prevailing errors with regard to pneumonia. I would remind those, however, who, being yet skeptical as to the value of a restorative treatment, may imagine that some of these cases might not have been pneumonia at all, that they were all di- agnosed, and treated publicly in the Royal Infirmary ; were examined not only by myself, but by my intelligent clerks and assistants, and were all made the subject of Clinical Lectures and commentaries at the bedside. There is, therefore, the positive certainty, not only that every one of these cases was a genuine case of pneumonia, but that no other cases of the disease but what are tabulated were treated by me during the period referred to. It should be explained, however, that a few cases were partly treated by my colleagues, either before I assumed duty, or after I left it, in the too frequent rotations which occur among the Clin- ical Professors in the Infirmary. Such cases are not inserted. It is further necessary to point out that two or three cases brought into the house by the police in an exhausted condition, and who died before I saw them, are also not inserted. It is the more important to refer to such occurrences, because they serve to account for the differences which must always exist between hospital and clinical statistics. Grisolle has very unjustly alluded to this difference in the hospital of Vienna, with a view of throwing distrust on the conclusions of Dietl. But every hos- pital physician must be aware that the general records of the House af- ford no index whatever to the number of acute pneumonias treated clin- ically, comprehending as they do not only consecutive, latent, and chronic pneumonias, but not unfrequently cases of pneumonia which have entered in a dying condition, and have not been treated at all. 1. The first great fact which the preceding figures serve to establish is, that simple primary pneumonia, whether single or double, if treated by the restorative plan, is not a fatal disease. Surely 105 cases, of which 26 were double, are sufficient to establish this proposition, especially when it is considered that they were diffused over sixteen years, and oc- PNEUMONIA. 711 ourred In all seasons. Among these, also, the whole of one lung was iuyolved in no less than 15 cases, and the symptoms in many of them were exceedingly severe. Neither will anything as to strength of con- stitution, or change of type, explain the result, as several of the cases were those of healthy, vigorous young laborers, whilst others were those of weak and broken-down sempstresses. In any and every case the dis- ease goes through its natural progress, if the system be not too much exhausted, either naturally or by the interference of the physician ; and if a judicious restorative treatment be adopted. 2. As a general rule, it will be observed that prostration and weaken- ing complications or remedies not only materially lengthen the period of the disease, but especially prolong the convalescence. This will be seen on referring to Nos. 6, 20, 71, 100, 101, 104, 118, and 119 in the Table. It is easily understood, therefore, how it happened that the anti- phlogistic treatment of former days proved so fatal. The facts collected for mo by Dr. Thorburn from former case-books of the Iloyal Infirmary, prove that in weak cases a lowering treatment was still employed, though not to so great an extent as in robust persons. 8. It is generally supposed that the amount of lung affected by pneumonia must influence the result and duration of the disease. As to the results, all my cases recovered, even the 15 cases where the whole of one lung was involved, as well as the 26 cases where portions of both lungs were affected. In one complicated case (No. 56) the whole lung on the right side, and two-thirds of the lung on the left side, were si- multaneously affected, thus leaving only one-third of a lung to respire with, and yet without bleeding, but aided by nutrients and restoratives, she was convalescent on the 14th day, and left the house quite well, after a sixteen days’ residence. With regard to duration, the extent of the disease does not exert so much influence as is generally supposed. If only a fourth of one lung be affected, the recovery may take place in eight days ; but after that, whether the half or the whole of one lung, or two-thirds of both lungs, be involved, it does not appear to cause much difference. Cases with half a lung pneumonic recovered in 15, with two-thirds of a lung in 14, with a whole lung m 10, and^with portions of both lungs in 14 days, on the average. 4. Since the observations of Louis, it has been supposed that a pneu- monia at the apex of a lung was more fatal and more prolonged than one at the base ; and so it may be with an antiphlogistic treatment. But with a restorative treatment, the preceding facts show that in eleven cases where the disease was confined to the apex, recovery took place in all, and on an average on the thirteenth day. 5. For palliating symptoms, and especially pain and dyspnoea, warm fomentations and poultices I believe to be the best and safest remedies. Chloroform has been given by Varentrapp, and others, with good effect. No doubt also small bleedings, to the extent of 8 or 12 ounces, give re- lief; but in debilitated persons they are dangerous, and in all tend, by weakening the strength at a period when the depressed system is strug- gling to regain its equilibrium, to prolong the convalescence and favor angerous sequelae. Still, a small bleeding may be employed as a pallia- tive with caution, to relieve engorgement of the lungs, and congestion of 712 DISEASES OP THE RESPIRATORY SYSTEM. the right side of the heart, although it is very rarely required. (See p. 313.) It should be remembered, in cases of double pneumonia, that there is often great dyspnoea on the sixth or seventh day, which will gen- erally yield to warm poultices locally, and moderate doses of wine. (See Commentary, p. 681.) 6. As a curative treatment I am satisfied that the best plan is rest in bed, nutritive drinks, especially good beef-tea, from the firsts assisted by 4 to 8 oz. of port wine, if the pulse becomes weak, and solid nutrients as soon as they can be taken. The elimination of the exudation may be further assisted by salines (Acetate of Ammonia, and small doses of Tartar Emetic, l-16th of a grain) and diuretics (Nitric Ether), although nature will accomplish this herself if the strength of the body be main- tained. All active purgatives, contra-stimulants, depressants, anodynes, and lowering remedies of every description, should be avoided. 7. As a further proof of the advantage of the Restorative treatment, it may be mentioned that in no single instance has a case of acute pneu- monia in my hands degenerated into the chronic form, or become gan- grenous, even in the 11 cases where the disease was confined to the apex. Several cases have entered the house already chronic from neglect, want of nutrients, or as the result of a lowering treatment — circumstances that indicate sufficiently well the causes which produce it. After carefully studying all that has been written on the subject of Pneumonia, as well as the numerous statistical tables of the results of various kinds of practice, I can only account for the remarkable success which has followed the restorative treatment in my hands, by supposing that Acute Pneumonia is not a fatal disease if the strength be supported and there be no complication. The former idea of medical practitioners, that it was a dangerous disorder, and recjuired active depletion and anti- phlogistics to prevent its passing into the suppurative or fatal stage, was erroneous, and the result of the imperfect knowledge of pathology which then existed. Suppuration, so far from being fatal, is, as we have en- deavored to show, necessary to the resolution of the disease ; and death, so far from being prevented by depletion, occurred once in every three cases. The late Dr. Todd, while he supported, also stim.ulated to a great extent, and the result of his practice was a mortalit}" of one in nine cases.^ In not one of my uncomplicated cases has there, I repeat, been a death for sixteen years, although twenty-six were double cases, and fifteen were cases in which the whole lung was involved. Why, therefore, any such case should have died in the practice of Dr. Todd, I can only ascribe to unnecessary stimulation, as that seems to be the only point in which his practice differed from mine. As to the numerous remedies given in this complaint, I believe that, when not injurious, they are for the most part inert. It will be observed that in several of the first cases given in the Table, antimony was ad- ministered in grain doses, and that gradually its amount was diminished. Rv some (Todd) this drug is thought to act best w’hen it occasions no symptoms; bv others (Scoda) it is only thought to be beneficial when it causes vomiting or diarrhoea. Rut in none of the cases tabula ted vas any influence produced by it on the progress of the disease. Scoda, who * Clinical Lectures by Beale, p. 310. PNEUMONIA. 713 has experimented largely and carefully as to the effect of numerous drugs in pneumonia, admits that no kind of treatment exerts any influence on the rate of mortality, which he thinks is always about 1 in 8 or 9. The rate of the best homoeopathic statistics (Tessier) is 1 in 13|, and that of the most judicious kind of mixed practice, by which different remedies are adapted to various symptoms, according to the age of the patients and stage of the disease, is 1 in 9 (Huss, Bamberger). It follows that no practice hitherto proposed has been so successful as mine — that is, 1 death in 32l cases. In the uncomplicated cases of Huss, the mortality was 1 in 17, whereas among mine there was no death at all. The author of an able article in the British and Foreign Medical Review for July 1858, endeavored to show from the contrary results obtained by statistics, that the result was governed by hygienic laws, or peculiarities, such as age, season, climate, neglect of the disease at an early period, its stage, and especially its sthenic or asthenic type. I consider that my table is calculated to show the fallacy of such reason- ing, and that, looking at the time over which it extends, as well as all the other circumstances to which he has adverted, it might easily be shown that the uniform good results in my uncomplicated cases depend on some other cause. That cause, I can have no doubt, is simply supporting the patient by nutrients and restoratives from the commencement. The want of that support explains the mortality in the practice of those who, while they do not actually lower their patients by treatment, fail to see that, in a certain proportion of cases, either the disease itself, or excessive stimulation, exhausts and proves fatal. Case CLIY .* — Chronic Fneumonia of Upper Third of Right Lung — Gangrenous Abscess — Recoverg. IItstory. — B etsy Brown, at. 48, married, a washerwoman — admitted September 12tb, 1856. Had always enjoyed good health until the 22d of last month, when, in consequence of exposure to cold and wet, she experienced rigors, followed by heat, but without headache, thirst, or loss of appetite. This was followed by cough and expectoration, symptoms which have continued ever since. Two days ago she brought up a tea-spoonful of blood. Symptoms on Admission. — She complains of pain in the right hypochondrium, under the false ribs, not increased by inspiration. On percussion there is dulness over right apex anteriorly, and upper third of the right lung posteriorly. Inspiration heard over dull area is harsh, with occasional snoring during expiration. Vocal resonance greatly increased. Sputum scanty, tenacious, purulent, with brownish streaks. Other portions of lungs healthy ; no friction audible. Slight giddiness, tinnitus aurium, and feeling of weakness. Pulse 80, equal, and of moderate strength. Hepatic dulness normal. Other functions well performed. B Opii Camph. ^ ss ; Vin. Ipecac. 3 ij ; Mist. Scillce ad § vj. A table-spoonful to be taken three or four times a day. Progress op the Case. — September Ath. — Expectoration more free. A blister to be applied to upper part of right chest anteriorly. Sept. 29^/i. — There has been little change, except on the day before yesterday, when she vomited her food, complained of headache, and presented slight febrile symptoms. Pulse to-day is 80, and weak ; no shivering. Bowels costive. R saline mixture., with of wine., and to have ^ ss of castor-oil. Oct. Id. — Sputum and breath during the last few days have been of an offensive odor. Sputum is copious, purulent, of a somewhat dirty yellow color. Fine crepitation is now audible on inspiration under the clavicle, and down to third rib, with sibilus during prolonged expiration. Posteriorly over dull region, respira- * Reported by Mr. John Glen, Clinical Cl erk. 714 DISEASES OF THE EESPIRATORY SA^STEM. tion is feeble. Over lower two-thirds of right lung, respiratory murmurs greatly exaggerated ; patient feels very weak. To have | vj of wine daily. Oct. hth. — Over right lung posteriorly, moist rales are now heard ; below spine of scapula they are very coarse. Expiration is prolonged, loud, and tubular. Vocal resonance amounts to bronchophony immediately below spine of scapula. Oct. lOth. — Since last report has continued to be very weak, with feeble pulse at 80, notwithstanding employment of nutrients and wine, which she has no appetite to avail herself of Cheeks flushed ; skin hot, with general febrile symptoms. Sputum copious, still foetid, and consider- ably stained with dark blood. No evidence of lung- tissue on microscopic examination. Posteriorly, immediately below spine of scapula, the moist rattles are very coarse, with bronchial resonance of the voice approaching pectoriloquy. Continue nutrients and wine. Oct. %)th. — The amount of sputum has gradually declined since last report, and the coarse moist rales have slowly disappeared from right back. There is now dry cavernous breathing, with pectoriloquy below spine of right scapula. Tec. llth . — Since last report she has been alternately better and worse, the sputum being at some times copious, and at others scanty, but not foetid. Moist rales also have occasionally, on the former occasions, returned in the right back, with more or less sibilus on ex- piration. For some days there has been harsh inspiratory murmur at apex of left lung, and prolonged expiration, without dulness on percussion, but with considerable increase of vocal resonance. Has been taking cod-liver oil. Tec. 26^A. — Since last report there has been a gradual improvement in her general health. Appetite has returned, and her strength permits her to sit up during the day. No moist rales are audible in right back, but loud tubular breathing, with increased vocal resonance. Jan. 20/A. — Has been for some time apparently quite well, and says she enjoys perfect health. Tubular breathing and broncliophonic resonance of voice, with dulness on percussion, are still present over upper third of right back. At left apex also, inspira- tion somewhat harsh, with increase of vocal resonance. Dismissed. Commentary . — In this case a woman, 48 years of age, who tells us she had always enjoyed good health, is attacked with moderate fever, cough, and expectoration, with all the physical signs of a pneumonia in the upper third of the right lung. The sputum becomes foetid, and a gangrenous abscess forms, from which she slowly recovers, under the action of nutrients and wine, leaving, however, as traces of the disease, evidences of condensation in the pulmonary tissue affected. In all such cases there is extreme difficulty in separating the disease from phthisis. Indeed, there is little pathological distinction between a chronic pneu- monia and pulmonary phthisis. Moreover, the latter, though the real disease, may supervene upon the former, of which the following is an example : — Case CLY.* — Chronic Pneumonia of loth Lungs., with Ulceration — Tenth — Great Conde^isation, with Cavities and Pigmentary Teposits in the Lungs — Chronic Tubercle in various Organs — Tisease of both Bupra-renal Capsules., without bronzing of the shin. History. — John Cunningham, get. 52, married, a shoemaker — admitted December 8th, 1856. He states that having previously been in the enjoyment of good health, three months ago while walking he became heated, and took off part of his apparel. On his return home he was attacked with shivering and severe pains in the breast and lumbar regions. A violent cold ensued, but he continued his employment. Three weeks ago he was obliged to give up work. A blister applied to the chest to-day, before admission, has mitigated the pain there. Symptoms ox Admission. — Percussion over left front of chest gives almost tym- panitic resonance, but the tone is flat, with a strong sense of resistance. Crack-pot sound is elicited in second intercostal space. Over right side, resonance more full and less tympanitic, but still somewhat flat. Posteriorly some flat tone, with a resonance not fully clear. On auscultation, marked increase of vocal resonance over left apex. * Reported by Mr. W. Guy, Clinical Clerk. PNEUMONIA. 715 abo over left supra-scapular region ; elsewhere normal. At left apex, inspiration and expiration are blowing and cavernous in character, and expiration is prolonged. After cough, fine moist sounds ai’e heard at close of inspiration. Laterally large moist sounds are more or less heard with inspiration, and coarse in character, while expira- tion is loud in tone. On right side the same moist sounds are heard, coarser in char- acter, with both inspiration and expiration. Posteriorly, respiratory murmurs somewhat loud. No moist rales, except over right supra-scapular region. Expiration is every- where prolonged. Cough is violent, accompanied with a great quantity of frothy, tenacious, and somewhat dirty and blackish-looking sputum, with a few streaks of blood. Pulse 88, small and weak. Urine, sp. gr. 1020 ; voided in small quantities, of a high color, throwing down a large quantity of lithates. Chlorides plentiful ; other functions normal. Progress of the Case. — December Wth. — Under left clavicle to-day, hoarse c'avernous rales, with both respiratory murmurs, accompanied with faint but distinct crepitation and bronchophony. Posteriorly at left apex, loud tubular breathing, with both murmurs ; inferiorly fine crepitation, mixed at the termination of insi>iration with a loud sibilant murmur. Dec. \Mh. — To have a blister applied over sternum. Dec. \^th. Complains of indigestion and feverishness. Pulse 100, hard, but compressible. U Acetalis Potass. 3j; Aquce Acet. Ammon. §j; Aquam ad | vj. M. A table- spoonful to he taken every three hours. Dec. 18^A. — Feverishness has disappeared; sputum of a dark-brown color ; is not foetid. On microscopic examination, numerous well-formed pus cells are seen, but no pulmonary tissue. Dec. 2Zd. — Takes nourish- ing diet with 3 iv of wine. Says he eats all his food. Anxious to go out, but cannot on account of weakness. January 2d. — Countenance expressive of great weakness, sallow and pale. Tongue covered with a brown crust ; dry, hard, and cracked. Pulse 108, weak ; cough at night severe, preventing sleep. Physical signs unaltered ; cannot rise to sitting posture without aid. Jan. %th. — Died at 1 o’clock p.m. Sectio Cadaver is. — Forty -seven hours after death. Thorax. — The upper lobe, and upper half of middle lobe, of right lung condensed and indurated. On section, the cut surface presented an iron grey passing into a black color. At the apex there was a cavity resembling a tubercular one about the size of a walnut. The inferior portion of this lung also somewhat condensed, but more spongy. The whole of left lung condensed and indurated. On section, the same iron- grey color was everywhere observable except at the base, where there existed masses varying in size from a hazel-nut to that of a chestnut, of a dirty red colored hepatiza- tion. Portions of the condensed tissue everywhere sunk in water. At the apex and at the back of this lung below the pleurae, which were adherent, there was a cavity four inches long, and about an inch in breadth, with very irregular broken down walls. This communicated with several smaller anfractuous cavities. Heart normal. Abdomen. — Slight simple constriction of the pyloric orifice of the stomach. Over the mucous surface of the small intestine, extending from the termination of the ileum to about two feet of the end of the duodenum, were numerous cicatrices of former ulcers, with everted edges, and the surrounding mucous membrane puckered and drawn in. There were a few similar cicatrices in the large intestine. The mesenteric glands were a little enlarged, and contained yellow tubercular matter. The right supra-renal capsule felt thick and hard, and weighed 290 grains. It was everywhere infiltrated with yellow, opaque, tubercular-looking matter of solid consistence, but friable under pressure. Perhaps about one-tenth only of the gland presented its natural texture. Two tubercular masses, the size of filbert-nuts, were present in the left supra-renal capsule, surrounded by indurated tissue. One-fourth of its texture was natural. Other organs normal. Microscopic Examination. — Fluid pressed from the iron-grey and black hepatiza- tion contained — First, A great number of large granule cells. Secondly, Numerous pigment cells. Thirdly, Colorless epithelial cells, isolated and aggregated in masses. Some of these cells were peculiarly colorless, and resembled those in waxy textures. Fourthly, A few starch and celloid bodies. Fifthly, Numerous pigment and fatty granules floating loose. On making a section of this tissue with a Valentine’s knife, these elements were seen everywhere infiltrating the pulmonary texture. The fluid pressed from the dirty red colored hepatization, in the base of the opposite lung, con- tained numerous pus corpuscles with epithelial cells ; comparatively few granule cells, V16 DISEASES OF THE EESPIEATORY SYSTEM. and no pigment. A portion of the grey exudation, which here and there resembled infiltrated tubercle, was composed of amorphous molecular matter. The yellow masses in the supra-renal capsules presented the characteristic structure of tubercle. Commentary . — This man’s account of his case (and he seemed very intelligent) was, that the pulmonary disease commenced in the manner described, three months before admission. He also denied having been ever seriously ill before. Yet the examination after death revealed evidences in the lungs, intestines, mesenteric glands, and supra-renal capsules, of chronic tubercular disease. The fever, rapid ulceration of both lungs, and subsequent prostration, as in the last case, however, were apparently owing to a pneumonia, which became chronic. In such a case, the vital powers were unable to effect those rapid changes which we have seen to be the characteristic of acute pneumonia, and he died. The diagnosis between such a disease and phthisis pulnionalis, I regard as impossible. The two forms of exudation present similar physical and vital characters. In neither this nor the former case, was the general appearance of the patient, or history of the disease, in any way similar to that of phthisis; and practically it is of little moment whether we have to do with a low form of exudation m young persons, which we call tubercle, or a similar one in old persons, which we call chronic pneu- monia. In this case, however, there was tubercle of a chronic character in several organs, and among others in both supra-renal capsules, although there was certainly no bronzing of the skin during life. Case CLVI .'^ — Gangrene of the Lunge — Dysentery. History. — Thomas Marshall, set. 29, a chimney-sweep — admitted November 23, 1852. He states that he has been troubled with slight cough for many years back. Eight weeks ago he experienced rigors without any obvious cause, followed by increase of the cough, looseness of the bowels, severe griping pains in the abdomen, and fre- quent desire to go to stool, with much straining and tenesmus. He observed a small quantity of blood in the stools, which sometimes consisted only of about a table- spoonful of blood mixed with frothy mucus. The calls to stool were at first so numer- ous that he cannot state even the probable number in the twenty-four hours. They abated somewhat under treatment at one of the dispensaries, but the diarrhoea has continued more or less ever since. During the last eight weeks the cough has become much aggravated, and the sputa increased in quantity. Two days before admission, he observed that the sputa were of a dirty red color, having formerly consisted of thick purulent masses without any tinge. He states that for the last eight or ten weeks he has been losing flesh and strength to a great degree, though he does not present a very emaciated appearance. His diet, also, during that period, has been very defective, both in quantity and quality ; but previously he had always been able to procure good food. He is addicted to the immoderate use of spirits, and has several times had delirium tremens. Symptoms on Admission. — On admission, the chest on percussion appears resonant throughout, except over the upper third of right lung, where very slight dulness can be detected. The respiratory murmur is heard all over the chest, but under the right clavicle it is harsh and exaggerated, and the vocal resonance greatly increased. Pos- teriorly, there is comparative dulness on percussion, and increased vocal resonance over the whole of riglit side, but most marked at the apex. Over the lower third, on the same side, fine crepitation can be heard during forced inspiration. Sputum in large quantity, consisting of frothy tenacious mucus, of a dirty brown color, becoming more fluid upon standing, and of very offensive odor. When examined by the microscope, numerous pus-cells, some blood corpuscles, and large quantities of disintegrated epi- thelium, can be detected. Has no pain in chest. Breathing is not labored, but cough is troublesome, especially at night, occurring in paroxysms. Expectoration difficult. The tongue is dry, with slight, dirty-yellow fur ; troublesome thirst, but appetite good. ^ Reported by Mr. W. M. Calder, Clinical Clerk. PNEUMONIA. Ill No nausea, but frequent inclination to vomit when the cough is severe. No uneasiness iu the bowels when at rest, but griping pains are generally present when at stool. There is, distinct tenderness on percussion in the right iliac region, over a space of about two inches. The bowels have been open six times during the last twenty-four hours. The stools are very copious, of thin fluid consistence, and of a brownish-red color. They contain numerous blood-corpuscles, as determined by the microscope. The urine is passed in small quantity, but otherwise normal. There are slight tremors of the hands, but no other symptoms of delirium tremens. Other functions normal. IJ Tinct. Opii 3 ij ; I'inct. Catechu ? ss ; Confect. Aromat, 3 ij ; Mist. CretcB | v. M. A tab’ e-spoonful to he taken every four hours. Haheat enema., cum Tinct. Opii 3 j- jElh. Sulph. m. xl ; Mucilaginis 3 ij ; Mist. Camph. ^ j. Fiat haustus. To he taken at bed-time. Ordered also nutritious diet and 4 oz. of wine. Progress op the Case. — November 26. — Bowels open nine or ten times during the twenty-four hours ; stools watery, having distinct traces of blood. Much griping pain when at stool. Cough severe. Expectoration copious. Dec. 1. — Diarrhoea con- tinues, notwithstanding he has taken regularly the astringent mixture and opiate euemata. To-day the skin is hot and dry, the appetite bad, with great thirst. To have a 5 gr. pill of lead and opium every third hour. Dec. 2. — Has had four or five stools since last night. They are faeculent, but of very thin consistence, unmixed with blood. He feels very weak, and complains much of pain in the chest, especially on the right side. Dulness on percussion is increased over the whole of the right side posteriorly, and is most marked over the lower third. There is great increase also of the vocal resonance, amounting to pectoriloquy in the supra-scapular region; loud moist rales, like gurgling, are heard over the right back. On the left side the respira- tion is harsh and exaggerated, and the vocal resonance is also loud. Breath and ex- pectoration foetid. Omit the lead and opium pill and continue the medicine ordered on the 2Uh. Dec. 6. — Diarrhoea abated, but he feels very weak, and the cough is trouble- some ; crepitation, with increased vocal resonance, pretty general over the left back. To have 3 oz. of spirits. Dec. 9. — Diari'hoea has returned — stools thin and fmcal, con- taining a good deal of blood. To have a starch injection with Tinct. Opii 3 iss. Dec. 14. — Diarrhoea abated somewhat until to-day, when it has again returned as severely as before. Much. pain in lower part of abdomen ; consideraVfle griping and tenesmus; pulse 100, small and weak, but regular. The opiate enema has heeyi continued every evening since last report., and he has been taking a chloric ether and morphia mixture to relieve the spasmodic cough. Apply a blister {f by 2>) to the abdomen. Increase the wine to 6 oz. Dec. 18. — Has rallied greatly since last report, but to-day the diarrhoea has again returned. The cough is very troublesome — sputa tinged with blood ; over the whole of the right back there are harsh gurgling rales, with a noise approaching to a metallic character when he coughs ; mucous rattles heard over left back ; the offen- sive odor of breath and sputa has increased since last noticed. To have the follow- ing draught at bedtime. B Mur. Morph. 3j; continue the 2> oz of spirits. Tinct. Catechu 3j; Mist. Cretce ^j; Spir. Ammon. Aromat. 3 ss. M. Sumat hora somni. Jan. 1. — Died this morning at five a.m. Little change took place in the symp- toms after last report. One day he appeared to sink, but h^e rallied again the next. Diarrhoea continued, averaging about twelve stools in twenty-four hours. The stools consisted of very small quantities of dark matter, with mucus, and occasionally a little blood. He continued taking the mixture of ammonia, etc., and the astringents wit’i an opiate enema, which latterly was administered twice a day. Sedio Cadaver is. — Thirty -one hours after death. Body much emaciated. Thorax. — Heart and pericardium normal. Right lung united to thoracic walls by firm and universal pleuritic adhesions. On its being removed and bisected, a black gangrenous cavity, five inches long and four broad, was exposed, occupying the upper and middle lobes. It contained an extremely foetid olive-green diffluent matter, having no distinct structure. The walls of the cavity presented a firm lining membrane of condensed fibrous tissue, internally of pulpy consistence and blackish-brown color. The surrounding pulmonary tissue, posteriorly and inferiorly, was hepatized and friable, with a few anfractuous cavities also gangrenous. Anteriorly the lung was emphyse- matous, with here and there portions of collapsed tissue. The left lung adhered to the thoracic walls posteriorly by pleuritic adhesions. On being removed and bisected, the lower lobe end inferior portion of upper lobe was congested, and presented a brick-red color ; hepatized and dense in various places, with irregular cavities containing foetid V18 DISEASES OF THE KESPIKATORY SYSTEil. brown sloughs, varying in size from that of a pea to a pigeon’s egg, and communicating more or less with each other. AbdomexN. — Mucous surface of cascum and ascending colon closely studded with irregular-shaped ulcerations, varying in size from a pin’s head to a sixpence. Some oi these were evidently chronic, and in process of healing, with a thickened worm-eaten edge and a bluish granular base ; others contained a sloughing centre, involving more or less of the muscular coat. Similar ulcers were scattered, but more sparsely, through the transverse and descending colon. Other abdominal organs healthy. Cimmentary . — In this case we have an example of pneumonia in both lungs, which passed into gangrene, associated with acute dysentery, occurring in an individual whose constitution had been impaired by ad- diction to intoxicating drinks. Dysentery, generally prevails during the autumn months, in Edinburgh, to a greater or less extent; and in the case of Marshall it came on without any obvious cause in September, and was ushered in by rigors, followed by bloody and purulent discharges at stool, with tenesmus and abdominal pain. About the same time, also, pectoral symptoms were complained of, although it is not probable that decided pneumonia was then occasioned. Even when he came into the house it was limited in extent, and ran a tolerably acute course subse- quently. The febrile symptoms, therefore, v/hich existed previous to his admission, were most probably connected with the dysentery. This ran its usual course, producing sloughing ulcers in the mucous membrane of the large intestines to a considerable extent ; and by the irritation and continued discharge they occasioned (which could not be checked), gradually prostrated the patient, and was the chief cause of his death. It is seldom we have an opportunity of seeing a more illustrative case of gtingrene of the lungs, than this man presented — large and circum- scribed on the right side, extended and diffused on the left side. That the gangrene was preceded by pneumonia in both lungs there can be little doubt, as all the functional signs of the lesion were present during life, whilst after death the gangrenous cavities were everywhere surrounded by distinct pulmonary hepatization. There is every reason to suppose that the same general causes which produced the sloughing sores in the intes- tines, occasioned the gangrenous cavities in the lungs. A deficiency of vital power in the organism prevented those transformations necessary for the absorption of the exudation, and thus it died and underwent putre- faction. Inflammatory gangrene and ulceration both depend on death of the exudation, but in the former case there occur those peculiar chemi- cal changes which induce putrefaction. The only symptom which in- dicates this change is foetor of the breath or of the sputum, which was very apparent in Marshall on his admission to the house, and was greatly increased afterwards. In the following case I diagnosed a gangrenous cavity in the right lung, and separated it from phthisis, partly on account of the foetid odor, and partly on account of the situation and limitation of the cavern. Case CL VII. — Gangrenous Abscess of the Right Lung^ caused hg sxcallow- ing a piece of Chicken Bone four and a half xjears previously. History. — Thomas Neal, set. 27, a footman, of sober habits — admitted December 4th, 1848. He says that he was quite well up to four years and a half ago, when, while eating part of a chicken, and laughing, he was suddenly seized with coughing * Reported by Mr. James Struthers, Clinical Clerk. PNEUMONIA. n9 and a sense of suffocation, producing lividity of the face. He thinks he swallowed a portion of chicken bone, but is by no means sure. At ail events, he experienced a severe pain at the time across the lower part of the chest, followed by a short, dry, tickling cough, accompanied by a wheezing noise in the throat. In an hour he recovered and went about his usual employment. The cough, however, continued, and after three months was accompanied by a frothy expectoration, which gradually increased. About three years ago he entered St. George’s Hospital, London, but was dismissed in a fortnight. Shortly after, he observed blood in the sputum, which now became foetid. He has labored under constant cough, with expectoration of foetid pus and moi’e or less blood ever since. Symptoms on Admission. — On admission he complained of frequent cough and profuse expectoration of a viscid, slightly frothy matter, stained with blood and of gangrenous odor. He was pale, but by no means emaciated. On percussing the chest, there was considerable dulness over the two inferior thirds of the right lung, both anteriorly and posteriorly. At a point a little below the right nipple, the dulness was more marked than either above or below. On auscultation there was great increase of the vocal resonance over the whole right side of the chest, most so over the dull spot below the nipple. Posteriorly, about the middle of the lung, there was a circumscribed gurgling rale, heard over an extent about two inches square, and not audible above or below it. At this point also there was perfect pectoriloquy. The respiratory murmur over the other parts of the lung was harsh, and here and there accompanied by mucous and sibilant rales. These signs were less evident at the upper than over the lower two-thirds of the organ. Over the left lung the percussion was normal, the respiratory murmurs puerile but otherwise healthy. All the other functions were well performed, if we except the occasional loading of the urine with lithates, and trifling perspiration at night. Progress op the Case. — The treatment was directed to supporting his strength, giving cough and antispasmodic mixtures, and introducing a seton below the right nipple. This produced considerable local irritation, but caused diminution in the gurgling rale, expectoration, and cough, so much so, that he insisted on leaving the Infirmary, February 8, 1849. He continued, however, to be attended by the clinical clerk, now Dr. James Struthers of Leith, from whose report the following account is taken : — “ Towards the middle of March his appetite and strength began to fail ; he lost flesh and became feverish, thirsty, and restless ; was obliged to confine himself to the house, and suffered from shortness of breath, even when at rest ; the cough and expectoration continued much the same ; he had no rigors, and was free from pain. On the morning of the 24th, he awoke suffering from great increase of cough and shortness of breath, and continued during the day to expectorate, at intervals of a few minutes, large quantities of frothy sputa, deeply tinged with blood, and much more foetid than usual. I was asked to visit him at his own house on the 25th, and found him much weaker than when I had seen him fome weeks previously. The cough was constant, the expectoration profuse, the sputa frothy and mixed with florid blood ; the breath and sputa had a gangrenous odor which was very perceptible on approaching the bed. He had no pain, his chief complaint being of great weakness, dyspnoea, and occasional feeling of suffocation. The respirations were 45 ; the pulse 130, weak and wiry. On examining the chest, the right side was found scarcely to move on inspiration, and was universally dull on percussion ; all natural respiratory sound was absent ; gurgling was audible over its greater part, both in front and be- hind, with coarse mucous and subcrepitant rale towards the upper and lower parts. Although the voice was weak, the vocal resonance was much increased, and there was very distinct bronchophony over the inferior two-thirds. There was no friction sound audible. The left side was very resonant, and, with the exception of puerile respira- tion, and some subcrepitous rale, inferiorly, presented nothing unusual. During the next three days, he became rapidly weaker ; the cough and dyspnoea increased ; he could speak only in monosyllables ; the respirations rose to 68, and the pulse to 140 ; he expectorated daily about two pints of thin bloody sputa, which had a strong gangrenous odor, and latterly flowed in an almost continuous stream from the mouth. On the 29th, he became typhoid, had hiccup and slight delirium, and died in the evening.” Sectio Cadaveris. — Thirty-six hours after death. The features were much collapsed ; there was some yellowness of the skin ; and a copious discharge of thin brown fluid from the mouth and nostrils. Percussion of the chest elicited the same sounds as during the last days of life. 120 DISEASES OF THE EESPIRATOKY SYSTEM. Thorax. — The right lung, with the exception of the lower part of the anterior border, was found firmly adherent to the walls. The adhesions were short, dense, and of a white color. The lung was removed without laceration ; it was somewhat diminished in bulk, of a dark red color, and had a pulpy feel. The apex was occupied by a closed cavity, the size of a small orange, which was distended with a brown dirty-looking fluid of the consistence of cream, and having a most intense gangrenous odor. The wall of this cavity approached the pleura superiorly; its inner surface was very irregular, presenting numerous shreds of disorganised pulmo- nary tissue. At the middle of the lung posteriorly, and about half an inch from the surface, there was another cavity, the size of a walnut, lined with a dense grey- colored membrane, one line in thickness, and broken up in several places ; it was partially filled with a dirty-colored fluid, and opened directly into a bronchial tube, the size of a crow-quill, at the other extremity of which the foreign body was found at a future stage of the dissec- tion. In the neighborhood of this cavity, and throughout the Fig 454 whole of the inferior and posterior parts, the lung was riddled with numerous small cavities, varying in size from that of a hazel-nut to that of a pea. Some of these were closed and filled with a fluid similar to that found ill the one at the apex ; others were nearly empty, more or less anfractuous, and communicated freely with the bronchial tubes ; the walls of some were formed of a thick dense membrane ; those of others were soft and ragged. The middle part of the anterior, and a small portion of the inferior border, were in a state of grey hepatization, and were the only parts free from cavities. On laying open the nchus, a small piece of bone was found at the bifurcation of the middle primary division ; it was lying almost loose, and came away without any force being used ; it was quite clean, and bore a strong resemblance to part of a verte- bra of a small animal, being of an irre- gular elongated form, and presenting several sharp spicula. The mucous mem- brane 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 color, but otherwise presented nothing abnormal. In the pleura, there 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 no- dules, 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 gland^^ especially those on the right side, were greatly hypertrophied, several of them being as large as pigeon’s eggs ; they contained no foreign matter. The heart was of the normal size ; its muscuiar and valvular structures were healthy ; and all the cavi- ties contained both firm decolorised and dark loose clots. The bloody examined under the microscope, presented the red and white corpuscles in the usual proportions Abdomen. — The abdominal viscera were in all respects normal. Microscopic Examination. — The fluid from the abscess at the apex of the right lung, on being examined under the microscope, was found to contain small shreds of fibrous tissue, broken down pus globules, and a large number of crystals of the triple phosphate and of the urate of ammonia (Fig. 455). Commentary . — The physical signs in this case clearly indicated the existence of a cavity in the right lung, which, from its position, and Fig. 454. Fragment of chicken-bone found in the right bronchus, in Neal’s case. Fig. 455. Fluid in the chronic abscess of the right lung in Neal’s case, a. Fibrous tissue ; A, broken-down pus cells ; c, crystals of triple phosphate ; and 6^, urate of ammonia. — {James Struthers.) 250 dia7n. PNEUMONIA. 721 from the general history of the case, was not likely to be tuberculai. On the other hand, its gangrenous character was revealed by the pecu- liar odor, and his account of its origin rendered it probable that the cause was a foreign body impacted in the bronchus. At the same time, he was never very certain as to the fact of having swallowed the piece of bone, and, in many conversations I had with him on that point, he invariably stated that such was merely his impression, but he was not sure. It is of importance to notice this fact, because it seems very pro- bable that when iu St. Gleorge’s Hospital, his account may have been a doubtful one there also, and may have prevented recourse to an opera- tion which then might possibly have been undertaken with success. It would be interesting 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 dis- missed in a fortnight. Certainly, it cannot be imagined that if any cer- tainty existed as to the impaction at that time of a foreign body in the lung, no eifort would have been made to extract it, especially when the uniform ultimate fatality of such an occurrence is taken into considera- tion. At all events, this case points out how, in a young man of perfect health, structural disorganization slowly, but surely, proceeds after such an occurrence, and it strongly inculcates the necessity of early careful examination and of operative interference. Another cause of gangrene in the lung is the occasional impaction of clots of blood, whether the result of phlebitis or from floating coagula coining from the right side of the heart. As an example we may cite a well-marked case given by Mr. Gr. W. Callender, in the ninth volume of the Pathological Society’s Transactions. One of the tertiary divisions of the pulmonary artery was oc- cupied by a clot of decolorized fibrin in the form of a hollow globule. Its diameter was about two lines greater than that of the artery below, so that at this point the vessel seemed to have undergone some slight dilata- tion. Just beyond the place at which this clot had obstructed the canal, the artery bifurcated. The blood had penetrated one of its divisions by means of a short and narrow channel, formed 45^ by the side of the abo vementioned 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 it^ divisions obstructed by another clot, which, unlike the others, was solid throughout. The portion ot pulmonary tissue with which this artery communicated, was in a state of gangrene, as also was its pleural covering. In this case various masses of coagulated fibrin were adherent to the tricuspid valve, Fig. 456. Part of the left lucg, with clots occupying branches of the pulmonary artery. — {Callender.^ wo j 46 722 DISEASES OF THE EESPIRATOEY SYSTEM. and the clots found in the branches of the pulmonary artery in the lung were most likely derived from them, as the vein itself was healthy. The hollowing out of the nearer of these coagula to the heart also was probably owing to the subsequent action of the current of blood, whilst the one further distant remained solid, and completely arrested the cir- culation. PHTHISIS PULMONALIS. Case CLVIII.* — Phthisis Pulmonalis in its last stage, with Incompe- tency of the Aortic Valves — Cod liver Oil and Nutrients — Complete Recovery. History. — Patrick Barclay, get. 15, admitted June 26, 1849. His previous history indicated that he had been of scrofulous habit from infancy. He attended the indus- trial school regularly until a week ago, but could not take much exercise on account of a sore leg, which originated twelve months previously in a fall. His diet has for a long time been very poor. On the 18th he was attacked with cough, and this has con- tinued till admission. He also complains of dyspnoea on exertion. Syme’Toms on Admission. — On admission, he is excessively emaciated. He com- plains of cough, which is sometimes very prolonged, but has no pain or difficulty of breathing. The chest expands well on inspiration. Cough easily excited, and occa- sionally severe. Sputa viscid, frothy, and tinged with blood. On percussion, there is great dulness on 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 l ales are also heard in the upper part in front. Behind, on the right side, vocal re- sonance not so distinct, but lales the same as in front. Pulse 114, strong and sharp. The heart’s apex beats below sixth rib ; impulse increased ; but percussion does not indicate internal expansion. On auscultation, a chirping musical murmur is heard over the apex of the heart, at the end of the first sound. This murmur becomes much more faint towards the base. To the left 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 ]iatient holds his breath. Tongue slightly furred ; appetite good ; some thirst. Bowels regular. Urine natural; sp. gr. 1020 — not coagulable. Chest, face, and arms, are covered with an eruption of prurigo, which he has had several times. On the t!ic right thigh, towards the lower part there are several cicatrices, and three sinuses, which communicate with dead bone. Is much troubled with sweating, which at night is very profuse. To have good diet with sweet milk morning and evening, and a dessertspoonful of cod-liver oil three times a day. Mist. Seillce 3 iv. ; Tinct. Opii Ammon. 3 ss ; Aq. Cinnam. § iss ; Aquee 5 iij. M. Hedf-an-ounce three times a day. Progress of the Case. — June 30^7i. — Friction rale less. Gurgling rale on right side. Upper part of chest to he rubbed with Tartar Emetic Ointment. July 2d. Chirping murmur has become faint, and occasionally is inaudible. Has vomited his food several times. Half a drachm of Naphtha to be added to mixture; to have beer for drink. 5th. — Chirping murmur quite gone. 8^/t. — Chirping murmur returned. Cough severe, causing vomiting. Eruption, brought out by ointment, painful. Omit the Ointment and Mixture. Pidv. Tragacanth. Co. 3 1 ; N aphthae Medic. 3 i; Pol. Mur. Morph. 3 iij ; Syrup. Aurantii 3SS; Mist. Scillce § v. M. A table-spoon- ful thrice a day. 21s?. — A seton was introduced beneath the right clavicle. Still vomits in the morning, but takes food and medicine better. Aug. 6?/t. — The expiratory murmurs under right clavicle are now quite dry. V omiting is diminished. Omit the Mix- ture. Ferri Citrat. 3 ss ; Tinct. et Syrupi Aurantii f ss ; Inf us. Calumbce ^ vi. M. A table-spoonful three times a day. \2th. — The seton discharges freely, causing great irritation, and is to be withdrawn. Sept. 7th. — Appearance of patient much im- proved. Sounds of cavity in chest continue dry. Takes now again a table-spoonful of the oil three times a day. Oct. 28?/i. — Musical murmur has entirely disappeared. He is becoming quite fat, and is able to go about the ward all day. Complains only of slight * Reported by Messrs. Hugh Balfour, Sanderson, and Dewar, Clinical Clerks. PHTHISIS PULMONALIS. 723 cough at night, and palpitation on exertion. The right infra-clavicular region is be^ coming flat. Omit the mixture aud also the cod-liver oil. Nov. \%th. — Cough has returned, with slight mucous expectoration; and, on auscultation, mucous and sibilant rales are h(‘ard all over the chest. Ordered to recommence the oil. Mist. Scillie Vini Ipecac. 3 ij ; Sol. Mur. Morph. 3 i. M. A table-spoonful three ti nes a day. From this time he rapidly improved. The cavity became perfect ly dry, and respiration over it was accompanied by blowing murmurs. Cough and expecto- ration greatly diminished. His general appearance is healthy, and he is very stout. On January 18<'A, it is noted that, on percussion, a distinct cracked-pot sound is heard in the right infra-clavicular region, and faintly also on the left side. On auscultation the heart’s sounds are loud all over the chest, the second sound being accompanied with a distinct bellows murmur. Musical murmur has never returned. There is bronchophony and prolonged expiration in the right infra-clavicular region, but no moist sounds. Sleeps well, and is very little troubled with cough. Does not sweat ; is very fat ; appetite good. This boy, as far as all general symptoms are concerned, may be regarded as having been in good health for the last two months. Feb. Fith . — On percussion, the chest was tolerably resonant on both sides ; but there was slight dulness under the right clavicle. On auscultation, 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, and there is considerable vocal resonance, but not amounting to bronchophony — no moist rales. In the corresponding situation on the left side, the inspiration is 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 ‘•I'oth^ 1850. Since leaving the house he has been at the Industrial School, but has been frequently exposed to cold; and latterly the cough and expectoration, which ho says had quite left him, have returned, and been gradually getting more severe. The sweating returned with the cough. A week before admis- sion, he, with the other boys of the school, went to Portobello to bathe, and notwith- standing his remonstrances, the master insisted on his going into the water, saying it would do him good. He however became much worse. On admission, the physical signs were coarse moist rale under the right clavicle, imperfect pectoriloquy, and creaking friction noises, harsh inspiration, and prolonged expiration under left clavicle ; but the dulness in this position is very slight, when compared 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, expectoraiion, and other symptoms ceased, and he was discharged J/arc/i 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 tveeks. Since then he has been constantly etnployed 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 somewhat 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 tlie 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 admission into the house. The cough rapidly diminished, and is now only present in the morn- ing on waking. His bodily functions, he says, are in every respect perfectly well per- formed. The wound in the thigh is cicatrised, and were it not for the cardiac disease, this lad might be considered in robust health. The following is the result of a careful e.xamination of the chest made December 23 this situation was complete, and there was absence of expansion during respiration. There could now also be heard harsh inspiration, with prolonged expiration under the right clavicle ; the resonance on percussion also was here slightly in, paired. During June, he was much troubled with nausea and vomiting. On the 21st he was attacked with rigors, followed by all the symptoms of continued fever, which terminated by diaphoresis on the seventh day. Shortly after, he was attacked with variola, which ran its usual course. During July and August, there was gradual but marked improvement of his general health. At the end of the last-named month, the left wrist-joint was firmly anchylosed, and all the carious openings had closed up. He still had occasional diarrhoea. There was still dulness on left side, but the mucous rales were not heard so low down anteriorly. Fine crepitation with increased vocal resonance was now audible under the right clavicle. Up to the middle of October he continued slowly to improve ; the sweatings and diarrhoea had ceased, and the cough was much less seveie. He now complained of considerable pain during micturition, and on examining the urine it was found to contain nume- rous pus-corpuscles, and to be coagulable by heat and nitric acid. He continued to feel pain on urinating, and to pass pus by the urethra during the month of October. On the 3c? of November the report is : — “ Marked dulness on percussion over the left cliest 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. No sweating or diarrhoea. Still occasional nausea and vomiting. General strength much impioved, and now walks about the ward, sitting up a great portion of the day.” The report on the 21s? of December is: — “Still marked dulness over the whole of left side, exci'pt under the clavicle, where it is tympanitic, with cracked-pot sound. Resonance on right side good. Under acromial end of left clavicle feeble, and distant gurgling is heard — the respiration having more of a blowing character than formerly, with perfect pectoriloquy. The moist rales over the other parts of this side have disap- peared. On right side, puerile respiration is heard over the inferior half of lung ; otherwise, the breath-sounds are normal. Posteriorly, dulness of the whole of left side, but there is no cracked-pot sound. On auscultation, the signs are the same as are licard anterioily. 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, winch, on examination with the microscope, are seen to be composed of numcrou.s pus-corpusc es embedded in mucus, slightly coagulable on PHTPIISIS PULMONALIS. 729 the addition of heat and nitric acid. Pain on micturition diminished.” From this time he continued, on the whole, to improve steadily, and was so well during the summer of 1862, as to walk about constantly in the open air, and went out of the house, by his own desire, on the 1st of the following August. About tlie 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 hmmaturia. 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, aegophony. Under the right clavicle there were fine moist rale on inspiration, and increased vocal resonance, but the chest expanded well on this side, and was otherwise normal. The fever, prosti'ation, and discharge of pus by urine, continued without intermission, and he died December 4, 1852. Sectio Cadaver is. — Forty hours after death. Body greatly emaciated ; the right carpal bones anchylosed, with marks of nume- rous old sinuses on the skin in their neighborliood. Chest. — Pleurae on the right side adherent at the apex, by loose bands of chronic lymph. The right lung indurated at the apex over an extent the size of a hen’s egg, and strongly puckered externally. On section, this indurated portion was seen to contain several encysted cretaceous concretions with the intervening pulmonary substance condensed, hard, and fibrous. A few chronic miliary tubercles w^ere also scattered through the upper lobe ; but the rest of the lung was spongy, crcj)itant, and healthy. The pleurae on the left side were everywhere firmly adherent, and over the superior half of the lung, which was much atrophied, they were converted into a dense white fibrous mass, three-fourths of an inch thick, which gradually diminished in thickness inferiorly. The left lung was not the volume of the closed fist; it was non-crepitant, felt indurated, but at the same time flaccid, evidently from internal cavities. On section, the entire mass was riddled with cavities more or less communicating with each other, containing purulent matter, and having a smooth lining membrane. Many of them ])resented a pouch-like foian, and were identical with what liave 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 co.isisted 01 a close dense fibrous texture, of bluish color, fi'om pigmentary deposits, in which no remains of pulmonary structure could be found. The bronchi con- tained a considerable quantity of viscid muco-purulent matter. Heart, larynx, and trachea healthy. Abdomen. — The large intestines, especially the caecum, were congested ; exhi- biting here and there patches of slate-colored pigment, with traces of cicatrized ulcerations, together with one superficial chronic erosion about half an inch in diameter, of irregular form. The kidneys were of natural size, and on section dis- played dilatation of the pelves, with pouch-like enlargements, the result of scro- fulous abscesses, filled with pus. The secreting substance was everywhere atro- phied, and the tubular substance in many places obliterated. Mesenteric glands and other organs healthy. Microscopic Examination. — A careful microscopic examination of the lining membrane of the pulmonary abscesses exhibited nothing but fibrous tissue, destitute of epithelium. There was nowhere any trace of a mucous surface. Commentarif . — The treatment of this case was conducted on the principles, and according to the rules afterwards to be detailed. It was directed principally to improve the appetite, diminish the nausea, vomit- ing, and diarrhoea, and support the strength by means of cod-liver oil and generous diet. Externally, repeated blisters were applied. During the attack of febricula and variola, antimonials were given in small doses. Latterly numerous remedies were administered to lessen the pains during micturition, such as anodynes; u.va ursse; bals. copaibae ; diuretics, etc. ; but an enema of starch and solution of morphia succeeded better than 730 DISEASES OF THE EESPIRATORY SYSTEM. anything else. It was always observed that in proportion as the d3^s- peptic symptoms were relieved, and the assimilation of cod-liver oil and food took place, so his health improved ; and by great care he was not only kept alive for two years, but I had sanguine expectation of an ulti- mate recovery, when he met with the accident which, by exciting acute disease in the kidneys, caused his death. This case presented many points of resemblance to that of Barclay (Case CLVIII.), especially in the scrofulous diathesis and scrofulous caries of the bones, and the cavity under one clavicle, on admission. The diseased lung was more extensively afiected however, and the derange- ment of the stomach more violent and persistent. Indeed, throughout the progress of his case, the chief difficulty in the treatment was the management of the stomach and bowels. The cod-liver oil and diet did not produce the same marked effect as in the case of Barclay, but their operation, though slow, was still very decided ; and for a long time I considered that the pulmonary lesion in this lad was in progress of cure, exactly in the same manner as took place in Case CLVIII. The dissec- tion after death demonstrated that in fact the lung was undergoing con- traction, and that the tubercular disease was being arrested. It presented a remarkable specimen of one of the modes in which this is occasionally accomplished, namely, by the formation of pouches or cavities, the lining membranes of which become smooth, and cease to exude tubercle. This condition of the lung has been described by morbid 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 ; j- and in the second, from the formation of fibrous matters, the contraction of which causes this enlargement from without. A consideration of the details of this case, however, must convince every physician that we had here to do with large tubercular excavations, which, by compressing the lung, had obliterated the whole of its texture, and converted it into a con- tracted fibrous envelope of these excavations. All trace of tubercular matter had disappeared, with the exception of two small cretaceous con- cretions, and the respiratory function 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 pul- monary lesion would ultimately have healed, it is difficult to say ; but there can be no doubt he might have lived a long time in this condition had he not met with the accident which caused his death. But that many such lesions maj" be arrested, and life continue, is proved by the observations of Benaud, who has given figures of what he calls dilata- tions of the bronchi, many of which were evidently the result of tuber- cular ulceration. J Cruveilhier ^ has also figured a lung presenting similar appearances. In the case of another man, called Joseph Finnie, which closely resembled that of Finlay, I diagnosed, during life, the same contraction of the lung from tubercular excavations, and the same chronic dilatations in connection with the bronchi. This man died of Bright’s disease in * Dublin Medical Journal, vol. xiii. 1838. f Laennec, vol, i. p. 201. f Memoires de I’Academie Royale de Medecine, tome 4"'®, Plate 4, Fig. 1 ; Plate 5, Fig. 1 ; Plate 7, Fig. 2. § Anatomic Pathologique, Livraison 32, Plate 5, Fig. 3. PHTHISIS PULMONALIS. 731 the Koyal Infirmary, January 1853 ; and on dissection a similar state of the pulmonary texture was discovered, with the exception that the atrophy of the organ was not so great, whilst traces of tubercular infil- tration were more evident. Case CLXI.^ — Chronic Phthisis — Enlarged Liver — Albuminuria — Large Evcavation in Left Lung — Cicatrices and Induration of Right Lung — JVaxg Liver and Kidnegs — Tubercular Ulceration of Intestines. History. — Margaret Clark, aet. 39 — admitted November 12th, 1844. She says that for two years previous to admission she was laboring under frequent attacks of cough, with profuse expectoration and spitting ol blood. During this period she has become greatly emaciated and very weak, sweating all night, with occasional diarrhoea. Catamenia have been absent during the last three months. Symptoms on Admission.— 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 ot the lung. On auscultation over left side, loud gurgling is audible, with pectoriloquy, extending over the whole anterior surface, but diminishing somewhat towards the base. Under right clavicle there is loud mucous rale on inspiration, with bronchophony. Breath sounds inferiorly normal. Posteriorly, the physical signs are similar to those in front. There is considerable dyspncea 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 func- tions normal. Naphthce Medecin. 3 j ; Tr. Card. comp. | j ; Mist. Camph. 3 v. M. A sixth part to be taken three times a-day. Milk mixed with an equal part of lime water and strong beef-tea with toast, to be taken frequently in small quantities. Progress op 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 disappeared. At each catamenial period there has been considerable haemoptysis, continuing several days, and amounting often to several ounces per day. Shortly after admission the appetite impx’oved, 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 sus- pended, and bitter vegetable infusions and tinctures administered, 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 alternate- ly 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 extending below the level of the umbili- cus on the right side, presenting a rounded margin and forming a distinct abdominal tumor. The emaciation is extreme, and latterly there have been considerable vomit- ing and diarrhoea. There is a hectic flush on the cheeks. The skin is warm ; pulse 120, feeble; profuse sweating at night ; loud gurgling rales still audible on left side of chest, with cracked-pot sound on percussion, and pectoriloquy. On right side there are loud vocal resonance under clavicle, slight dulness on percussion, and dry cavern- ous 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 1 ij of gininstead of wine. Sp. jEther. Nit. § ss ; Tr. Digitalis 3 ij ; Mist. Scillce c. ad I vj. M. One table-spoonful to be taken three times a day. July ‘14:th. — 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 liga- ment when she sits up. ffidema has extended above the knee. Weakness has in- creased. August l^th. — 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 ether and morphia draughts. At 4 a.m. this morning, respiration became very difficult, and shortly after she died. * Reported by Mr. Bum Murdoch, Clinical Clerk. 732 DISEASES OF THE RESPIRATORY SYSTEM. Sectio Cadaver is. — Thirty -one hours after death. Body greatly emaciated. Thorax. — Both pleurae strongly adherent throughout by chronic adhesions. 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, containing 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 internally 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, formino" small purulent collections, varying in size from a pea to that of a hazel nut. Through- out the upper lobe of right lung there were a few excavations, quite dry, 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-gray color 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, elongated in form, and all were enclosed in indurated capsules. The two inferior lobes were emphysematous anteriorly. In the centre of the lowest one was an indurated white patch, the size of half-a-ciown, with radii stretching from it in all directions. On cutting through it, it was seen to con- sist externally of dense white fibrous tissue, an eighth of an inch in thickness, and immediately below it was a mass of indurated tubercle, the size of a hazel nut, of iron-gray color, 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. Abdomen. — 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 f.om above downw’ards was 12 inches ; breadth 8 inches. Length of left lobe was 8 inches ; breadth, 6 inches. Its entire weight was '7 lbs. 9 oz. The greatest thickness of the organ from behind forwards was four inches. In texture it was of waxy con- sistence and appearance, of a dirty yellow color, dense feel, smooth section, presenting semi-translucent edges. The spleen weiglied 7 oz. 5 dr., and was healthy. The mucous membrane of the csecum was of a black tint, which extended up the ascending and half way across the transverse colon, gradually diminishing in intensity. This dis- colored portion of the membrane was studded over w ith 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 shilling, with irregular raised edges, and dirty yellowdsh base. Mesenteric glands everywhere enlarged, of a white color and in- durated ; some contained tubercular deposits. Both kidneys waxy ; externally pale, indurated, and rough ; internally, cortical substance atrophied, pale, and on section having translucent edges. The uterus contained in its inferior wall a fibrous tumor the size of a walnut. Three others the size of peas were on its anterior surface ; ovaries contracted, rugose, and of semi-cartilaginous consistence. Other organs healthy. Microscopic Examination. — The tubercle everywhere presented its usual charac- ters. The cells of the liver had undergone a remarkable change, being colorless, re- refracting light, deprived of nuclei, and forming, when compressed together, a trans- lucent, amorphous mass. The black matter in the CEecum was composed of molecules 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 Infirmary. The prostration was extreme, an enormous excavation even then existed in the left, with smaller ones in the right lung. Careful treatment directed to restore the tone of the stomach, nutrients adminis- tered in small quantities, with wine and cod-liver oil, caused a gradual restoration, and my opinion is, that from that time the pulmonary dis- ease continued to diminish. The cavities on the right side became dry, cicatrices and cretaceous transformations of tbe tubercular matter pro- ceeded, and the large excavation on the left side became smaller and more circumscribed. The liver first, and then the kidneys, underwent tlic waxy transformation; oedema came on, and she sunk. I have already alluded to the peculiar character of this degeneration of the liver PHTHISIS PULMONALIS. 733 and kidney (p. 249). It is exceedingly common in phthisical cases, and in this instance was recognised and examined histologically with great care m 1815. Formerly it was confounded with fatty degeneration, and it has been supposed that cod-liver oil tends to its production. But a knowledge of the true nature of the waxy degeneration must negative such a supposition, as the liver is altogether free from fat. The inter- ruption 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 previous 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 CLYIIL) 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 perfectly 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 pal- liative practice. To carry out the former, however, upon correct prin- ciples, 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 complications. It may be well to make a few observations on each of these heads. I. — On the Natural Progress of Phthisis Pulmonalis — 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 Alls 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 pulmo- nary texture. A miliary tubercle may, in this manner, block up from three to twenty of these air vesicles (Figs. 160, 161). It now coagulates and constitutes a foreign solid body, which can only be removed by being again broken down and rendered capable of being either absorbed or excreted. Thus the miliary or infiltrated forms, whether gray or yellow, after a time soften, — a process which may commence at any part of the mass and gradually affect the whole. This softening is a disintegration or slow death of the tubercular exudation, constituting true ulceration, which is more or less extensive according to the amount and extent of the morbid deposit. (Figs. 157, 158, and 159.) When recent, the pulmonary parenchyma in the immediate neighbor- hood is more or less congested ; and when chronic, it is thickened and 734 DISEASES OF THE KESPIEATORY SYSTEM. indurated, often forming a capsule which surrounds the tubercular de- posit. The pleura also is very liable to be aflected ; when recently so, presenting soft fibrinous exudations with more or less adhesion ; where- as when chronic, these become fibrous, and reach a thickness and den- sity seldom seen in other diseases. The bronchi are necessarily in- Tig. 457 . vclved ; their extremities are among the first structures affected ; and as the tuberculosis proceeds, all the appearances characteristic of chronic Fig. 457. Section of a lung in the first stage of Phthisis Puhnonalis. Ulcerative softening is commencing at the apex. Two-thirds the real size. PHTHISIS PULMONALIS. V35 bronchitis are produced. As the ulcerative process extends, the lung is more, and more destroyed, the excavations become larger and more numerous (Figs. 458, 459), until at length it can no longer carry on its important functions, and the patient dies, or the fatal result, as very commonly happens, is hastened by disease in other organs. The ulcerative or destructive tendency of the tubercular exudation Fig. 458. ' has generally been supposed to be its chief characteristic ; but there are _ Fig. 458. Section of a lung in the second stage of Phthisis Pulmonalis. Tubercle is extensively infiltrated in the upper lobe, and a considerable cavity has formed. Ttoo-thirds the real size. 736 DISEASES OF THE RESPIRATORY SYSTEM. very few cases in which its progress is uniform. It is continually checked, and for a time slumbers; and all morbid anatomists have recognised, even in the worst specimens of tubercular lungs, numerous cicatrices and evidences of attempts to heal. These attempts are more or less perfect, and when ineffectual, it is owing to the circumstance that as one portion of lung cicatrizes, another becomes the seat of recent tubercle. Fig. 459. Cicatrices present different appearances, according as the cavities Fi". 459. Section of a lun" in the third stage of Phthisis Pulmonalis. A cavity occupies the superior half of the organ, and another smaller one has formed in the inferior lobe. Two-thirds the real size. PHTHISIS PULMONALIS. V37 from which they were formed have been superficial or deep seated. In the first case it will generally be observed that the pleurae are more or less adherent and thickened, and this frequently forms an external boundary to the tubercular cavity. As the matters which the cavity con- tains are expectorated or transformed, the lymph gradually contracts, draws the lung closely to the thoracic walls, from which it cannot be separated without great violence. Sometimes, however, it is deeper, and the adhesion is very slight or does not exist. In this case, when the walls of the cavern contract, the pleural surface of the lung is drawn in- wards, and in this way the irregular puckerings visible on the surface are produced. Occasionally no traces of tubercular matter are discovered either within or in the vicinity of these cicatrices. Under such circumstances they appear to be formed of dense fibrous tissue, and the parenchymatous substance in their vicinity is of a bluish-black color, from increased pig- mentary deposit, and of peculiar induration and density, owing to chronic exudatfion. More generally, however, the contraction and puckering will be found to have occurred around tubercle which has undergone various transformations. Occasionally there are round masses of crude tubercle surrounded by a cyst. They are of unusual density, still of a yellowish color; but contain granules of earthy salts more or less numerous. Often they are white and friable, resembling chalky matter. In this state the soft portions have been apparently absorbed, and the whole consists, under the microscope, of irregular masses of earthy matter, mixed with numerous granules and crystals of cholesterine (Figs. 162, 367). At other times the whole has been con- verted into a solid calcareous mass, frequently round, or occasionally with numerous prolongations and irregularities, which accurately fit the surface and bronchi with which they are in contact. These cretaceous and calcareous concretions may remain an indefinite time in the paren- chymatous substance of the lungs, or they may be evacuated through the bronchi with the sputa. The cyst which incloses them then forms a dense linear cicatrix. Such appear to be the usual modes in which tubercular ulcers heal. They occur in exactly the same manner as abscesses in other parenchy- matous tissues, the result of simple exudation ; and that the process in both is identical, is proved by the frequency with which in the latter calcareous deposits also take place. If, then, the further deposition of tubercle could be arrested, there seems no reason why cavities in the lung should not heal with the same frequency as ulcerations or abscesses in other internal organs. Indeed, the careful dissections of morbid anatomists have recently shown that this arrestment, instead of being a rare or occasional occurrence, really happens with extreme frequency. In 1845, I made a series of observations with reference to the cretace- ous masses and puckerings so frequently observed at the apices of the lungs in persons advanced in life. The conclusion arrived at was, that the spontaneous arrestment of tubercle in its early stage occurred in the proportion of from one-third to one-half of all the individuals who die after the age of forty. The observations of Rogee and Boudet, made at the Salpetriere and Bicetre Hospitals in Paris, amongst individuals 47 738 DISEASES OF THE EESPIRATOBY SYSTEM. generally above the age of seventy, showed the proportion in such per- sons to be respectively one-half and four-fifths. That the cretaceous and calcareous concretions, accompanied with puckerings, are really evidences of abortive tubercles, is established by the following facts : — 1. A form of indurated and circumscribed tubercle is frequently met with, gritty to the feel, which, on being dried, closely resembles cretaceous concretions. 2. These concretions are found exactly in the same situations as Fig. 460. tubercle. Thus they are most common in the apex, and in both lungs. They frequently occur in the bronchial, mesenteric, and other lymphatic glands, and in the psoas muscles, or other textures which have been the seat of tubercular depositions, or scrofulous abscesses. 3. When the lung is the seat of tubercular infiltration throughout, whilst recent tubercle occupies the inferior portion, and older tubercle, and perhaps caverns, the superior, the cretaceous and calcareous concre- tions will be found at the apex. 4. A comparison of the opposite lungs will frequently show, that whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect, and has occasionally even passed into a calcareous substance of stony hardness. 5. The seat of cicatrices admits of the same exceptions as the seat of tubercles. In one case, I have found the puckering and cicatrix in Fig. 460. Section of the summit of the right lung, exhibiting the cretaceous masses, more or less loaded with and surrounded by carbonaceous deposit. Many air vesicles are enlarged, constituting incipient emphysema. The preparation now in my posses- sion exhibits a, characteristic specimen of the mode in which a considerable amount of tubercular exudation is arrested by calcareous degeneration. Natural size. PHTHISIS PULMONALIS. ^39 tlie inferior lobe only ; and have met with three cases where the inferior Ijbe was throughout densely infiltrated with tubercle, whilst the superi- or was only slightly afiected. It has indeed been argued, that occasionally these cretaceous masses may be the result of a simple exudation. When they are found isolated in the middle or base of the organ such certainly may be the case, and consequently the fifth argument may be alfected. But this is rare, and can scarcely make any alteration in the vast proportion of those concre- tion -5 and puckerings which are undoubtedly the result of abortive tubercles. With these facts before us, and with the knowledge that there is nothing in the nature of tubercle itself which is opposed to the evidence of these anatomicl faacts, the frequent spontaneous cure of tubercle may now be considered established. Since these observations, however, have become known, it has been stated that after all, practically speaking, phthisis pulmonalis does not mean the existence of a few isolated tubercles scattered through the lung, and that what is really meant, is that advanced stage in which the lung is affected with ulceration, and in which the bodily powers are so lowered that perfecet rcovery seldom or never takes place. But here again a careful examination of the records of medicine will show that many even of these advanced cases have recovered. Laennec, Andral, Cruveilhier, Kingston, Pressat, Bogee, Boudet, and others, have pub- lished cases, where all the functional symptoms and physical signs of the disease, even in its most advanced stage, were present, and yet where the individual survived many years, ultimately died of some other disorder, and on dissection cicatrices and concretions were found in the lungs. I here show you a preparation, exhibiting a remarkable cicatrix in the lung, which I described and figured in the “ Monthly Journal ” for March 1850. It occurred in the following case : — Case CLXII. — 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 Cre- taceous Concretions^ with puckering at the Summit of Left Lung. “ John Keith, set. 60, a teacher of languages, was admitted into the Royal Infirmary, February 8th, 1844, in a state of coma, and died an hour afterwards. On examination, the membranes of the brain, at the base, were unusually congested, and covered with a considerable exudation of recently coagulated lymph, hero and there mingled with bloody extravasation. The apex of the right lung presented a remark- able cicatrix, consisting of a dense white fibrous tissue, varying in breadth from one- fourth to three-fourths of an inch, and measuring about three inches in length. The pleural surface in its neighborhood was considerably puckered. On making a section through the lung, parallel with the external cicatrix, the substance immediate- ly below presented linear indurations, of a black color, together with five cretaceous concretions, varying in size from a pin’s head to that of a large pea. The surrounding pulmonary substance was healthy (Fig. 461). The apex of the left lung was also strongly puckered, and contained six or seven cretaceous concretions, each surrounded by a black, dense, fibrous cyst. “ A very respectable-looking and intelligent man, who attended the post-mortem examination, informed me that Keith, in early life, was in very indifferent circum- stances, and had supported himself as a writer’s clerk. At the age of two-and- twenty or three-and-twenty, he labored under all the symptoms of a deep decline, and his life was despaired of. About this time, however, he was lost sight of by his friends ; but it was afterwards ascertained that he had become a parish school- master in the west of Scotland, and that his health had been re-established. He V40 DISEASES OP THE EESPIRATOKY SYSTEM. returned to Edinburgh six years before his death, and endeavored to gain a liveli- hood by teaching Latin and French. He succeeded but very imperfectly, and fell into dissipated habits. Latterly he had become subject to attacks of mania, appa- rently the result of drink. It was after an unusually severe attack of this kind that he was brought into the Infirmary, where he died in the manner previously described.” This case points out the following important facts, — 1st, That, at the age of twenty-two or twenty three, the patient had had a tubercular ulcer in the right lung, the size of which must have been very consider- able when the contracted cicatrix alone was three inches long. 2d, That tubercular exudation existed in the apex of the left lung. It is, there- Fig. 461. fore, very probable that the statement made by his friend at the exami- nation was correct — namely, that when young, he labored under all the symptoms of advanced phthisis pulmonalis. It is shown, 3 dly, That af- Fig. 461. The section of the upper portion of lung in Keith’s case seen from with- in, the apex having been left entire to show the deep puckerings which covered its sur- face. The line of the healed cavity is densely loaded with black carbonaceous deposit, in which are seen five cretaceous concretions, three of them encysted. This preparation, now in my possession, is perhaps a unique specimen, proving the healing, by cicatriza- tion, of an enormous tubercular excavation in the lung. Natural size. PHTHISIS PULMONALIS. 741 ter receiving the appointment of a parish schoolmaster, after changing his residence and occupation, while his social condition was greatly improved, these symptoms disappeared. We may consequently infer that it was about this period that the excavation on the right side healed and cica- trized, while the tubercular exudations on the left side were converted into cretaceous masses, and so rendered abortive. It demonstrates, 4thly, That when, at a more advanced age, he again fell into bad cir- cumstances, and even became a drunkard, tubercular exudations did not return, but that delirium tremens was induced, with simple exudation on the membranes of the brain, of which he died. Although the curability of phthisis pulmonalis, even in its most advanced stage, can now no longer be denied, it has been argued that this is entirely owing to the operations of nature, and that the physician can lay little claim to the result. Andral, who early admitted the occa- sional cicatrization of caverns, states this in the following words : — “ No fact,” he says, “ demonstrates that phthisis has been ever cured, for it is not art which operates in the cicatrization of caverns ; it can at most only favor this, by not opposing the operations of nature. For ages remedies have been sought either to combat the disposTion to tubercles, or to destroy them when formed, and thus innumerable specifics have- been employed and abandoned in turn, and chosen from every class of medicaments.”^ But if it be true, according to Hoffman, that ^^Medicus natwrcB minister non magister it follows that by carefully observ- ing the operations of nature, learning her methods of cure, imitating it as closely as possible, avoiding what she points out to be injurious, and furnishing what she evidently requires, we may at length arrive at rational indications of treatment. The cases both of Keith and Bar- clay, in my opinion, furnish evidence that we have in a great measure attained this end ; and this leads me to speak, in the second place, of II . — The Pathology and General Treatment of Phthisis Pidmonalis. Many observant physicians have not failed to notice, that phthisis pulmonalis is ushered in with a bad and capricious appetite, a furred or morbidly clean tongue, unusual acidity of the stomach and alimentary canal, anorexia, constipation alternating with diarrhoea, and a variety of symptoms denominated dyspeptic, or referable to a deranged state of the primae viae. Moreover, it can scarcely be denied that, in the great major- ity of cases, these are the symptoms which accompany phthisis throughout its progress, becoming more and more violent towards its termination. Now, as the nutritive properties of the blood are entirely dependent on a proper assimilation of food, and as this assimilation must be interfered with in the morbid conditions of the alimentary canal, the continuance of such conditions necessarily induces an impoverished state of that fluid, and imperfect growth of the tissues. Moreover, when, under such cir- cumstances, exudations occur, it has been shown by the histologist that they do not exhibit any tendency to perfect cell formations, Wt that corpuscles are produced, which form slowly, and slowly breaking down, cause softening and ulceration, which becomes more and more extensive as the amount of the exudation increases. An observation of the circumstances which precede the disease, or * Diet, de Med. 1st Edit. Phthisie. 742 DISEASES OF THE EESPIEATORY SYSTEM. its so-called causes, clearly indicates imperfect digestion and assimila- tion as its true origin. Thus phthisis is essentially a disorder of child- hood and youth — that is, the period of life when nutrition is directed to building up the tissues of the body. Diminish the proper quantity of food taken by a healthy adult, and tubercular diseases are not induced ; but if this be attempted with children or young persons, they are a most common result. It has been supposed that hereditary predisposition, a vitiated atmosphere, changeable temperature, certain unhealthy occupa- tions, humidity, particular localities, absence of light, and so on, predis- pose to phthisis. Very frequently several of these are found united, so that it is difficult to ascertain the influence of each. When they so ope- rate, however, they invariably produce, in the first place, more or less disorder of the nutritive functions, and are associated with dyspepsia or other signs of mal-assimilation of food. From a study of the symptoms, causes, morbid anatomy, and histo- logy of phthisis pulraonalis, we are therefore led to the conclusion, that it is a disease of the primary digestion, causing, — 1st, Impoverishment of the blood ; 2d, Local exudations into the lung, which present the characters of tubercular exudation ; and 3d, Owing to the successive formation and softening of these, and the ulceration which follows in the pulmonary or other tissues, the destructive results which distinguish the disease. Further observation shows, that circumstances which remove the mal-assimilation of food frequently check further tubercular exuda- tions, while those which previously existed become abortive, and that occasionally very extensive excavations in the pulmonary tissue may, owing to like circumstances, heal up and cicatrize. The curative treat- ment of this disease must therefore be directed, — 1st, To restoring the healthy nutrition of the economy ; 2d, To subduing local irritation ; and 3d, To the avoidance of those circumstances which are likely to deterio- rate the constitution on the one hand, or induce pulmonary symptoms on the other. 1. A healthy nutrition of the body cannot proceed without a proper admixture of mineral, albuminous, and oleaginous elements. This may be inferred from the physiological experiments of Tiedemann and Gmelin, Leuret and Lassaigne, Mageiidie, and others ; from an observation of the constituents of milk, the natural food of young mammiferous animals ; from a knowledge of the contents of the egg, which constitute the source from which the tissues of oviparous animals are formed before the shell is broken ; and from all that we know of the principles contained in the food of adult animals. The researches of chemists, as of Prout, Liebig, and others, point to the same generalisation, when they assert that car- bonised and nitrogenised, or, as they have been called, respiratory and sanguigenous food, are necessary to carry on nutrition, inasmuch as oil is a type of the one, and albumen of the other. The chemical theory is imperfect, however, because it does not point out how these elements form the tissues ; for it is not every form of carbonised or of albuminous food that is nutritious, but only such kinds of them as are convertible into oil and albumen. The reason of this was first pointed out by Dr. Ascherson of Berlin, in 1840, and made known by me to the profession in this country in PHTHISIS PIJLMOXALIS. Y43 1841. I have since endeavored to show, that the elementary molecules formed of a particle of oil, surrounded hy a layer of albumen, which are produced, as he described, by rubbing oil and albumen together, are not developed directly into blood-globules and other tissues, as he supposed, but must first pass through a series of transformations — a knowledge of which is highly important, not only to a comprehension of nutrition generally, but especially to that abnormal condition of it which occurs in phthisis. Thus the successive changes which occur for the purposes of assimilation in the healthy economy may be shortly enumerated as fol- lows : — 1st, Introduction into the stomach and alimentary canal of organic matter. 2d, Its transformation by the process of digestion into alb^uminous and oily compounds : this process is chemical. 3d, The imbibition of these through the mucous membrane in a fluid state, and their union in the termini of the villi and lacteals to form elementary gran- ules and nuclei ; this process is physical. 4th, The transformation of these, first, into chyle corpuscles, and secondly, into those of blood: which is a vital process. It is from this fluid, still further elaborated in numerous ways, that the nutritive materials of the tissues are derived, so that it must be evident, if the first steps of the process are improperly performed, the subsequent ones must also be interfered with. Hence we can readily comprehend how an improper quantity or quality of food, by diminishing the number of the elementary nutritive molecules, must impede nutrition. AVhen we examine with a magnifying power of 250 diameters a drop of chyle taken from the thoracic duct of an animal, three hours after it has eaten a meal, we observe that it contains, first, a molecular basis (Grulliver) of incalculably minute particles ; and secondly, numerous corpuscles in different stages of development into blood globules. • This molecular basis has been proved by numerous chemical analyses to con- sist principally of fat, eraulsionised by its admixture with albumen. In short, these two important principles, fat and albumen, constitute essen- tial elements of the nutritive cli3mie ; and the former divided into exceedingly minute particles by the latter, pass through the villi and form the milky fluid called chyle. It is unnecessary for me to trace the subse- quent changes this chyle undergoes by its passage through the mesenteric glands, and the successive stages of elaboration produced in it by the operation of the blood glands and the lungs. No one can doubt that the oil and the albumen so derived from the food, and so altered chemically and mechanically in the body, constitute the material from which blood is formed ; neither can there be any question that the presence and emulsionising of these elements in proper proportions, are absolutely necessary to supply and keep up the vital properties of the blood. Fig. 462. Chyle from the thoracic duct of a dog, three hours after eating a meal. «, Fluid chyle showing its molecular basis, and corpuscles in various stages of devel- opment into those of blood. 6, Corpuscles of chyle embedded in fibrillated fibrin. They are round in the centre, but more or less compressed and elongated towards the margin. 250 diam. Fig. 462. 744 DISEASES OP THE EESPIRATORY SYSTEM. The peculiarity of phthisis, however, is, that an excess of acidity exists in the alimentary canal, whereby the albuminous constituents of the food are rendered easily soluble, whilst the alkaline secretions of the saliva and of the pancreatic juice are more than neutralized, and rendered incapable either of transforming the carbonaceous constituents of vegetable food into oil, or of so preparing fatty matters introduced into the system, as will render them easily assimilable. Hence an in- creased amount of albumen enters the blood, and has been found to exist there by all chemical analysis, while fat is largely supplied by the ab- sorption of the adipose tissues of the body, causing the emaciation which characterises the disease. In the meanwhile, the lungs become especially liable to local congestions, leading to exudation of an albuminous kind : which is tubercle. This, in its turn, being deficient in the necessary proportion of fatty matter, elementary molecules are not formed so as to constitute nuclei capable of further development into cells ; they therefore remain abortive, and constitute tubercle corpuscles. .Thus a local disease is added to the constitutional disorder, and that compound affection is induced which we call phthisis pulmonalis, consisting of symptoms attributable partly to the alimentary canal, and partly to the pulmonary organs. To improve the faulty nutrition which originates and keeps up the disease, it is of all things important, therefore to cause a larger quantity of fatty matter to be assimilated. A mere increase in the amount, or even quality, of the food, will often accomplish this, as in the case of Keith. The treatment practised some years ago by Dr. Stewart of Erskine, which consisted in freely administering beef-steaks and porter, and causing exercise to be taken in the open air, excited considerable attention from its success. I have been informed, that in some parts of America the cure consists in living on the bone marrow of the buffalo, and that the consumptive patient gets so strong in this way, that he is at length able to bunt down the animal in the prairies. All kinds ( food rich in fat will not unfrequently produce the same effects, and hence the value long attributed to milk, especially ass’s milk, the produce of the dairy, as cream and butter, fat bacon, caviar, etc. But in order that such substances should be digested and assimilated, the powers of the stomach and alimentary canal must not have under- gone any great diminution. In most cases it will be found that the patient is unable to tolerate such kind of food, and that it either lies un- digested in the stomach, or is sooner or later vomited. Under these circumstances, the animal oils themselves are directly indicated, by giving which, we save the digestive apparatus, as it were, the trouble of manufacturing or separating them from the food. By giving consider- able quantities of oil directly, a large proportion of it is at once assimi- lated, and is rendered capable of entering into combination with the albumen, and thereby forming those elementary molecules so necessary for the formation of a healthy chyle. Such, it appears to me, is the rationale of the good effects of cod-liver oil. Since I introduced this substance to the notice of the profession in this country as a remedy for phthisis, in 1841, I have continually pre- scribed it in hospital, dispensary, and private practice. I need not per- PHTHISIS PULMOXALIS. 745 haps say, that I have given it in a very large number of cases, and have observed its effects in all the stages of the disease, and under almost every circumstance of age, sex, and condition. I have had the most ex- tensive opportunities of examining the bodies of those who have died after taking it in considerable quantities, and am still observing the cases of many persons who may be said to have owed their lives to its employ- ment. Further, I have carefully watched the progress it has made in the good opinion of the professional public, and perused all that has been published regarding it in the literature of this and other countries. It were certainly easy for me, therefore, to write at great length on this subject ; but I do not see that anything of utility could be added to what I have already published. The following is a summary of my views regarding cod-liver oil as a remedy for phthisis : — 1. Cod-liver oil is, as M. Taufflied pointed out, an analeptic (di/aXa/x/5di/co, to repair), and is indicated in all cases of abnormal nutrition dependent on want of assimilation of fatty matter. 2. It is readily digestible under circumstances where no other kind of animal food can be taken in sufficient quantity to furnish the tissues with a proper amount of fatty material. 3. It operates by combining with the excess of albuminous consti- tuents of the chyme, and forming in the villi and terminal lacteals those elementary molecules of which the chyle is originally composed. 4. Its effects in phthisis are to nourish the body, which increases in bulk and in vigor; to check fresh exudations of tubercular matter, and to diminish the cough, expectoration, and perspiration. 5. The common dose for an adult is a table-spoonful three times a day, which may be often increased to four, or even six, with advantage. When the stomach is irritable, however, the dose to commence with should be a tea or dessert-spoonful. 6. The kind of oil is of little importance thernpeutically. The pure kinds are most agreeable to the palate ; but the brown coarser kinds have long been used with advantage, and may still be employed with confidence whenever cheapness is an object. 7. I have never observed its employment to induce pneumonia, or fatty disease of the liver or kidney, however long continued, although such complications of phthisis are also exceedingly frequent. But in some rare cases the oil cannot, even under the best manage- ment, be retained on the stomach, and efforts have been made to intro- duce fat into the economy by some other channel, such as by the skin and rectum. The former plan was first tried by I)r. Baur of Tubingen, who rubbed various kinds of oil into the skin, and even recommended oil baths. Persons occasionally got better under this as they do under every other kind of treatment, but the excessive trouble, and sense of unclean* liness which greasy frictions occasion, are strong objections to its use. Its costliness also renders it inapplicable to the poor. Oily enemata were recommended by Dr. Buist of Aberdeen. But it must be evident that as nature never intended mankind to be permanently nourished either by the skin or by the rectum, so, in imitation of her processes, the object of an analeptic treatment in pulmonary tuberculosis must be to cause the elements of the food to be taken by the mouth ; to diminish 746 DISEASES OF THE KESPIEATOEY SYSTEM. the dyspeptic symptoms, and induce assimilation by the lacteal rather than by the lymphatic vessels. 2. The second indication — namely, to subdue local irritation — is only to be followed out in acute cases by much the same practice as guides us in the treatment of pneumonia, which is the general cause of such irrita- tion. From what has been previously said on that subject, it must be evident that, however practitioners may flatter themselves that by bleed- ing or mercury they have checked inflammation, these remedies in phthisis, so far from arresting the local lesion, have only accelerated it. In the chronic forms of the disease this indication is only to be met by topical counter-irritation. Hence a seton or issue, a succession of blisters, tartar emetic ointment, and croton oil, are all beneflcial, and may be used according to circumstances. Cold sponging, employed with great precaution, so as not to produce a chill, but rather a glow of heat afterwards, is also beneficial. Such are the only means in our power to meet this important indication, because, combined with this local lower- ing treatment, the general system must be invigorated to the utmost. This is the difficult problem to be worked out in the treatment of phthisis, and in doing so we shall be much assisted by paying particular attention to the third indication. 3. The avoidance of those circumstances likely to deteriorate the constitution on the one hand, or induce pulmonary symptoms on the other, offers a wide field for the judieious practitioner, especially in his character as a watchful guardian over his patient’s health. One of the great difficulties we have to overcome in this climate, is the frequent variations of temperature, and the sudden changes from fervent heat to chilling cold. Supposing that you have the means of supporting nutri- tion and keeping down local irritation, it is by no means certain that good will be accomplished, from the impossibility of securing those hygienic regulations and that equable climate, which are necessary to carry out the third indication. In the first place, nutrition itself is more connected with proper exercise and breathing fresh air than many people imagine. It does not merely consist in stimulating the appetite and giving good things to eat. It requires — 1st, Food in proper quan- tity and quality ; 2d, Proper digestion ; 3d, Healthy formation of blood ; 4th, A certain exchange between the blood and the external air on the one hand, and between the blood and the tissues on the other ; and 5th, It requires that there should be proper excretion, that is, separation of what has performed its allotted function and become useless. All these processes are necessary for nutrition, and not merely one or two of them, for they are all essentially connected with, and dependent on, one another. Hence the means of prevention consist in carrying out those hygienic regulations which secure the performance of these difier- ent nutritive acts, the most important of which are attention to climate, exercise, and diet. Much has been written on climate, but the one which appears to me best is that which will enable the phthisical patient to pass a few hours every day in the open air, without exposure to cold or vicissitudes of PHTHISIS PULMONALIS. 747 temperature on the one hand, or excessive heat on the other. Whenever such a favored locality may be found during the winter and spring months, its advantages should be considered as dependent on exercise, and on the stimulus given to the nutritive functions, rather than to its influence on the lungs directly. The great mass of those affected with phthisis, however, have not the means of searching out a favorable climate on the Continent, or even of maintaining themselves in a sheltered nook on the western or south- western coasts of this country. It has, therefore, been proposed that such buildings as the Crystal Palace should be converted into winter gardens and public promenades. Not to speak of the intellectual and recreative purposes that-such a plan would subserve, it is worthy of our consideration how far it would tender to promote health in general, but especially, how it would conduce to the cure of phthisis. Its great ad- vantage would be offering the means of exercise in a pure atmosphere, at an eq[uable temperature. It is easy for us, by confining patients in a suite of rooms in which the heat is regulated, to secure immunity from cold and change of air ; but such a contrivance is most intolerable to the patient; the mind becomes peevish, which in itself is a powerful obstacle to the proper performance of the digestive functions. But above all, the body is deprived of exercise — that necessary stimulus to the appetite, respiration, and other functions. Some years ago, I succeeded in confining a consumptive patient to his room for an entire winter. His spirits suffered greatly ; but on the whole he supported the imprison- ment with resolution. Next winter, however, nothing could induce him to remain at home, and one day he rushed out of the house, ascended Arthur’s Seat, and w«\s much better in consequence. Since then I have been convinced that, although by confinement you may gain some ad- vantages, on the whole it is a prejudicial practice if rigorously carried out. What is required in these cases is the means of exercise, whether on foot, on horseback, or in a carriage, where the patient is protected from cold winds, and where the mind can be amused by pleasant sights and cheerful conversation. Such is the case in all those favored localities considered best for consumptive people, and such would be the advan- tages derived from resorting to the Crystal Palace as a winter garden and promenade. Delicate individuals could be transported there by means of a close carriage, in the worst seasons, without difficulty, and on entering it could breathe for hours a pure, balmy air, meet their friends, take exercise in various ways, read, work, or otherwise amuse themselves. Such an out-door means of recreation, combined with careful hygienic regulations at home, would go far to remove many of the difficulties which we have to encounter in the ordinary treatment of consumption. With regard to diet, it may be said, in general terms, that one of a nutritious kind, consisting of a good proportion of animal food abound- ing in fat, is best adapted for phthisical cases, whilst everything that in- duces acidity should be avoided. But, as previously stated, the difficulty consists in causing such diet to be taken, on account of the bad appetite and dyspeptic or febrile symptoms which prevail. No effort, therefore, should be spared to overcome the obstacles which prevent food of suffi- •748 DISEASES OF THE RESPIEATORY SYSTEM. cient quality and quantity from being digested, the appropriate means for doing which must vary according to the circumstances of the case, and will be treated of immediately. The strongest stimulus to the appe- tite, however, is exercise, and hence the importance of the considerations already entered into, with reference to securing what is essential in the treatment of the disease, namely, good digestion and proper assimilation. If the pathology of pulmonary tuberculosis formerly described be correct, it indicates what are the means best adapted for preventing as well as arresting the disease when it has already commenced. These are, for the infant, a healthy nurse, cleanliness, and careful attention to all those circumstances which tend to increase the bodily vigor and to secure good digestion. At the time of weaning and of teething, the most watchful care becomes necessary, so that local irritation and its effects may be prevented as much as possible, and a proper diet, contain- ing a sufficient amount of the fatty principles, be taken. During ado- lescence, indulgence in indigestible articles of food should be avoided, especially pastry, unripe fruit, salted provisions, and acid drinks, while the habit of eating a certain quant', ty of fat should be encouraged, and, if necessary, rendered imperative. The same precautions, conjoined with proper bodily and mental exercise, avoiding exhausting and too fatigu- ing occupations, should subsequently be maintained until the predisposi- tion to tubercular disease has been completely overcome. In short, every- thing that can support and invigorate should be adopted, and everything that can exhaust and depress should be shunned. As vitiation of the chyle and blood precedes the local deposition of a tubercular exudation, it necessarily follows that the numerous class of delicate invalids whose chief complaint is derangement of the digestive process, with languor and debility, may, by the hygienic means now indicated, and proper treat- ment of the dyspepsia, be restored to health. "V\^ere it possible in all cases for these three indications to be carried out, I feel satisfied the cure of phthisis would be more frequent ; but in the treatment of this disease, the physician has to struggle not only with the deadly nature of the disorder, but with numerous difficulties over which he has no control, such as, among the poorer classes, the impossi- bility of procuring good diet, and the thousand imprudences not only they, but the majority of invalids, are continually committing. Then another great difficulty is, to convince the patient that, notwithstanding the removal of his urgent symptoms, the disease is not cured, and that these will return, if the causes which originally produced them are again allowed to operate. Sometimes I have found it difficult to keep hospital patients in the house when they are doing well, at other times they are sent out in accordance with certain regulations, which oblige the admission of more acute cases. This was the case with Barclay. (Case CLVIII.) So long as he was under treatment, or rather enjoyed the comforts and good diet of the Infirmary, so long was he well. But sent out, exposed to misery, to insufficient food, and work, he became worse. Lastly, the attempt to relieve distressing symptoms interferes much more than is generally supposed with the curative treatment. This leads me to speak of the PHTHISIS PULMONALIS. 749 III . — Special Treatment of Phthisis Puhnonalis. Under the head of General Treatment of Phthisis Pulnionalis, I have pointed out the means of meeting the three indications which should never be lost sight of in this disease. But every case requires a special treatment in addition, which will depend on the unusual severity of this or that symptom, or the existence of peculiar complications. It is to the undue importance given to this special, as distinguished from the general treatment, that I attribute much of that want of success experi- enced by practitioners. Thus it is by no means uncommon to meet with patients who are taking at the same time a mixture containing squills and ipecacuanha to relieve the cough; an anodyne draught to cause sleep and diminish irritability ; a mixture containing catechu, gallic acid, tannin, or other astringents, to check diarrhoea; acetate of lead and opium pills to diminish haemoptysis ; sulphuric acid drops to relieve the sweating ; and cod-liver oil in addition. I have seen many persons tak- ing all these medicines and several others at one time, with a mass of bottles and boxes at the bedside sufficient to furnish an apothecary’s shop, without its ever suggesting itself apparently to the practitioner, that the stomach drenched with so many nauseating things is thereby pre- vented from performing its healthy functions. In many cases there can be little doubt that this treaGment of symptoms, with a view to their palliation, whilst it destroys all hope of cure, ultimately fails even to relieve the particular functional derangement to which it is directed. Still these symptoms require attention; but their causes, and the means required for their relief, will be best understood by speaking of each in succession. Cough and Expectoration . — At first the cough in phthisis is dry and hacking. When tubercle softens or bronchitis is present, it becomes moist and more prolonged. When excavations exist, it is hollow and reverberating. In every case cough is a spasmodic action, occasioned by exciting the branches of the pneumogastric nerves, and causing simulta- neous reflex movements in the bronchial tubes and muscles of the chest. The expectoration following dry cough is at first scanty and muco- purulent, and afterwards copious and purulent. When it assumes the nummular form — that is, occurs in viscid rounded masses, swimming in a fluid clear mucus — it is generally brought up from pulmonary exca- vations. The accumulation of the sputum in the bronchial tubes is an exciter of cough ; and hence the latter symptom is often best combated by those means which diminish the amount of sputum. When, on the other hand, the cough is dry, those remedies should be used which diminish the sensibility of the nerves. In the first case, the amount of mucus and pus formed will materially depend on the weakness of the body, and the onward progress of the tubercle. Hence good nourish- ment and attention to the digestive functions are the best means of check- ing bith the cough and the expectoration; whereas giving nauseating mixtures of ipecacuanha and squills is perhaps the worst treatment that can be employed. There is no point which experience has rendered me more certain of than that, however these symptoms may be palliated by cough and anodyne remedies, the stomach is thereby rendered intolerant 750 DISEASES OF THE EESPIEATORY SYSTEM. of food, and the curative tendency of the disease is impeded. On the other hand, nothing is more remarkable than the spontaneous cessation of the cough and expectoration on the restoration of the digestive func- tions and improvement in nutrition. When the cough is dry, as may occur in the first stage, with crude tubercle, and in the last stage, with dry cavities, counter-irritation is the best remedy, employed in various forms. Opium may relieve, but it never cures. The occasional use of the sponge saturated in a solution of nitrate of silver, is frequently of the greatest service. (See Laryngitis.) Loss of Appetite. — This is the most constant and important symptom of phthisis, inasmuch as it interferes more than any other with the nutritive processes. If food, or the analeptic, cod-liver oil, cannot be taken and digested, it is vain to hope for amelioration in any of the essential symptoms of the disease. Hence we should avoid a mistake into which the inexperienced are very liable to fall. Nothing is more common than for phthisical patients to tell their medical attendams that their appetite is good, and that they eat plentifully, when more careful inquiry proves that the consumption of food is altogether inade- quate, and that they loathe every kind of animal diet. In the same manner, they say they are quite well, or better, when they are evidently sinking. We should never be satisfied with general statements, but determine the kind and amount of food taken, when sufficient proof will be discovered, in the vast majority of cases, of the derangement, formerly alluded to, of the appetite and digestive powders. V ery com- monly also, there will be acid and other unpleasant tastes in the mouth. In all such cases, especially if too much medicine has been already given, the stomach should be allowed to repose itself before anything be ad- ministered, even cod-liver oil. Sweet milk, with toasted bread, and small portions of meat nicely cooked, so as to tempt the capricious ap- petite, should be tried. Then ten drops of the Sp. Ammon. Aromat., given every four hours in a wine-glassful of some bitter infusion, such as that of Calumba or Gentian, with a little Tr. Aurantii, Tr. Cardamomi, or other carminative. In this way the stomach often regains its tone, food is taken better, and then cod-liver oil may be tried, first in tea- spoonful doses, cautiously incre.ased. Sh-.uld this plan succeed, amelio- ration in the symptoms will be almost certainly observed. Nausea ayid Vomiting. — Not untrequently the stomach is still more deranged ; there is a feeling of nausea and even vomiting on taking food. In the latter stages of phthisis, vomiting is also sometimes occasioned by violence of the cough, and the propagation of reflex actions, by means of the par vagum, to the stomach. In the former case, the sickness is to be alleviated by carefully avoiding all those substances wdiich are likely to occasion a nauseating eficct, by not overloading the stomach, but allowing it to have repo-se. In cases where too much medicine has been administered, a suspension of all medicaments for a few days will frequently enable the practitioner to introduce nourish- ment cautiously with the best effect. I have found tie following mixture very effectual in checking the vomiting in phthisis: NaphtluB J^fedicinalis 3j>; Tr. Cardamomi comp 3j; Mist. CamphorcE 1 vij. M. ft. mist. Of which a sixth part may be taken every four hours. PHTHISIS PULMONALIS. 151 When it depends on the cough, those remedies advised for that symptom should be given. I have tried emetics for the relief of nausea and vomiting, but with no good result. Dlarrhcea . — This is a very common symptom throughout the whole progress of phthisis, at first depending on the excess of acidity in the alimentary canal, to which we have alluded, but in advanced cases con- nected with tubercular deposits and ulceration in the intestinal gland. The best method of checking this troublesome symptom is by improving the quality and amount of the food. The moment the digestive pro- cesses are renovated, this, with the other functional derangements of the alimentary canal, will disappear. Hence at an early period we should avoid large doses of opium, gallic acid, tannin, and other powerful astringents, and depend upon the mildest remedies of this class, such as chalk with aromatic confection, or an antacid, such as a few grains of carbonate of potash. When, on the other hand, in advanced phthisis, continued diarrhoea appears, and is obstinate under such treat- ment, then it may be presumed that tubercular disease of the intestine is present, and the stronger astringents with opium may be given as palliatives. Ucemoptysis . — This symptom sometimes appears suddenly in indivi- duals in whom there has been no previous suspicion of phthisis, and in whom, on careful examination, no physical signs of the disease can be detected. On other occasions, the sputum may be more or less streaked with blood ; and lastly, it may occur in the advanced stage of the dis- ease, apparently from ulceration of a tolerably large vessel. In all these cases the best remedy is perfect quietude, and avoidance of every kind of excitement, bodily and mental. Astringents have been recommended, especially acetate of lead and opium ; but how these remedies can operate, I am at a loss to understand ; and I have never seen a case in which their administration was unequivocally useful. I have now met with several cases where supposed pulmonary haemorrhage really origi- nated in follicular disease of the pharynx or larynx, and with the sup- posed phthisical symptoms, was removed by the use of the probang and nitrate of silver solution. Sweating I regard as a symptom of weakness, and therefore as a com- mon, though by no means a special one in phthisis. Here, again, the truly curative treatment will consist in renovating the nutritive pro- cesses, and adding strength to the economy. It will always be observed that, if cod-liver oil and good diet produce their beneficial efiect, the sweating, together with the cough and expectoration, ceases. On the other hand, giving acid drops to relieve this symptom, as is the common practice, by adding to the already acid state of the alimentary canal, is directly opposed to the digestion of the fatty principles, which require assimilation. It should not be forgotten that consumptive patients, and all those suffering from pulmonary diseases, are especially sensitive to cold. The impeded transpiration from the lungs in such cases, is counterbalanced by increased action of the skin, which becomes unusually liable to the influence of diminished temperature. Again, cold applied to the surface immediately produces, by reflex action, spasmodic cough and excitation V52 DISEASES OF THE KESPIKATORT SYSTEM. of the lungs. Every observant person must have noticed how cough is induced by crossing a lobby, going out into the open air, a draught of wind entering the room, getting into a cold bed, etc. etc. The mere exposure of the face to the air on a cold day, takes away the breath, induces cough, and obliges the patient instinctively to muffle up the mouth. The numerous precautions, therefore, that ought to be taken by the phthisical individual, should be pointed out, especially the necessity of warm clothing, to which large additions should be made on going out into the air. Thus, covering the lower part of the face is important as a means of extra clothing, and not as a means of breathing warm air, as the favorers of respirators imagine. The patient should always sit with his back to the horse or to a steam-engine, and if by accident his shoes or clothes become wet, they should be changed as soon as possible. In the house, ladies should have a shawl near them, to put on in going from one room to another, in descending a stair to dinner, etc. By at- tention to these minutiae, much suffering and cough may be avoided. Febrile Symptoms . — The quick pulse, general excitement, loss of appetite, and thirst, which are so common in the progress of phthisical cases, are' dependent on the same causes as those which induce sympto- matic fever in general. Vascular distention, resulting in exudation and its absorption, is proceeding with greater or less intensity in the lungs, and frequently in other organs. This leads to nervous irritation and increase of fibrin in the blood, accompanied by febrile phenomena. The intensity of these is always in proportion to the activity ot local disease, or to the amount of secondary absorption going on from the tissues, or from morbid deposits. Nothing is more common than attacks of so- called local inflammations in phthisis, and the careful physician may often determine by physical signs the supervention of pleurisy, pneu- monia, or bronchitis, on the previously observed lesion, and not unfre- quently laryngitis, enteritis, or other disorders. In such cases, nature herself dictates that the analeptic treatment, otherwise appropriate, is no longer applicable — food disgusts, and fluids are eagerly demanded. Under these circumstances, it has been common to apply leeches to the inflamed part, and extract blood by cupping, measures which undoubtedly cause temporary relief, but which are wholly opposed to the plan of gen- eral treatment formerly recommended, and to what we know of the patho- logy of the disease. Every attack of febrile excitement is followed by a corresponding collapse, and it should never be forgotten that, in a dis- ease which is essentially one of weakness, the patient’s strength should be husbanded as much as possible. Hence the treatment I depend on in such circumstances consists of at first the internal administration of the neutral salts, especially of tartar emetic in small doses, combined with diuretics, in order to favor crisis by the urine. Subsequently quinine is undoubtedly advantageous. I have satisfied myself that such attacks are not to be cut short by leeches or cupping, and although in many cases, as previously stated, temporary relief is produced, the ex- posure of the person, and unpleasant character of the applications, the trickling of blood, and wet sponges, as often irritate, and give rise to unnecessary risk. Still there are cases where topical blood-letting, if it cannot be shown to have advanced the cure, cannot be proved to have PHTHISIS PULMONALIS. 753 done harm ; but these cases, as far as my observation goes, are very few in number. In the rapidly febrile cases, or the so-called instances of acute phthisis, mercury has been recommended ; but I have never seen it produce the slightest benefit. Debility . — This is a very common symptom of phthisis from the first, and frequently leads the patient into indolence both ot mind and body, a condition very unfavorable for the nutritive functions, upon the successful accomplishment of which its remoral depends. It is to remove the weakness that tonics have been administered, but I have never seen quinine, bitter infusions, or even chalybeates, of much service alone, while the continual use of nauseous medicine disgusts the patient, and interferes with the functions of the stomach. Here again the great indication is to remove the dyspeptic symptoms, give cod-liver oil, an animal diet, and improve the appetite by gentle exercise and change of scene. Should the practitioner succeed in renovating the nutritive functions, it is often surprising how the strength increases, in itself a sufficient proof as to what ought to be the method of removing the debility. I have frequently seen patients who have been so weak that they could not sit up in bed without assistance, so strengthened by the analeptic treatment, that they have subsequently walked about and taken horse-exercise without fatigue, and this after all the vegetable, mineral, and acid tonics had been tried in vain. Despondency and Anxiety . — It is impossible for the careful practitioner to avoid noticing the injurious influence of depressing mental emotions on the progress of phthisis. Indeed the worst cases are those of indi- viduals with mild, placid, and unimpassioned characters, who give way to the feelings of languor and debility which oppress them. Such per- sons are most amiable patients — they give no trouble — anything will do for them — they resign themselves to circumstances, and state that they are eating well and getting better up to the last. These are cases of bad augury, for it is exceedingly difficult to inspire them with sufficient energy to take exercise, or to carry out those regulations which are abso- lutely essential to renovate the appetite and the nutritive functions. Such persons are benefited by slow travelling, cheerful society, and everything that can elevate the spirits, and, insensibly to themselves, communicate a stimulant to the mental and bodily powers. Anxiety, on the other hand, though it may sometimes depress and interfere with the digestive functions, is often a most useful adjunct to the physician. Those who experience it are most careful of their health, sometimes indeed too much so, but if once satisfied of the benefit of any particular line of treatment, they pursue it with energy. These are cases of good augury, and most of the permanent cures I have witnessed have been in such persons — medical men, and others acquainted with the nature of their disease, who have exhibited resolution, and a noble fortitude, and have bravely struggled against local pain, general debility, and nervous fear.* * For numerous other facta and observations connected with the pathology and treatment of phthisis, see the Author’s work on Pulmonary Consumption, 8vo, 2d edition. Edinburgh. 48 754 DISEASES OF THE RESPIRATORY SYSTEM. CANCER OF THE LUNG. Case CLXIII.* — Cancer of the Lung, Thyroid Body, and Lymphatic Glands of the Nech — Bro7ichitis — Leucoeythemia. History. — Margaret Stewart, a cook, aet. 60 — admitted into the clinical ward July 16, 1851. For some years back she has been subject to a short dry cough, which has never been troublesome except after cooking a larger dinner than usual. With the exception of an attack of diarrhoea when the cholera was prevalent, she has been more or less constipated. Has never suffered from epistaxis or other form of haemorrhage. Four weeks ago she first perceived a swelling in the neck, wliich, com- mencing in front, has gradually spread towards the right side. Latterly her breathing has become short and hurried ; her strength has decreased ; and the cough has been accompanied by considerable expectoration. Symptoms on Admission. — On admission, the neck presents a prominent indurated swelling anteriorly, measuring about four inches in diameter, evidently owing to en- largement of the thyroid body. A chain of enlarged glands extends from the anterior swelling round the right side of the neck, a little beyond the ear. She complains of great weakness, constant sweating at night, and cough with copious frothy expectora- tion. The chest is everywhere resonant on percussion. There are loud sonorous and moist rales heard over the whole chest, especially posteriorly and infei iorly. The vocal resonance is also unusually loud, but equal on both sides. The tongue is furred, dark brown in the centre ; deglutition is difficult, apparently from pressure of the enlarged cervical glands. The appetite is bad, with an acid taste in the mouth. Other functions properly performed. Progress of the Case. — She continued in this condition for several days, during M'hich iodine and counter-irritants were applied to the neck, and expectorants and antispasmodics taken internally to relieve the cough. The dyspnoea, however, gradually increased; deglutition became more difficult, and her strength diminished. On the ZQth of July the urine was ascertained to contain albumen, which had previously not existed. She died without a struggle, August ^th. Sectio Cadaveris. — Forty hours after Death. Neck. — On dissecting the integuments from the neck on the right side, a con- siderable number of glands, about the size of a barley-corn and small pea, were observed in clusters between the platysma myoides and sterno-mastoid muscle. A hard tumor existed in front of the neck, stretching along the whole front of the trachea, and over the great vessels on either side beneath the sterno-mastoid muscles, and posteriorly on the right side, as far back as the transverse processes of the ver- tebrae, and down beneath the clavicle to the anterior surface of the first rib, where it was firmly adherent to the periosteum. A prolongation of the tumor, about the size of two walnuts, passed beneath the sternum at its upper end, being attached to its periosteum. This prolongation on section presented the outline of a congeries of enlarged lymphatic glands, having a white appearance, in some places soft, and even diffluent, and yielding on pressure a copious milky cancerous juice. Thorax. — There were lax adhesions at various points on the pleurte on both sides. The pleural cavities contained a little fluid on the right side, amounting to about five ounces. At the lower part of the left lung, and also at the back part of right lung, there was a small amount of recent membranous exudation. A multitude of small cancerous nodules were scattered throughout the vdiole of both lungs. Some were immediately below the pleurae, and some in the substance of the organs. For the most part these masses were scattered pretty equally, being as numerous at the base as at the apex, and varying from the size of a millet-seed to that of a small walnut. Some were of firm consistence, and others soft and friable, presenting various degrees of induration. They all on pressure yielded a copious milky juice. The mucous membrane of the bronchi was of a mahogany color, and the tubes were more or less filled with muco-purulont matter. Abdomen. — Abdominal organs healthy. Microscopic Examination. — The cancerous juice squeezed from the cervical glands, and the nodules scattered throughout the lungs, contained numerous cancer cells, which it is unnecessary to describe minutely here. (See p. 139.) Associated * Reported by Mr. D. 0. Hoile, Clinical Clerk. CAXCER OF THE LUNG. 7o3 s? with these were a considerable number of round colorless corpuscles, varying in diameter from the 150th to the 100th of a millimetre in diameter. An unusual number of these cells also existed » -o^ in the blood, as was determined f both before and after death (See Leucocythemia). ^ ""o* :l- :■ frp- -;(e ••• ^ Commentary . — In tlio case before us, the che^'t was frequently examined with great care, and was ascertained to be every- where resonant on per- Figrics. Fig. 464. cussion. Loud sonorous and moist rales were heard on both sides, especially posteriorly and inferiorly. Hence there were all the signs of bronchitis, which was f)und 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. Whether the conjoined signs of aug- mented or unusual resonance of the lungs, bronchitis 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, from those connected with collapse of the lung, which is so common a result of chronic bronchitis. In the present case I was in great doubt, notwithstanding my acquaintance with the valuable sign of tumor 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 tlie latter there are unusual dulness, and re- sistance on percussion, increased vocal resonance and tubular breathing, or diminished respiration, according to the density, position, and extent of the cancerous infiltration. If with these signs there be indications of the existence of cancer in other parts of the body, there will be little difficulty in forming the diagnosis ; and even should these 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 labors of Stokes, Hughes, M‘Donnell, Walshe, and Kilgour, the means of diagnosing this lesion with certainty are very defective. In the present work, eight other cases are recorded in which cancer of the lung existed (Case XXX., * Monthly Journal of Medical Science, June 1850. Fig. 463. Corpuscles in cancerous juice squeezed from the thyroid body. Fig. 464. 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. 260 diam. 15Q DISEASES OF THE RESPIRATORY SYSTEM. XXXIX., LIIL, LXXIII., LXXIX., LXXXV., LXXXYL, CXY.) lu oue of these the pleurae only were afl'ected (Case LXXXYI.) With the exception of Case XXX IX., 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 pulmonary cancer was present. Case LXXXY. alone presented the gelatinous sputum ticged with blood, or the currant jelly expectoration described by Stokes. In Case LIII. there were 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 LXXXIX. there was thoracic aneurism, to which all the physical signs were attributable. When infiltrated cancer exists to any amount in the apex of the lungs, associated with cancer in other or- gans, or with an evident tumor in the neck or mediastinum, the diagnosis is comparatively easy. Nothing can be more variable than the minute structure of cancer in the lung. When recent, it may present delicate round or oval cells (Fig. 287). When more advanced it may exhibit large compound cells (Fig. 294), as in case LXXXY. When in the infiltrated form and softened to any extent, I have seen the whole reduced to a mass of irregularly-formed nuclei, as in Fig. 348. On one occasion I found a large mass of bran-like looking cancer of the lung, somewhat fibrous, and principally composed of elongated fusiform corpuscles. CARBONACEOUS LUNGS. Case CLXIY."^ — Carbonaceous Lungs with Black Expectoration. History. — Thomas Wilson, aet. 38, collier, from the Oakley Mines, near Dunferm- line, was admitted into the clinical ward 26th 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 occupa- tion, working almost constantly with wet feet, and frequently wdth the whole of his clothes drenched. During the laying open of a new surface for the working of coal, he has often worked in an atmosphere barely capable of supporting the combustion of the miners’ lamps ; he has observed this particularly when working iron-stone. Not- withstanding, it was only six months ago that he began to be troubled with short dry cough, and difficulty of breathing. He continued to work till about four months ago, when the cough became more severe ; he had much dyspnoea, and frequent profuse expectoration, especially at night. Two weeks after this — that is, about fourteen weeks ago — he was laid up from work ; and about the same time, while under treat- ment, he began to spit much, and observed that the expectoration was of a deep black color. 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 ex- piration. 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 * Reported by Mr. W. Calder, Clinical Clerk. CARBONACEOUS LUNGS. 157 vocal resonance both anteriorly and posteriorly ; it is particularly loud in front imme- diately below the clavicle, but there is nothing abnormal to be detected in the respira- tory 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 becomes 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 present he can lie in any position without uneasiness. The sputum is in considera- ble quantity, adheres tenaciously to the bottom of the spit-box, and is of an intense black color. On being placed in water, a small portion of a lighter color swims on the surface, but the greater part sinks immediately. On being allowed to stand for a 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. potassa?, though boiled with the sputum, do not in the least affect its color. The other systems are quite normal. Has good appetite ; no sour or unpleasant taste in his mouth. Bow- els 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 examination was 88, soft and full; during his stay in the house has averaged about 76. He was or- dered an expectorant mixture ; and during the last fortnight he was in the house, he had three table-spoonfuls of cod-liver oil daily. He went out by his own desire in August, the symptoms having undergone little change. Microscopic examination op the Sputum. — On placing a small portion of the sputum below the microscope, many of the epithelial cells are seen loaded with the black carbonaceous matter. In some of them the nuclei are evident, the matter being deposited between them and the cell walls ; in others, the nuclei are quite con- cealed. In other parts of the field all appearance of cells is lost, and nothing but apparently homogeneous black masses are visible. Some of the cells may also be seen ruptured, and the black contents poured out. (See Fig. 360.) Commentary . — The physical signs existing in this case leave us in little doubt that there was considerable condensation at the apex of both lungs. This was indicated on one side by considerable dulness on per- cussion, and on the other by a pealing vocal resonance. It is true, the resonance in this place was unaccompanied by any change in the percus- sion note, a circumstance that may be caused by the existence of slight emphysema counterbalancing the increased density of the pulmonary tissue. The history of the man’s case, the nature of his employment, and the black sputum, at once indicated to us that this condensation 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 CLXV.* — Carhonaceous Lungs with Black Expectoration in a Female. History. — Christina Nasmyth, ast. 42, the wife of a coal-miner residing near Mus" selburgh— admitted 21st May, 1857. For nine years previous to marriage she worked in a coal-pit, being engaged in pushing the trucks along the tram-ways. She married at sixteen years of age, and has never since worked in the pit. She has had four chil- dren, all healthy. Her own health she declares to have been excellent till January, 1857. About this time she noticed a cough accompanied by sputum of inky lilack color, 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; cough is unfrequent, short, and rather dry ; sputum scanty, consisting of frothy blood with tenacious masses of bluish-l)lack mucus ; painful sense of tightness over the breast ; the voice is harsh and broken. There is slight dulness under right clavicle, with creaking sound during inspiration, prolonged expiration, and some increase of vocal res ince. There is cracked-pot sound under left clavicle, bronchial respiration with a few moist sounds at close of in- ^ Keported by S. de Melho Aserappa, Clinical Clerk. 758 DISEASES OP THE EESPIKATOEY SYSTEM. spiration, and increased vocal resonance; posteriorly, percussion seems unimpaired; no moist sounds are audible, but occasional sibilant and snoring sounds during expira- tion over middle of both lungs. The cardiac organ is normal in position and size ; the first sound is rough at apex ; the pulse is 80, and of good strength. Appetite is de- fective; occasional thirst in the mornings; no vomiting; considerable flatulence ; bowels are opened generally every second day ; menstruation regular ; urine 1010 sp. gr,, otherwise normal. Progress of the Case. — May 2Bd — No trace of blood in the sputum, which consists of several tenacious masses of a bluish-black color, floating in a slightly vis- cous mucus. On microscopic examination, there are seen numerous molecules of pig- ment 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. 2<6th — No moist sounds are now audible under left clavicle ; respiration continues to be loudly bronchial at left apex, and less so, but still unusually loud over the right ; hoarseness of voice has diminished. 27/'A. — Ordered Emplastrum Picis (6 by 6) to he f she expressed herself so well that she was desirous of going out. Peeling satisfied that this request on her part was to procure the means of im- position, permission to go out was granted, and Mr. William Ciilder, one of the cliuiciil clerks, agreed to follow her. She went straight to the market, and was seen, after making inquiries of one or two butchers, to purchase a pig’s bladder. Three days afterwards, January I was shown at the visit, a macerated piece of this bladder, which she affirmed had been passed during the night, and was a portion of a ruptured cyst. According to her own account, there had been violent bearing-down pains for three nights previously. I proceeded to inspect the substance, and on informing her that it was a piece of pig’s bladder, her astonishment and alarm may easily bo con- ceived. She subsequently confessed this imposture, but nothing could induce her to communicate anything with regard to her former ones. Commentary . — In June 1852, I received from a highly respectable practitioner in the north of Scotland, a bottle containing several cysts, with a letter informing me that they had been passed per vayinam by this woman then laboring under ovario-uterine disease. He wrote that “ The patient, about eighteen years ago, had a mature child. Her labor was followed by an attack of peritonitis, and she dates her present ail- ments from this period. Before the case came under my care, she had been long in hospital for ovarian dropsy, and was there repeatedly tapped. During the last few years she has passed per vagmaniy from time to time, one of the membranous productions of which I herewith send you speci- mens. You will perceive that in some instances they were perfect casts of the interior of the uterus ; in others they have been broken in tlie re- moval. When she first applied to me, the paracentesis had been delayed beyond the usual time. The dropsical accumulation was great, and her general health in a very unsatisfiictory state for surgical interference ; and before I could make up my mind to operate, nature kindly came to the relief of doctor and patient, and managed the thing so well that I have allowed the good dame to have everything her own way since. She did it thus : a membranous cyst was thrown off, and this was immediately V74 DISEASES OF THE GEXITO-UEINAKY SYSTEM. followed by the discharge, fer vaginam, of the dropsical fluid, to the amount of several pints. That this also came from the uterus, I'satisfied myself by tactile examination whilst the fluid was passing. Since then this process, the discharge first of the membrane (distended with serum), and immediately after of the effusion, has been repeated every few months, the patient in the interval enjoying an astonishing measure of health.” Without entering into a minute description of these cysts, it will suflice to say, that after carefully examining them, I came to the conclu- sion that they were the urinary bladders of some animal — and from the size (between two and three inches in their long diameter), perhaps of lambs or small pigs. They had evidently been macerated, and the ex- ternal and half of the muscular coat removed, and the smooth mucous surface turned inside out. In some of them, however, there could be sec-n the two openings of the ureters, whilst in others fragments of one or both tubes were still attached. On communicating my opinion as to the nature of these cysts to her medical attendant, and hinting that so far the woman was an impostor, he replied as follows : — “ I removed two or three of the membranes, on as many difierent occasions, from the vagina, and the state of the os uteri, as ascertained on their removal, was always such as to leave no doubt in my mind as to their having been ejected from the uterine cavity. On each occasion the woman sufiered severely, having had regular and painful uterine contrac- tions, till the diseased product was expelled, and profuse haemorrhage afterwards generally inducing syncope. I mentioned in my former note that I have more than once felt the dropsical fluid (which, as I also stated, is generally discharged shortly after the sac) passing from the os uteri. Add to this that the woman’s circumstances are such that it would be next to impossible for her to procure the means of perpetrating the trick you suspect her of. The membranes w^ere kept by me for years immersed in spirits. May not this circumstance have rendered your examination of them less satisfactory.” In this letter my correspondent announced his intention of sending the woman to Edinburgh, if I would take her into the Clinical Ward of the Infirmary. This I promised to do, and having passed another ‘‘ cyst” in the interval, she came to Edinburgh. On reviewing the facts of this case, it appears probable that C3’Sts formed in the left ovary had burst at successive times into some portion of the left Fallopian tube, and so been gradually emptied; and that with a view of exciting further sympathy, she had introduced the macerated urinary bladders of lambs, sheep, or pigs into the vagina, and pretended that they had been formed in the uterus. Case CLXIX ."^ — Ovarian Dropsy — Perforation of the Descending Colon from without inwards — Death from Ichorhcemia and persistent Diarrhoea. History. — Janet M‘Leod, single, aet. 38, a shirt-maker — admitted May 16th, 1863. Observed, four years ago, that her waist was somewhat enlarged, and that there was swelling and pain in the right iliac region. The abdomen gradually enlarged, but she sutfercd no inconvenience until September 1862, when she ceased to menstruate, and suffered from occasional Icucorrhoea, breathlessness, and difficulty of micturition. On the morning of Api il 7th she woke with severe pain diffused over the abdomen. Pur- gatives caused no relief; and on the 12th she could pass no urine, and vomited all * Reported by Mr. Alfred Lewis, Clinical Clerk. OVAEIAN DROPSY. 775 ingesta. These symptoms, though somewhat ameliorated since, have continued more or less up to the present time. Symptoms on Admission. — The abdomen is greatly enlarged and tense, measuring 38^ inches in circumference, is symmetrical, dull on percussion, and on palpation communicates a distinct feeling of fluctuation. There is considerable pain on pres- sure, especially in the epigastric and right hypochondriac regions. The skin is hot, and she perspires at times profusely. Though not emaciated she has a haggard look. Respiration thoracic. Pulse 120, weak and small. Tongue furred ; no appetite ; great thirst ; constipated. Passes urine with great difficulty. On being removed with a catheter it was found to be 1035 sp. gr., not albuminous, but loaded with urates. Catamenia ceased; no leucorrhoea ; other functions normal. Haheat 01. Ricini § ss; R Sp. ./Eilier. Nit. 3 ij ; Chlorodynce 3 ss ; Mint. CampJiorce § j — Signa To be taken at hed-thne. A large warm poidtice to he applied to the abdomen. May 29//i. — Has continued to feel constant pain on right side of abdomen, increased on pressure, with fever, sleeplessness, and constipation. Anodynes, gentle laxatives, with occa- sional starch enemata, and moist warmth locally, have failed to give relief. To-day there is looseness of the bowels, much of the pain is diminished, and she feels better. May ^Oth. — Bowels have been opened four times. An injection with 3 ss of Acetate of Lead and TTxij of Tr. Opii. From this time, however, the diarrhoea became per- sistent, and caused great weakness, for which, in addition to astringents by mouth and rectum, nutrients and wine were liberally administered. The fever became more in- tense ; the tongue brown and dry ; face sallow ; pulse 130, weak ; the local pain was diminished ; and she sunk, exhausted, June 14th. Sectio Cadaveris. — Thirty hours after death. Body emaciated. Abdomen prominent, especially superiorly, where it was tym- panitic on percussion. It measured 38 inches in circumference. xVbdomen. — On cutting through the abdominal parietes a cavity the size of an adult head was opened into, containing foetid air and ichorous purulent matter. Its walls were formed by a large ovarian cyst, which was united to the parietal perito- neum anteriorly, to the intestines laterally, superiorly, and inferiorly, while posteriorly the right ovary was seen to be greatly enlarged and transformed into cysts, varying in size from a millet seed to a cocoa-nut. In the descending colon was a ragged, gan- grenous opening, about the size of a shilling, freely communicating with the ovarian cavity, wider on its peritoneal than on its mucous surface. On removing the large ovarian tumor, the cysts were found to contain various fluids. In a few was a fluid like coffee grounds, in others pus, but in most colloid matter. All the other organs were healthy. Commentary. — This case exhibits an example of a large ovarian tumor causing peritonitis and adhesions to the neighboring viscera, and at length, by pressure upon the descending colon, perforating a passage through that gut. The symptoms, which previous to the perforation had been those of great local pain and constipation, were immediately changed on the communication taking place. The pain diminished, and diarrhoea became the leading symptom. Air entering the ovarian sac from the gut, produced ichorous suppuration, ichorhaemia, and death by exhaustion. These symptoms well contrast with the effects of perforation of the gut taking place from within outwards. Pathology of Ovarian Dropsy. The subject of encysted tumors of the ovary has been considerably elucidated by Hodgkin, Seymour, Bright, Cruveilhier, Midler, and nu- merous recent observers. From these it would appear that the ovary may be the seat, 1st, of a simple cyst ; 2d, of a compound cyst, formed of a capsule containing a number of secondary cysts ; and 3d, of similar cysts more or less combined with a sarcomatous structure, generally considered of a cancerous nature. The first of these seldom becomes larger than an orange, and is for the most part only detected after death. The two latter 776 DISEASES OF THE GENITO-URINARY SYSTEM. frequently reach a large size, and contain several gallons of fluid, con- stituting what has been called ovarian dropsy. In these cases, the accu- mulation of fluid sooner or later interferes with the process of respiration, so as to render paracentesis necessary. This operation is repeated again and again at shorter intervals, until the patient sinks. On dissection, death is found to have been occasioned by peritonitis, by suppurative in- flammation within the sac, or by exhaustion. The source of the fluids removed by tapping in ovarian dropsy, was pointed out by me in 1846.^ On some occasions the serum exists within the cavity of the abdomen, and the tumor can be felt to move or float in it. At other times it is confined within the cystic tumor. Thus some have supposed the fluid to be ascitic, caused by pressure on the large abdominal veins, whilst others have supposed that the growth irritates the peritoneum, and occasions an increased effusion of serum. In the case of Fleming (Case CLXVI.), it was also argued by some of the ob- jectors to ovariotomy, that excision of the tumor would not remove the ascites, as that was probably dependent on causes unconnected with it. Now, in that and in similar cases, where four or five gallons have fre- quently been removed from the abdominal cavity, it must be evident that the amount of fluid could not be contained in the cysts of a tumor only the size of the human head. Neither could it have been the result of peritonitis, as the fluid was clear and of a brownish amber color. Again, the liver and other abdominal viscera were healthy, and they could not have caused venous obstruction ; nor was it likely that such an ovarian tumor, floating as it did mostly in fluid, could by its pressure, have occasioned efi'usion of that fluid from the veins. It must be concluded, therefore, that in such cases the fluid is secreted within the tumor, and passes through one or more openings in its walls into the peritoneal cavity. The mode of growth and the structure of encysted tumors of the ovary. — In all the specimens of the disease I have examined, whether the growth is only the size of a walnut, or is so large that it has entirely filled the abdomen, the original form and structure of the ovary has dis- appeared. Some suppose a new growth is formed in the organ. Others consider the cysts are produced by accumulating fluid distending the spaces in the areolar tissues of the organ. I have always maintained that they originate from the Grraafian vesicles, and that the external capsule is formed by the thickening and extension of the fibrous membrane which covers the organ. The recent observations of Dr. Wilson Fox not only sup- port this view, but indicate very ingeniously how the papillary growths so frequently observed on the internal walls of the cysts are concerned in the production of secondary cysts. According to him the papillae, covered with epithelium, on being pushed outwards leave spaces between them, which subsequently enlarging and being occluded at their orifice produce the cysts. These, he thinks, by the growth of partitions or formation of re-duplications, may occasion other internal cysts, and so the process be repeated. This idea will be better understood by Figs. 465, 466. Sooner or later the enlarged ovary is found to consist of a dense fibrous envelope or sac, containing internally numerous secondary cysts attached to its walls. As the tumor developes itself these cysts become * Pathological and Clinical Observations on encysted Tumors of the Ovary. Edinburgh Medical and Surgical Journal, vol. Ixv. OVAEIAN DROPSY. larf^er more numerous, and crowded together. Each individual second- ary" cyst contains a clear glairy or gelatinous fluid, and is composed ot a firm fibrous capsule, lined by a smooth membrane. On making a thin section completely through the walls of these cysts, their greatest thick- ness will be found, on .a microscopic examination, to be composed of fibrous tissue, lined internally by a layer of epithelial cells. The whole are richly supplied with blood-vessels. Fig. 467. Fig. 468. Fig. 469. Fig. 470. As the tumor enlarges, it ascends from the pelvis, where it is origin- ally confined, and occupies more and more of the abdominal c-avity. The Fallopian tube aud broad ligament become elongated. The fimbriated extremity of the former is sometimes obliterated, at others it stands out from the morbid mass. Sometimes the tumor forms adhesions externally, more or less extensive, to the peritoneum, omentum, colon, or neighbor- ing viscera. At others it floats loose in a fluid within the abdominal cavity. Meanwhile the internal cysts press upon each other, they become dis- Fig. 46.5. Vertical section through the wall of an ovarian cyst, showing the papil- lary growths (6) and the spaces between them (a) which, on being closed in, become cysts lined with epithelium. A cyst so formed is seen below (e). — Wihon Fox. Fig. 466. Subsequent formations proceeding in the walls of simple cysts so pro- duced causing compound cysts (a, b ). — Wiho7i Fox. 100 diain. Fig. 467. Section of the wall of an ovarian cyst, with epithelial cells in situ. Fig. 468. Polygonal epithelial cells from the same lining membrane. Fig. 469. Oval epithelial cells from the lining membrane of an ovarian cyst. Fig. 470. Cells in fluid removed from an ovarian dropsy. 250 diam. 778 DISEASES OF THE GENITO-URINARY SYSTEM. tended with fluid, the blood-vessels are compressed, and in such places further growth is checked. In consequence of this, absorption of their structure occurs, and one or more open into each other, as was pointed out by Hodgkin, constituting a multilocular cyst. Occasionally the pressure acting upon the external sac causes it to become thinner and thinner, until at length perforations are produced in it also, through which the fluid contents of the cyst escape into the abdominal cavity. Thus relieved from pressure, the margins of these perforations become once more vascular, and of considerable thickness, often resembling the round perforating ulcer of the stomach so well described by Cruveilhier. Under such circumstances, the internal membrane of the cyst continues to secrete and pour its fluid into the peritoneum, rendering paracentesis necessary. At other times the external sac adheres to the abdominal walls, and the secondary cysts only burst or open into each other inter- nally, so that after a certain period, three, two, or only one cavity may remain, with bands stretching across and forming imperfect septa, or with a few small cysts attached to the internal wall, and clearly indicating its original structure. In either case, sooner or later, suppuration is in most instances established within one or more of the cysts, or within the ex- ternal sac itself. This suppuration seems to occur in some cases by the formation of pus corpuscles in the gelatinous matter ; in others by an in- flammatory exudation filling the cyst, which is afterwards converted into pus. The patient does not long survive this occurrence. If perforation have taken place in the external wall of the tumor, peritonitis is general- ly induced; if not, the patient sinks exhausted, whether the pus be evacuated or not. Occasionally more or less blood is extravasated into the inflamed cysts, which, with the various stages of suppuration, cause the sanguinolent, coiFee-like, greenish, or purulent fluids so often observed. The gelatinous contents of the cysts vary greatly in difi’erent cases: in some being diffluent, in others glairy like white of egg, whilst in many it is semi-solid, resembling coagulated calf ’s-foot jelly, or strong size. When fluid, it frequently contains flocculi, which are patches of epithelial membrane, more or less united together by granular matter. When gelatiniform, it often contains faint oval corpuscles, or a few primitive corpuscles. (See Figs. 202, 203.) Occasionally an opalescent or opaque creamy appearance is communicated to the jelly by the formation of pus corpuscles or minute granules (Fig. 322), and sometimes it is wholly filamentous, mixed with granule cells and other products of inflammation. This jelly-like matter presents various characters, chemical and struc- tural. Acetic acid frequently causes to be precipitated a white mem- brane, having all the characters of fibrous tissue. Grranules, cells, and filaments may also be observed in it in various stages, as is the case with recent exudation from the serous membranes, or in other simple forms of hyaline blastema. •Not unfrequently the ovary contains hairy and other growths, teeth (p. 203), and calcareous deposits, and may be the seat of cancer. In this last case I also pointed out and figured in the memoir referred to, that the so-called cancer often consists of an epithelioma of a remarkable kind, columnar epithelial cells forming and separating in great abund- ance.* I have now examined several such diseased ovaries; one espe- ^ Ibid. Case II. Fig. 1. OVAKIAN DEOPSY. 779 . cially, forwarded to me by the late Mr. Russell, of Birmingham, exhibited to tlie naked eye all the characters of cystic eucephaloma, and yielded an abundant milky juice. On examining this with a microscope, it was seen to contain, 1st, numerous columnar epithelial cells, with fatty granules accumulated within their broad extremities ; 2d, a multitude ot diaphanous celloid bodies," and, 3d, numerous free nuclei, as in Figs. 471, 472, 473. See also Fig. 207. The diagnosis of ovarian tumors was formerly very defective ; so much so, indeed, as in some cases to have led to the opening of the abdomen to excise a tumor which bad no existence, and in many others to the performance of an operation when, from adhesions or other causes, the growth could not be removed. In all cases of abdominal tumor, there are two questions which every practitioner desires to answer with certainty, namely, 1st, What is the seat ? and, 2d, What is the nature of the tumor ? With regard to the first point, I must refer to obstetrical works, in which all the circumstances, local and general, are pointed out, which distinguish such ovarian growths from pregnancy, with which they have often been confounded. Therein also will be found the means of exploring the cavity of the uterus with the uterine sound, an instrument which, by enabling the practitioner to elevate, depress, or bring forward, the fundus of the organ, so as to permit of its being felt through the integuments, in various positions above the pubis, affords most valuable information. In cases of ovarian dropsy, the information thus arrived at is negative, but this becomes of immense importance when the question arises (as it always does,) Is the tumor uterine or ovarian ? In the case of Fleming this point was anxiously debated, but when on the introduction of the sound the fundus of the uterus could be distinctly felt above the pubis presenting its usual rounded character, there could no longer be any sus- picion that the tumor originated in that organ. Again, by pushing the uterus from side to side, we are enabled to act upon the ovaries and to determine, by the impulses communicated to the hand, whether the Fig. 4*71. Groups of columnar epithelium in the juice of an encephalomatous cystic growth of the ovary, with fatty granules accumulated at their extremities. Fig. 472, Diaphanous celloid bodies, naked nuclei, and granule cells. Fig. 473. a, The nuclei after the addition of acetic acid ; 6, the columnar epitheli- um acted on by the same re agent. 250 diam. V80 DISEASES OP THE GENITO-URINARY SYSTEM. tumor be on the right or left side, and to form a tolerable idea, in certain cases, whether it be free or attached. By means of this instrument, then, we are materially assisted in resolving the first important question re- garding the seat of the tumor. A microscopic examination of the fluid removed by paracentesis may also sometimes give important indications as to the nature of the tumor. If, for instance, the fluid be clear, with polygonal or rounded and swollen epithelial cells (see Figs. 468 and 470), they are highly characteristic of cystic ovarian growths. If columnar epithelial cells are found in quan- tity there is probably an epitheliomatous cancroid of the ovary (see I^gs. 207, 471 and 472). If, on the other hand, there be pus or blood cor- puscles, areolar texture, or calcareous salts and deposits, the amount of purulent formation, hemorrhage, disintegration, or mineral degenera- tion, may be judged of thereby. Treatment of Ovarian Dropsy. The anatomical examination of encysted tumors of the ovary must convince every one that they are not curable by internal medicines. The idea that a dense fibrous envelope, containing numerous secondary cyLts, all richly furnished with blood-vessels, can be absorbed through the agency of mercury, iodine, or any other drug, is purely imaginary. There is not one positive fact to support such an opinion. Neither can it be supposed, from what has been described of the mode in which these tumors are developed, that so long as any of the secondary cysts remain intact, a cure can be hoped for. But we have seen that the natural course of these secondary cysts is to open into each other, until at length only one large cyst remains. Under such circumstances it may be con- ceived that a rupture might, by exciting inflammation, and thus destroy- ing the secreting surfaces, or inducing adhesions between them, cause a radical cure of the disease. Such is probably the explanation of those rare cases of cysts, well established in science, which have apparently burst, and rapidly disappeared. A case of this kind has been recorded by Lebert,* in which the tumor burst into the peritoneum and subse- quently disappeared. In other cases the tumor may unite with neigh- boring hollow viscera, and by ulceration empty its contents into them, so that they are discharged (Cases CLXVII., CLXVIII., and CLXIX.), or it may open on the external surface. When a perfect cure has been brought about in this way, it wdll generally be observed that the progress of the morbid growth has been chronic, that consequently time has been allowed for all the secondary cysts to open into each other, and that the itiflammation which follows the rupture may then be supposed to act by obliterating or causing adhesions between the walls of the cyst, as in the case of hydrocele. When, on the other hand, sudden rupture of the ex- ternal sac takes place, whilst some of the cysts remain entire, the termi- nation in cure is impossible, and the peritonitis and other effects occa- sioned more frequently cause death. The occasional occurrence of such spontaneous recoveries has led to the proposition of producing permanent artificial openings, with a view of *Physiologie Pathologique, tome ii. p. VI. OVAEIAN DROPSY. 781 imitating a natural cure. Mr. Bainbridge of Liverpool suggested making an incision into the sac, and uniting its edges with the external 'vvound ; and Dr. Tilt of London has proposed making a minute aperture by means of Vienna paste, so as to cause a permanent opening. Such practice can only be useful at a particular period in the growth of ovarian tumors — that is, when all the internal cysts have broken down into one. But such cases are exceedingly rare, and such practice can be of no real advantage until we learn to distinguish in the living subject unilocular from multilocular cysts. Numerous cases and dissections of ovarian tumors have convinced me, that, in the present state of the art, this knowledge is not to be arrived at with any degree of certainty ; and that consequently any proposal, however valuable in itself, which is founded upon the assumption of our possessing that knowledge, is not likely to be practically beneficial. The same remark applies to injections of the tincture of iodine or any other fluid, which can only operate on individual cysts, and not on the entire growth. It is astonishing how some individuals accommodate themselves to very large abdominal swellings. I have known several cases where the patient has labored under an enormous encysted tumor of the ovary for ten and even fifteen years. On the other hand, many facts demon- strate that when once paracentesis is had recourse to as a palliative mea- sure, suppuration within the cysts, and a cachectic state of the constitution is more likely to supervene. One important practical rule, therefore, to be followed in the treatment of these cases is, not hastily to have recourse to tapping, but, rather, by all possible means of delay, to further the natural disposition, which the internal cysts exhibit under pressure of forming one large sac. This once accomplished there is nothing incon- sistent in supposing that inflammation produced artiflcially is as capable of producing a permanent cure as is a spontaneous rupture. There is every reason to believe that artificial pressure is capable of facilitating the absorption of the walls of the secondary cysts, and their opening into each other; but we possess no means of ascertaining when only one sac is produced. That it has succeeded in obliterating and ultimately curing the disease, however, has been proved by Mr. Isaac Brown,"* who by binding a book on the tumor firmly, has caused inflammation and disin- tegration of the internal cysts, and then letting out the pus, has actually cured some cases. The practice, however, is by no means safe. Case CLXVII. seems to me illustrative of the efiects of pressure. It must be acknowledged that the seven months which had elapsed between the time the tumor was first perceptible, and the period when it spon- taneously burst into the bladder and collapsed, was a remarkably short one. In the most favorable cases this result takes about two years to accomplish by itself ; but in the instance of Pyper, the tumor was sub- jected to the gradually increasing and equable pressure of the pregnant uterus, and to its influence must, I think, be attributed the fortunate result and rapid breaking down of the secondary cysts. The ulceration into the bladder was probably determined by the direction the pressure had assumed in this case, and, of course could not be imitated artificially. There still only remain two methods of curing an ovarian dropsy by art — viz., 1st by excison ; and 2d, by pressure followed by puncture. * See cases recorded in the Lancet. V82 DISEASES OP THE GENITO-UEINARY SYSTEM. Cases CLXVII. and CLXVIII. confirm the views suggested by pathology with regard to the modus operandi of the latter treatment; and if in cases which do not admit of extirpation, pressure be so gradually and equably applied as to obliterate the internal or secondary cysts, an artificial open- ing then made would cure the disease. The difficulty is to ascertain when the moment for making the puncture has arrived — in other words, when a multilocular is converted into a unilocular cyst. In the present state of the art, this, as I have said, is impossible ; but as an exact in- dication of the difficulty is often the best preliminary to its removal, -I do not despair of one day seeing it completely conquered by the cultiva- tors of medicine. As regards excision, the practice of late years has tended to confirm its propriety in such cases as that of Fleming, (Case CLXVI.), in which the tumor has no adhesions of any extent to the abdominal walls, where its presence is the cause of great deformity and much suffering, and where the youth and general health of the patient and freedom from other diseases, hold out hopes of a favorable termination. The general result of the now numerous operations by Clay, Atlee, Baker Brown, Spencer Wells, Thomas Keith, and others, is about one death in three, although there is a belief that if greater care were observed in choosing only ap- propriate cases, the ratio of mortality would be much diminished. NEPHRITIS AND PYELITIS. Case CLXX.* — Acute Nepliro^Pyelittis — Recovenj. History. — Helen Kessick, set. 65, a nurse — admitted November 25, 1852. States that for the last twenty years she has been subject at intervals to occasional pains in the lumbar region. She had never experienced any difficulty or uneasiness in mictu- rition, till about five years ago, when she noticed that the urine was tinged with blood ; this was accompanied with pain in the right lumbar region, preceded by shivering, and followed by febrile symptoms. She was admitted into the Royal Infirmary, where she remained for seven weeks, and was dismissed cured. She had no return of the symptoms till about twelve months ago, when she was again seized with shivering, and a return of the lumbar pain. During the summer the urine was tinged with blood for two days, but afterwards again became normal, and she continued better till about four weeks ago, when she once more experienced pain on passing water, which, with increased uneasiness in the lumbar region, has continued up to the present date. Symptoms on Admission. — On admission, tongue much furred ; appetite bad ; great thirst ; no nausea ; complains of pain in the epigastric region, but no tumor or hard- ness can be detected ; bowels have not been opened for two days. She has considerable pain in right lumbar and both hypochondriac regions, also in the hypogastrium after making water, which is passed in less quantity than usual. Urine sp. gr. 1016, coag- ulable by heat and nitric acid, and deposits, on standing, a copious ropy mucus-like sediment, showing, under the microscope, large quantities of pus globules, and a few crystals of triple phosphate ; pulse, 76, soft ; no palpitation of heart ; complains of occasional headache with frequent giddiness, and muscae volitantes ; sleeps ill at night, and complains much of cold feet ; other functions normal. Liquor. Potass. ; Bp. Addi. Nit. afi 3 ij ; Bol. Mur. Morph. 3 iii ; Mist. Camph. ? v. M. Snniat 3 ss quarid qudqnehord. R 01. Ricini ^j. Sumat siatim. To nse barley roater as a drink. Progress of the Case. — December Uh. — Feels very weak ; continues otherwise in much the same state ; urine still albuminous, with copious deposits, containing pus and * Reported by Mr. F. B. de Chaumont, Clinical Clerk. NEPHRITIS AND PYELITIS. 783 triple phosphates. To have 3 oz. of loine. Dec. 11. — Continued to improve till last nignt, when she was seized with shivering and pain in lumbar and epigastric regions; great nausea and vomiting ; tongue moist, but much furred ; great headache ; urine as before. Omitt. mist, et vinum. R Sol. Antimon 3 iij ; Sp. AEth. Nit. 3 j ; Aquae Acet, Ammon, et Aquae § iiss. M. Sumat ter indie. Warm fomentations to be ap- plied to the loins. Dec. 13. — Was rather better yesterday, but has still pain in right lumbar region. To-day she is still sick, the pain in right lumbar region somewhat increased ; there is great dysuria ; the urine is of high color ; still albuminous, sp. gr. 1018, with copious sediment, showing, under the microscope, numerous blood globules, and a quantity of debris of cells mixed with the pus and triple phosphates, which are still as abundant as formerly. Dec. l^th . — Was no better yesterday, and began to complain of severe pain in the hypogastrium. Omitt. mist. Tinct. Hposcijam. § ss ; Sol. Mur. Morph. 3 iss ; Mucilaginis ^ij ; Aquae §iii. M. Sumat 3 j ter in die. To-day she still complains of the pain in hypogastric and lumbar regions. The urine is diminished in quantity, and deposits, on standing, a viscid tenacious sediment, which, in addition to the blood corpuscles, pus, and triple phosphates, now shows casts of the urinary tubes, crowded with granules. 7b he cupped on the lumbar region to 8 oz. Dec. 16^/i. — Only 6 oz. were obtained by the cupping. The pain in back is much relieved, and she is able to sit up in bed without uneasiness, but there is still pain in the hypogastrium ; pulse 72, soft; tongue still furred; no nausea or vomiting, but some pain in the bowels ; headache nearly gone ; urine of a dirty red color, still coagulable, showing blood, pus, and phosphates under the microscope, as before. Habeat enema domesticum et sumat Sol. Mur. Morph. 3 ss. et Mucilaginis 3 j ex aquf hord somni. Dec. ISth . — Symptoms much the same as at last report. Urine sp. gr. 1015, and again shows casts of the urinary tubes. The bladder was sounded to-day, but nothing ab- normal could be detected. Dec. 20th . — Urine contains a large quantity of gelatinous mucus, in which a few broken-down granular casts can bo detected. Sol. Mur. Morph. 3 ss ; Tinct. Hyoscyam. 3 i ; Mucilaginis 3 j ; Fiat, haust. omni nocte sumcndus. U- Decoct, llvce Ursi | x ; Tinct. Hyoscyam. 3 j ; Sp. jEih. Nit. | j ; Mucilaginis § ij. M. swnat 3 i ter indie. Dec. 20th. — Continues in much the same state, but the pain in the hypogastrium has considerable increased. She had some sweating last night, and the pulse is now 86 and soft ; the tongue is still furred ; no appetite ; great thirst; bowels not open for some days ; great dysuria ; urine presents the same characters as before. Applic. hirudines quatuor hypogastrio et postea bene fovcatur. Pulv. Jalapce et Pulv. Scammon. aa gr. vi. M. Sumat hord somni\ Sol. Adur. Morph. 3ss; Mucilaginis §j. M. Sumat eras mane. Dec. 20th. — The pain in the hypogas- trium having greatly abated, the leeches were omitted at the patient’s request ; the bowels were weli opened by the medicine. To-day she feels much better, and slept well with- out the draught. Tongue more clean and moist, but the urine contains rather more blood. Jayiuary li7, 1853. — She still continues improving, but pain in the hypogas- trium is not quite gone. The urine is more natural in color, the deposit greatly de- creased, and the blood has now disappeared. Alarch 0th . — Since last report has expe- rienced occasional lumbar pain, but on the whole has been slowly getting well. The urine, which has gradually been geiting clearer, is reported to-day as quite normal, and free from albumen. A slight hernial protrusion has been discovered in the right iliac region, to which a truss was applied. March 2%th . — Dismissed relieved of all her symptoms. Commentary.— This was a case of acute nepl)ritis, with tendency to recurrence, exhibiting local pain, inflammation of the mucous membrane (pyelitis), as shown by the excessive discharge of mucus and pus, and inflammation of the secreting substance of the organs, as proved by the frequent appearance of blood, casts of the tubes, and the persistent albumen. During a period of four months, however, during which a variety of treatment was had recourse to, as recounted in the report, all the urinary symptoms disappeared, although there was still a tendency to the return of pain in the lumbar region. This case indicates the mode in which acute cases of the kidney frequently pass into chronic ones ; but from the circumstance that the right kidney only was attacked, and that the left one could still secrete a sufficient quantity of urine, no oedema or dropsy occurred. 784 DISEASES OF THE GENITO-URINAKY SYSTEM. Case CLXXI.^ — Suhamite Nephritis^ with great Anasarca — Recovery. Acute Nephritis of Left Kidney — Recovery. History. — Anne Hewison, set. 18, a servant — admitted Dec. 14th, 1856. She has been in the Surgical Hospital on three occasions during the last four months, on account of abscesses in and about the axillae, from which she is now free. For six weeks she has experienced pain in the lumbar regions, most severe when the weather was cold, and increased by coughing and hard breatliing. A fortnight ago she observed that the feet and abdomen were swollen. Since then she has become slightly anasarcous. Symptoms on Admission. — The integument all over the body is oedematous, and the face especially is considerably swollen. All the depending parts of the trunk, together with the extremities, are pale, pitting readily on pressure. The catamenia have appeared on three occasions at the interval of a fortnight, and been very copious. The urine is highly albuminous, sp. gr. 1010, diminished greatly in quantity, but the exact amount cannot be ascertained. Numerous waxy casts are visible in it under the microscope. The chest is resonant everywhere on percussion. Sibilant sounds are audible at the apex of right lung, both with inspiration and expiration, the remains, she says, of a cold that has troubled her for five weeks. She suffers occasionally from palpitation ; but the circulatory system on examination is normal. Pulse 80, of good strength. The abdomen very tumid, with distinct fluctuation, and painful on pressure over the whole anterior surface, but most so on the right side opposite the lumbar region. The digestive system, otherwise, and the nervous functions, are normal. Habeat Potass. Bitart. Dj ter in die. Progress of the Case. — December \%th. — The amount of urine passed is greatly increased and has amounted to 51 oz. during the last 24 hours. Dec. 'lOth. — The whole body is now much less oedematous. Pulse 75. Passed 150 oz. of urine during the last 24 hours. Dec. ^loth. — Has passed about 100 oz. of urine daily, which is pale, sp. gi’. 1010, and now only faintly albuminous. (Edema of extremities has now disap- peared, but still some swelling of face and abdomen. There are slight febrile symp- toms. Pulse 100, weak. Complains to-day of sore throat. The tonsils are enlarged, and the mucous membrane of fauces congested. An astringent gargle was ordered., and warm poultices to be applied to the throat. Dec. 26(/o — Yesterday afternoon and to-day she passed urine of a dark-brown color. It is highly albuminous, with a sedi- ment composed of urates and blood discs, as seen under the microscope. There is pain in the left loin. Throat not so painful. Face anxious. Pulse 90, of good strength. To omit the bitartrate of potass. IJ Sp. jEther. Nit. 3 ij ; Mucilaginis § ij ; Aq. Font. §\'j. M. Two table-spoonfuls to be taken every four hours ; warm fomentations to the left lumbar region. Dec. 28^/i. — Has continued to feel pain in the left loin, which is in- creased on pressure. Has passed 24 oz. of urine during the last 24 hours, highly albu- minous, less dark, and now of a light chocolate color, turbid, with no layer of fat perceptible on repose, but numerous tube-casts and some urates and blood corpuscles seen in it with the microscope. All sore throat, fever, and oedema of the integuments have now di>=appeared. Pulse 84, firm, Dec. ^\st. — Has passed from 50 to 60 oz. of urine daily. Has still dull pain in the loins, but otherwise better. From this time she began to sit up and walk about the ward. The lumbar pains returned at intervals, but finally left her Ja7i. 2Uh. The urine also retained a trace of albumen for sometime ; occasionally, however, disappearing fora day. On the l^thof Jan. she took Potass. Bitart. gr. x. ter in die. The urine was examined daily, and on Jan. Tlth up to the 30^/q not a trace of albumen could be discovered. She was then dismissed quite well. Commentary . — In this case, a somewhat chronic form of nephritis or Bright’s disease appeared before her admission, which occasioned intense general anasarca of the body, and was characterised by albumi- nous urine containing numerous waxy casts. The oedematous face and general appearance were in this girl highly distinctive of renal dropsy. The strong diuretic effects of the bitartrate of potash in scruple doses, caused this to' disappear. She was then seized with acute nephritis of the left kidney, as indicated by the febrile symptoms, pain in the left loin, increased on pressure, bloody and turbid urine, etc. From this * Reported by Mr. M‘Leod Pemberton, Clinical Clerk. NEPHRITIS AND PYELITIS. '785 also she gradually recovered under the employment of gentle diuretics, demulcents, and warm fomentations locally. All trace of tendency to permanent albuminuria — so common a sequela of nephritis — was also got rid of by the action of small doses of cream of tartar. The occurrence of sore throat and febrile symptoms with this last attack, induced me to inquire carefully as to whether there was any proof of scarlatina, but I could not discover any. Case CLXXII.* — Acute Desquamative Nephritis^ proving rapidly fatal from, Diminished flow of Urine,, General Anasarca, and (Edema of the Lungs. History. — William Lawson, set. 34, married, was admitted to the Skin Ward November 28, 1856, for an attack of scabies, which had lasted four months. He has been drinking freely lately — is anaemic and emaciated. On examination, innumerable minute isolated vesicles are to be seen scattered over the whole body, with the exception of the head and neck ; most abundant on the flexor surfaces. On the legs there are a few patches of eczema. Dec. 2d. — He was ordered to rub himself all over twice a day with simple lard, which, on the 6th, was exchanged for sulphur ointment. Commencement of the Disease. — December \lth. — Especial attention was directed to him to-day in consequence of cough and evident dyspnoea. He thinks he must have caught cold from being so long naked when employed rubbing himself. Since the '7th he has observed slight oedema of his feet, which was followed by coufih. He has paid little attention to these symptoms. The urine is found to be highly albuminous and of brownish color. On microscopic examination of the sediment, it was seen to contain numerous desquamative tube casts. His cough troubles him chiefly at night, when he finds there is difficulty in breathing or lying in the hori- zontal posture. On percussion there is slight impairment of resonance over right chest anteriorly, below level of third rib. There is no increase of vocal resonance. The respiratory murmurs are more feeble than on the left side, and inspiration is occasionally sibilant. Posteriorly, percussion over lower half of both sides gives resonance of a somewhat flat tone. Fine moist sounds attend the close of inspira- tion, and expiration, feeble below, is exaggerated superiorly. 8p. uEther. Nit. I ss ; Tr. Digitalis; Tr. Scillce, aa 3 iss ; Aquam ad ^ vi. M. A table-spoonful to be taken every four hours. Progress of the Case. — December \2th. — Over dull region anteriorly moist sounds, clicking in character and few in number, attend the extreme close of inspira- tion. Vocal resonance also slightly increased in area of dulness, and posteriorly there is slight comparative dulness over middle third of right side. Urine of brown smoky color, with blood corpuscles visible under the microscope. Sputum scanty, purulent, not streaked with blood. Extract ^ iv of blood from the loins by cupping. Omit the mixture. To have 3 ss of Bitartrate of Potash three times a day, and § ij of Grin daily. December IMh. — Since last report the dyspnoea has been gradual- ly increasing, and the pulse becoming weaker. It is now 100, and soft. The sputum is scanty, purulent, not tinged with blood. Percussion over both lungs inferiorly and posteriorly is impaired, especially on the right side. On auscultation, a fine moist rattle accompanies the inspiration, and there is an increase of the vocal reson- ance. Urine presents the same characters as formerly, and contains chlorides in abundance, but does not amount to § xx daily. The gin is increased to § iij daily. To have § iv of port wine in addition. U Ammon. Carb. Dij ; Tr. Card. Comp. 3 j ; Aquam ad f vj ; Ft. mist. A table-spoonfal to be taken every second hour. December nth . — Has been steadily getting worse. The respirations are now 40 in the minute, and he is obliged to retain the sitting posture. Takes no nourishment. Pulse 126, very feeble. Crepitation and increased vocal resonance now heard posteriorly as high as spine of scapula. No pain. Pulse 80, of good strength. To be dry cupped over chest and back ; warm bottles to feet. Towards evening the face more pallid, hands and forearms cold and slightly oedematous. At 9 p.m. the breathing was 48 per minute, and so labored that he was bled to about | xiij. Towards close of venesec- tion the pulse at the left wrist, previously imperceptible, could be detected small and 60 * Reported by Mr Wm Guy Clinical Clerk. 786 DISEASES OF THE GENITO-URINARY ST STEM. exceedingly weak ; and patient (on inquiry) admitted himself to be slightly relieved although to others this was not perceptible. Fifteen minims of Sol. Mur. Morph, ordered. December \d>ih. — His wife states that he slept from three to six o’clock this morning. The dyspnoea is as great as before the venesection ; respiration catching in character. Has passed very little urine, and that at stool ; on examination it was found to contain pus corpuscles in considerable quantity, besides the casts before mentioned. He is obliged to sit up and lean forward in bed ; his intellect is somewhat impaired. During the night delirious. December 20^A. — Evidently sinking, but conscious. Z>e- cember 21st.- — Died this morning at half-past three o’clock. Sectio Cadaver is. — Thirty -three hours after death. The body is generally anasarcous, with great oedema of the scrotum ; surhtce pale ; no trace of scabies, with the exception of a few small circular cicatrices about the hands and fingers. Thorax. — All the cavities of the heart and large vessels were distended with blood, for the most part coagulated and decolorized. The cavities of the heart itself in consequence were dilated. This was especially observed of the left ventricle, the walls of which were rather thinner than natural. The pericardium and all the valves were healthy. The heart weighed 16 oz. The right pleura was everywhere strongly adherent. The right lung was moderately voluminous, and felt heavy. On section, it was seen to be highly cedematous, yielding on pressure a copious frothy fluid. No solid exudation anywhere. The left lung was unadherent, and rather less voluminous than the right one, and though cedematous was not so in the same degree. Abdomen. — On stripping off the capsule from the surface of the kidneys, they both appeared of their normal size, and of a pale fawn color. When cut into, the cones were found somewhat congested, the cortical tissue pale. Tlie latter con- tained numerous white lines or streaks, generally directed at right angles to the circumference of the organ. There was no trace of granulation, and the density of the kidneys was much diminished, the organs being more soft than usual. The liver was congested, but otherwise normal ; it weighed 4 lbs. The other abdominal viscera were healthy. Microscopic Examination. — On scraping a fresh cut surface of the kidney, a pulpy matter was readily obtained, which, on examination under a power of 250 dia- meters, was seen to be composed of large fragments of the tubes, crowded with epi- thelial cells, which were agglutinated together by a fine molecular matter. Groups of these cells surrounded by, or imbedded in, this molecular substance, could also be seen isolated. On the addition of acetic acid, the molecular matter and the walls of the cells were rendered more transparent, whilst the nuclei were unaffected. The urine in the bladder contained a few desquamative casts of the tubes, spermatozoa, and a number of isolated epithelial cells from the kidney. Commentary. — The acute disease of which this man died came on in the ward during the inunctions he practised over the body in order to remove a chronic scabies, which extended itself to a great- extent over the integument. The first approach was so slow as not to excite at- tention — he himself considering it as an ordinary cold. On the 10th of December, when cough and some dyspnoea attracted my notice, the feet and legs were already cedematous, and the urine diminished in quantity, as well as highly albuminous. It was observable, however, that there were no symptoms of fever, no local pain, and the question arose whether, in conjunction with diminished urinary excretion there was or was' not pneumonia. My diagnosis in the negative was assisted not only by the absence of febrile symptoms, and by the loud and superficial character of the crepitating rale in both lungs spreading upwards, but by the constant presence of chlorides in the urine (see p. 686). On the other hand, the chemical and microscopical examination of the urine soon left us in no doubt that we had to do with an acute attack of desquamative nephritis, producing general anasarca, and more especially rapid oeJema of the lungs. This diagnosis was fully confirmed NEPHRITIS AND PYELITIS. '787 by tlie dissection after death, the cortical portion of the kidneys being pale and comparatively free from blood, whilst the tubes were gorged with exudative granular matter, mingled with a mass of epithelial cells. Both lungs, especially the right one, were infiltrated with serum. The rapid progress of this case, evidently dependent on obstruction of the renal tubes, seemed to demand active remedies. But the state of the pulse and tendency to prostration from the commencement forbade antiphlogistic remedies, even had other considerations not pointed out their inutility (see p. 318.) For the same reasons, diaphoretics were too slow and uncertain in their action to be depended on, although morphia and local warmth were tried. Diuretics, therefore, were given, and subsequently stimulants to counteract exhaustion, a practice which, though condemned b}^ some on the principle that we stimulate an organ already in a state of irritation, we have too frequently seen succeed when all other remedies have failed, to have any doubt as to its value. The real danger, however, in this case was early to be traced to the consecutive efiPect on the lungs, and the difficulty the heart experienced in propelling the blood through those organs, so that at length as a palliative I determined on venesection. The man’s arm was so oedema- tous, and the vein so small, that I was obliged to perform the operation myself, and it is remarkable, as illustrative of the infrequency of phlebotomy now-a-days, that of three advanced students present only one had ever seen an individual bled, and that the nurse who held the basin fainted away. At this time the man’s pulse was imperceptible at the wrist, although the heart’s action was strong. He stated that he felt somewhat better, but I regretted to observe that little or no relief was afforded to him. Case CLXXIII.^ — Acute Desquamative and Hemorrhagic Nephritis — Hydrothorax — Collapse of the right Lung — Pulmonary (Edema and Bronchitis^ with symptoms of Pneumonia. History. — Andrew Cr.aig, set. 45, a waiter, stout and fat — admitted July 1st, 1851. He has had delirium tremens several times, and been of very dissipated habits. Six days ago, after unusual exertion, during which he was exposed to wet, he was seized with rigors, fever, and vomiting. Next day he observed his feet to be oedematous, and his urine to be highly colored ; cough and expectoration subse- quently made their appearance, and yesterday the breathing became very difficult ; symptoms which continued to increase. Sy.mptoms on Admission. — On admission the body generally is anasarcous, and the face puffy and bloated. He labors under great dyspnoea, has a troublesome cough, accompanied with a viscid sputum, in some places of a rusty color, and in others mingled with clots of blood the size of a pea. On percussion there is marked com- parative dulness at the base of right lung anteriorly, extending two inches above the hepatic dulness. Inspiratory murmur over this dull portion is accompanied by harsh and tubular breathing, with increase of the vocal resonance. Posteriorly, also, marked dulness on right side, over lower half of lung, with loud crepitation on inspi- ration, and bronchophony. The heart sounds are quick, healthy in character, impulse strong. Pulse 100, feeble. The urine is of a dark brown color, turbid, and much diminished in quantity; sp. gr. 1014; highly coagulable on the addition of heat and nitric acid, and exhibiting under the microscope numerous desquamative casts, mingled with blood corpuscles. Other functions normal. H Vin. Antim. 3 ij ; Sp. jEther. Pit. 3 ij ; AqucB § vss. M. A tahle-spoonful to he taken every four hours. To have 3 iij of wine daily. * Reported by Mr. W. M. Calder, Clinical Clerk. 18 B DISEASES OF THE GENITO-URINAEY SYSTEM. Progress of the Case. — 2d. — The dulness and crepitation posteriorly is now as high as the middle of scapula on right side, and there is commencing dulness, with crepitation audible low down, posteriorly over left lung. Dyspnoea increased. Other symptoms the same. To be cupped over chest, and 2 v of blood extracted. Hab. Pidv. Jalap, comp. 3 j- J^dy Zd . — Dulness now extends over two thirds of both lungs posteriorly and inferiorly, with loud bubbling rattles on inspiration, and bronchophony. Anasarca has greatly increased, the lower extremities and the scrotum being enlarged and distended. Only 8 oz. of urine passed since yesterday, and of dirty brown color, and turbid ; otherwise the same. Bowels well open. Dyspnoea now urgent. Cough frequent and troublesome. Sputum pneumonic. Pulse 120, weak. To have Pot. Bitart. 3 three times a day., and 3 iij of gin instead of the wine ; nutrients. July Ath . — Has passed 16 oz. of urine, and is somewhat better. Prostration continues great. Otherwise the same. July hth . — Comatose, and evidently sinking. He ex- pired on the morning of the Uh. Sectio Cadaveris. — Fifty hours after death. Anasarca of the whole body. Head. — The subarachnoid cavity contained a considerable quantity of fluid, ele- vating the surface above the convolutions. The lateral ventricles contained little serum. Otherwise normal. Thorax. — Each pleural cavity contained about a pint of sero-sanguinolent fluid. Both lungs condensed from collapse posteriorly, but crepitant anteriorly. On section they presented a smooth surface of purple color, and yielded on pressure a copious frothy fluid. The large bronchi were filled with muco-purulent matter, and their lining membrane was stained of a dark mahogany color, and highly congested. Heart weighed 19 oz. Hypertrophy, with dilatation of right ventricle. Valves healthy. Abdomen. — Kidneys of large size, the two weighing 18 oz. They were externally of a brownish purple color, the vessels everywhere congested, with hsemorrhagic spots, the size of pins’ heads, scattered numerously over their surface. On section, the cor- tical substance was mottled ; the dark congested patches being mingled with white, opaque, and fawn-colored substance. The malpighian bodies here and there were tinged with blood. The tubular cones were of a deep purple color, especially towards their base. The mucous membrane of the pelvis moderately congested. Liver con- gested and somewhat enlarged. Other organs normal. Microscopic Examination. — The fawn-colored portion of the cortical substance of the kidneys was soft, and the tubes crowded with desquamated epithelial cells mingled with molecular exudation. The vessels in the congested parts were tinged with blood. The haemorrhagic spots depended on the extravasation of blood into one or more convolutions of the tubes. Commentary. — This case was in many respects like the last, but its progress was even more rapid. The pulmonary oppression and oedema came on more quickly, and having been at first confined to the right side, accompanied with tenacious sputum of a rusty color, and ushered in by rigors and febrile symptoms, presented all the symptoms and physical signs of a pneumonia. Thus the febrile attack corresponded with the commencing period of the supposed pneumonia. Then the man was a waiter, and an habitual tippler, and we were called upon to decide whether the acute symptoms were connected with the lung or with the kidney. Now it is rare to see a case of acute nephritis producing gener- al anasarca, and running its course so rapidly, and in consequence we considered the renal disease to have been chronic — in short, an ordinary case of Bright’s disease, with supervening pneumonia. It turned out, however, to be an acute attack of nephritis, accompanied by rigors, fever, vomiting, etc., followed by rapid anasarca, and death by coma. The rusty sputum was also calculated to mislead ; for although the air tubes were filled with tenacious purulent mucus, there was no appearance after death of bloody extravasation into the parenchyma of the lung. It must, therefore, have been altogether bronchitic. Such a case of acute NEPHRITIS AND PYELITIS. 789 MPplirltis, so complicated, must be considered of extreme rarity. It oc curred before the value of testing the urine for chlorides was known, as a diagnostic sign of pneumonia, or I might have been assisted in attri- buting the acute symptoms to the kidneys rather than to the lungs. On dissection there was found the same desquamative nephritis as in the last case, associated with haemorrhage into the tubes and malpighian bodies, and intense congestion of the capillaries, especially on the sur- face. This, of course, added to the obstructive character of the lesion, and increased the fatality of the case. I cannot help thinking that many such cases as the two just recorded must have been mistaken by physi- cians for pneumonia, before the advantages of auscultation were known. If complicated with aortic disease, there would have been a hard vibrat- ing pulse, and large bleedings, and antiphlogistic remedies used, which would have hastened the fatal result. Modern medicine, by pointing out that such cases depend on obstruction of the uriniferous tubes by desqua- mated epithelium or extravasated blood, surely demonstrates that blood- letting can have little to do with their relief. Even as a palliative it often fails as Case CL XXII. sufficiently shows. The haemorrhage into the tubes and great vascular congestion in this case occasioned greater obstruction to the renal excretion than occurred in the former one. Hence the uraemia and head symptoms which existed for twenty-four hours before death, a symptom from which Lawson was comparatively free. Case CLXXIY.^ — Acute Nephritis — Chronic Pneumonia — (Edema of the Lung and Anasarca proving fatal — Perforating Ulcer of the Duodenum^ without symptoms. History. — James Abernetliy, aet. 41, a cooper — admitted July 21, 1855. States that he always enjoyed good health until swelling and suppuration occurred in his left hand, for which he entered the surgical hospital last April. Six weeks ago he ob- served his urine become as dark as porter, and his feet and legs to be swollen. These symptoms were preceded by rigors, but no pain in the loins or anywhere else. The oedema continued to extend, and three weeks ago dyspnoea came on, which has gradu- ally increased until now. He has had no cough nor expectoration. Symptoms ox Admission. — The urine is of a muddy brown color, deficient in quan- tity, no pain or difficulty in voiding it. It contains a considerable amount of albumen, with the normal amount of chlorides ; sp. gr. 1020. With the microscope there can be seen numerous waxy casts of various sizes, some stretching completely across the field, and branched, others convoluted. Many are filled with epithelium, several only half filled, and not a few are composed of a pale, diaphanous membrane. There are also present a few pus and blood corpuscles, and a good many granules and granule cells, with an abundance of phosphates. On percussing the chest the resonance is equal and good on both sides anteriorly. On the mouth being opened, a loud ci’acked- pot sound can be elicited over the whole anterior surface of right lung. Posteriorly there is dulness over the inferior half of this lung, with pealing resonance of the voice, and crepitation on inspiration. There is also slight crepitation, with sibilation over the lower half of the left lung posteriorly, but no dulness or increase of vocal resonance. Heart sounds are normal ; pulse 94, regular but weak. No appetite, great thirst ; abdomen somewhat distended and fluctuating. Skin generally anasarcous ; that over the back pitting deeply on pressure. The left arm, from the elbow down, is one mass of ulcer- ation, with purulent infiltration in the cellular tissue. He is very weak and exhausted. ^ Sp. yEth. Nit. 3 ij ; Sp>. yEth. Chloric. 3 iss ; Sol. Mur. Morph. 3 j ; Aquam ad * Reported by Mr. Robert Byers, Clinical Clerk. V90 DISEASES OF THE GENITO-UEINAEY SYSTEM. 3 viij ; Ft. mist. One ounce to he taken every nighty or when the breathing is urgent, Haheat. Potass. Bitart. ter in die. Progress of the Case. — July 25^A. — There has been little change until to-day, when he has become somnolent. Cannot take nutrients. Pulse continues very weak. Pry cupping, diaphor-etics, and diuretics have failed to increase the amount of mine. Continue nutrients and wine, at intervals, July 26^/i. — Loud crepitations now heard over both lungs posteriorly. Dyspnoea urgent. Surface covered with sweat, but no alleviation in the symptoms. Died on the 2'7th. Sectio Cadaveris . — Twenty hours after death. Body generally anasarcous ; left forearm the seat of erysipelatous ulceration. Thorax, — Both lungs oedematous, with coherent pleura. On separating these on the right side posteriorly, the pulmonary texture broke up, being rendered soft by chronic pneumonia, and being everywhere infiltrated with serum. At the apex of right lung, a few cretaceous masses. Abdomen. — On the under surface of the right lobe of the liver, below the peritoneal coat, were several calcareous concretions, the size of millet seeds, adherent in two places to the coats of veins, and projecting slightly into their canal (phlebolites). The gall-bladder was slightly thickened ; the cystic duct obstructed in its centre , but the hepatic duct pervious. Both kidneys were of a pale yellow color externally, slightly mottled with vascular patches. On section the cortical substance was slightly diminished 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 adlierent by soft lymph to the pancreas and a neighboring 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. Commentary. — Followiug on a prolonged ulceration in the arm, which had confined this patient to the surgical hospital, there super- vened desquamative nephritis, general anasarca, and oedema of the lungs, similar to what occui-red in the two preceding cases. There was also present universal adhesion of both pleurge, and disorganization of the posterior and inferior half of the right lung, as I conceive from a limited exudation into its texture. What, however, constitutes a remarkable feature in this case, is the presence of a chronic ulcer in the duodenum, which had not been manifested by any symptom what- ever ; which was attended by limited hemorrhage into the mucous coat of the intestine internally, and externally by exudation, or so- called effusion of lymph (peritonitis), without any local pain or uneasi- ness. The term Desquamative Nephritis was introduced by Dr. Johnson to denominate a lesion in which the tubes of the kidney are blocked up, not only by exudation, but by the separation and accumulation of their epithelial cells. Such desquamation, I believe, occurs occasion- ally in. all epithelial and epidermic structures. I have often seen it in the lung, forming what may be called a desquamative or vesicular pneumonia. If it occurs generally throughout both kidneys, as in the three last cases narrated, it is usually fatal ; but if partial, and a sufficient number of tubes are left unobstructed, so as to admit of increased action under the stimulus of diuretics a cure may be antici- pated. Under such circumstances, also, a spontaneous recovery may be hoped for which may be assisted by diaphoretics. So far from NEPHRITIS AND PYELITIS. V91 considering diuretics injurious, I believe that in such cases they hold out the only chance of successful treatment. Cupping and diaphoretics in such violent and rapid cases are wholly insufficient to overcome the tubular obstruction, however they may occasionally relieve. On the other hand, the good effects of diuretics were well observed in Cases CLX. and CLXX. Case CLXXY."^ — Nephritis followed hy the formation of a large Abscess in the Right Kidney^ opening into the lumbar cellular tissue— Ulcera- tion of Ureter and Bladder — Thichening of Mitral and Tricuspid Valves — Partial Atrophy of Lungs^ with and without Induration — Partial Oedema. History. — Margaret Martin, set. 47, servant — admitted 18th October 1852. She always enjoyed good health till about twelve months ago, when she was exposed to cold, and got her feet wet. Shortly after, she was attacked with dysuria, and observed that the urine was of a very dark red color, and much diminished in quantity. A week afterwards, she experienced sharp cutting pains in the hypogas- trium, stretching down the thighs. She was still able, however, to follow her usual occupation till the beginning of September last, when she suffered from pain in region of right kidney, in the larger joints, and from oedema of the legs, especially the right. The bowels have been very costive, and the abdomen has become much distended. Four weeks ago she passed some very dark, bloody-looking matter in the urine, which continued of a red color for five days. Her habits appear to have been rather intemperate. Symptoms on Admission. — On admission, the tongue is loaded in the centre with a dark fur ; great thirst, but appetite good ; bowels open. There is distinct fulness and dulness on percussion in the right lumbar region, extending as far forward as the umbilicus, and filling up the space between the false ribs and crest of the ilium ; and there is great tenderness on pressure over the same extent. Has some pain in micturition, shooting down the thighs, especially on right side, which is also some- what oedematous. Urine passed in very small quantity, sp. gr. 1015. It is albu- minous, and deposits on standing a copious sediment, showing under the microscope numerous pus and blood corpuscles. Pulse 90, of good strength, but occasionally intermitting. She has occasional palpitation. The cardiac d-ulness 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- siderably deformed, and the sternum highly arched ; but the chest is otherwise normal. Habeat enema c. 01. Terebinth. § i. Progress of the Case. — Nov. 20^/i. — The bowels not having been fully acted on by the enema, she was ordered last night half a drachm of Compound powder of Jalap., which caused copious stools. Inf us. Papav. § v ; Tinct. Hyoscyam. 3 ij ; Syrupi § i. M. Sumat § j ter in die. Nov. 21. — Has been complaining much of pain in loins and right leg. She was ordered an enema with half a drachm of the Sol. of Morphia on the evening of the 20th ; and last night, the pain having again returned and prevented her from sleeping ; she had the following draught : U Sol. Mur. Morph. 3 ss ; Tinct. Hyoscyam. 3j; Mucilaginis et Aq. Merdh. aa § ss. M. Nov. 22. — Feels much better to-day. There is less swelling of abdomen, little or no pain in the hypogastrium, but a feeling of soreness in right lumbar region. Bowels confined ; urine passed in small quantity, albuminous, and contains a large deposit, consisting chiefly of pus. Nov. 24. — Continues in the same state, but com- plains much of pain in bowels, which are still confined. Urine passed in small quantity. She was ordered yesterday the following : — B Bitart. Potass. 3 ii ; Gambog. gr. ij. M. Ft. pulv. hora somni sumend. et habeat mane Pulv. Doveri gr. xv. The bowels were freely opened, with considerable relief to painful distention of abdomen, but no diminution of the swelling and hardness. Apyl. Tinct. lodin. abdomini. Nov. 28. — Is complaining much of pain in abdomen and right leg, for which she had 10 grains of Dover's powder last night., with partial reliefi The cough is now troubling her more, and she seems much weaker. 1^ HJh. Chlor. 3 ij ; Sol. Mur. Morph. 3 j ; Sp. Ammon. Aromat. 3 iij ; Mist. Camph. § vss. M. Sumat § ss. ter \n die. Nov. 30. — On auscultation of chest, occasional moist rales are to be heard, * Reported by Mr. Francis M. Russell, Clinical Clerk. 192 DISEASES OF THE GENITO -URINARY SYSTEM. with prolonged expiration ; but no increase of vocal resonance. The sounds of th« heart are heard very distinct over the whole chest ; the apex beats in epigastrium , its action is irregular, and a blowing murmur accompanies the first sound. There is still tenderness in right lumbar region, with great pain in right iliac ; the swell- ing of abdomen has not diminished, and upon deep pressure, a distinct fulness and hardness can be felt in right iliac fossa, to which four leeches were ordered to he applied followed by warm, fomerdations. 8p. ^ther. Nit. ^ss ; Liquor. Potass. 3 ij ; Mucilag. § ij ; Sol. Mur. Morph. 3 hj ; Aquce ^ hj- M. Sumat § ss omni hora. Intermitt. alia medicamenta. Habeat Sp. Juniperi Co. § iii per diem. December 3. — Feels rather better, but bowels very 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 opened. She now feels much relieved of the pain in abdomen ; the tumor in right lumbar, umbilical, and iliac regions, remains unaffected. The oedema 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 circumscribed tumors 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 phosphate and amorphous urate of ammonia. The albumen has not disappeared. Lotion of Acetate of Lead and Opium to be applied to the arm., with warm fomenta- tions. Dec. 8. — Complains of great pain in arm, which is very much swollen, and generally hard, but pits slightly on pressure, and is of a white color at the upper part ; but at the wrist it is much darker, and on the back of the hand two large phlyctenge have formed during the night, and other portions of the surrounding surface vary in color, 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. Sp. Ammon. Arom. ; H^th. Chlor. aa 3 ij ; Tinct. Card. Co. 3 h : Mist. Carnph. § vii, M. Sumat 3 j singulis horis. To have 4 oz of Brandy. Dec. 9. — Died this morning about ten o’clock. Sectio Cadaveris. — Twenty-six hours after death. Anasarca, especially of right arm and leg, but nowhere extreme. A large tumor, 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. Thorax. — Pericardium contains about an ounce of serum, and on the surface of the heart are numerous opaque fibrous patches. Heart rather small. The free edges of the tricuspid and mitral valves were thickened and rounded, but with no distinct appearance of deposit on their surface. In the substance of the septal segment )f mitral valve, near its roots, there were a few calcareous masses. Weight of heart, 9| oz. Lungs. — Right pleura, normal ; lung throughout free from adhesions ; some serous engorgement, with considerable collapse posteriorly ; anterioi’ly, no marked emphysema. Left lung presents firm adhesion over upper lobe, which is much dimi- nished in volume, and has a dense, scarcely crepitating tissue. Abdomen. — On opening the abdomen, the tumor 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 tumor so as to obliterate the mesocolic folds in front, and keep the ascending colon closely in contact with it. It proved to be an abscess, containing about a quart of fluid, which was sero-purulent (with large proportion of pus), of a yellow color, with a faint greenish tinge, and a good deal of foetor. 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 rig! it side of the vertebrae, the periosteum of which was entire. The superior wall was very closely adherent to the liver, which, NEPHRITIS AND PYELITIS. 793 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 neighboring viscera were displaced by the tumor, but were healthy. Left kidney normal. Right kidney much dis- organized ; its size not altered ; on section, numerous abscesses containing pus like that within the tumor, occupying both the cortical and tubular part ; tlie walls of the abscess composed of flocculent and curdy greyish-yellow matter, presenting, under the microscope, the debris of cell forms, with 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 the abscesses. Several angular calculi, the size of mustard seeds, were impacted in one of the infundibula, the mucous membrane of which was smooth 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 the renal abscesses. The bladder had also fully one half of the mucous membrane re- moved in irregular patches by ulceration ; the remaining parts were much congested, but smooth. No 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 normal. The uterus contained a polypus, the size of a beau, composed principally of the mucous membrane, and attached to the posterior wall. Os uteri slightly tinged of a purplish color. Ovaries^ vagina^ and external parts normal. Other organs normal. Commentary . — The occurrence of abscess in the kidney is often a very insidious disease, existing frequently for many months, and giving rise to obscure pain in the back, occasional rigor, feverishness, and high- colored 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 suppura- tion of the cellular tissue behind the peritoneum, occurs, causing fever of a low type, and oedema more or less general. Such an occurrence usually proves fatal. In the present case, death was delayed apparently from the abscess having been, to a certain extent, circumscribed, and forming a large cyst, so as to present the form of a tumor, the nature of which, during life, was very difficult to determine, although the renal disease was clearly apparent. Case CLXXVI .^ — Scrofulous Nephritis and Abscesses in the Kidneys — Kx- tensive deposition of Tubercle in the Lungs and Intestines. History. — George Paton, get. 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 hoema- turia gave him no uneasiness until three weeks afterwards, when he began to suffer 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 suffer more or less in this way for two years, the pain and hmmaturia 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 admission on board the Dreadnought hospital ship at this time, and had his bladder repeatedly ex- amined 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 hiematuria. 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, aud on standing, emitted a putrid * Reported by Mr. Almeric W. Seymour, Clinical Clerk. 794 DISEASES OF THE GENITO-UUmARY SYSTEM. odor. He recovered partially from this attack, and went shortly afterwards on a voyage up the Danube, where his disease became aggravated from the exposui’e he was subjected to. Since that time his general health has been declining more rapidly than formerly. Symptoms 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 staaling, 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 ill the hypogastrium and right lumbar region, of a dragging character ; he has also pain in the point of the penis during and after micturition ; tongue moist and florid ; he complains of sore throat, and on examination the tonsils are seen to be enlarged and covered with pus. He has tenderness of the epigastrium, 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 lung, anteriorly and posteriorly ; on auscultation there is slight sibilation under the right clavicle, with slight increase 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 healthy. Ijt Inf us. Lini Ibj. To he taken ad libitum. Throat to he sponged with a solution of nitrate of silver'. Good diet. ProgPvESS op the Case. — July ‘lUh. — 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 color, contains less albumen, sp. gr. lOOY. Tinct. lodinei 3 i. To be painted over the lumbar region. B Ttecoct. JJvce JJrsi Ibj. One ounce to be taken four times a-day. August d)th. — During last week he has been suffering from nausea, vomiting, and looseness of bowels. Aug. Vlth. — These few days past he has had rigors, followed by heat of skin and sweating. The attacks last only for a couple of hours, and come on regularly at two o’clock. He has been ordered the following pills; — R jSnlph. Quince 3 ss ; Couf. Rosar. quant, suff. ft. massa in pilul. xx. dividenda. Two to be taken every sixth hour during the inter missiojis. Diarrhoea has continued, and for it he has been using the following mixture : — B Tinct. Catechu 3 vi ; Rol. Mur. Morph. 3 ij ; Conf.Aromat. 3i; Mist. Cretce § v. M. One table-spoonful to be taken three times a-day. Aug. 14/A. — Diarrhoea relieved ; urine less turbid ; sp. gr. 1009 ; not coagulable by heat and nitric acid. Aug. 21s^. — 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. This morning he died at four o’clock. Sectio Cadaveris. — Fiftij-eight hours after death. Body much emaciated ; rigor mortis considerable. Thorax. — Pericardium normal ; contained about three drachms of clear straw- colored serum. Heart small and soft ; valves healthy ; muscular substance pale ; under the microscope, the muscular fibres appear deficient in striae, and loaded with small fatty granules. Left pleura normal. Right pleura presents dense adhesions over the wliole of the lung, more marked, however, at the apex and base. I'he right lung itself was small, collapsed, and excessively emphysematous along its an- terior free margin. The apex presented numerous hard cicatrices, and on being cut into, showed numerous tubercular masses in all stages, some of them commencing to break down and disintegrate, others undergoing the process of hardening and repair. In one spot, about an inch below the apex, a small vomica, about the size of a hazel nut, existed. Left lung voluminous ; highly emphysematous ; cicatrized around the apex, the 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. Abdomen. — Liver normal in size, undergoing the fatty degeneration ; pale- colored and friable ; under the microscope, the hepatic cells appeared loaded with fat. Spleen normal. Small intestines healthy, slightly congested towards the lower part. Large intestines. The mucous membrane, throughout the whole extent, but particularly in the descending colon, sigmoid flexure, and rectum, appeared thickened, congested, and in many places ulcerated; the ulcers were small, their edges very slightly elevated, and their surface undergoing the process of separation. NEPHRITIS AND PYEIJTIS. '795 Right kidney was much enlarged ; quite smooth ; the capsule densely adherent. On dividing the ureter, pus escaped in considerable quantity from the pelvis of the kidney ; and on cutting into tlie 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 beyond the orifice of the ureter along the trigone of the bladder ; the ureter was quite per- vious, and contained a quantity of pus. Left kidney was small and lobulated ; the substance of the gland was found to have disappeared, leaving a large cavity, which was enclosed by a covering of the proper substance of the kidney, not exceeding four lines in thickness, and filled with cheesy matter of the consistence of putty ; the ureter was closed, except for two inches above the bladder ; externally, it was of normal size; muscular wall of bladder somewhat thickened, especially around the orifice of the right ureter ; mucous coat congested and much softened ; the bladder contained about 6 oz. of thick, turbid, semi-purulent matter. Commentary. — In this oase, the renal abscesses formed in a young man of scrofulous constitution, and exhibited a more lingering tendency than in the former one. Indeed, notwithstanding the great disorganiza- tion found in the kidneys after death, the fatal result was chiefly brought about by the intestinal disease, and the exhaustion caused by colliquative diarrhoea. The left kidney evidently presented the incipient changes which commonly precede the spontaneous cure of scrofulous abscesses in this, as in other internal organs. The purulent matter presented the consistence of putty, the animal portion having for the most part been broken down and absorbed, while the mineral portion was comparatively increased. In this manner, not uofrequently encysted cretaceous masses form in the kidney and remain latent, the rest of the renal substance performing its normal function. Sometimes an entire kidney may, in this manner, be completely destroyed, and the whole converted into a calcareous mass, of which I possess a remarkable example, from an indi- vidual who had quite recovered from the disease, and whose remaining kidney, though enlarged, was in its texture healthy. Indeed, the sponta- neous cure of tubercular depositions in the kidney, presents the same pathological history as that we have described of similar lesions occurring in the lungs, p. 738, and the puckerings, cicatrices, cretaceous and calca- reous concretions resulting: from them, have a similar simiificance. It follows that our general principles of treatment should also be the same, namely, supporting the constitution by analeptics and especially by cod- liver oil, so as to enable nature to bring about a cure. This ought always to be the primary object of treatment; whilst remedies directed to the renal symptoms should, although by no means neglected, be subordinate to that great end. In the present case this indication could not be ful- filled on account of the great irritability of the alimentary canal, especially of the stomach. For another example of this disease, see Case CLX. Case CLXXVII.'^ — Calculous Nephritis and Gangrenous Abscess of Right Kidney — Waxy Liver — Recto-Vesical Fistula. History. — James Allan, aet. 25, a tin and copper smith — admitted August 18, 1848. At three years of age was cut for stone by Mr. Liston. Thereafter he enjoyed good health until three years ago, when, after straining himself at a trial of strength, he was suddenly seized with a sharp pain in the right flank, just below the ribs. At the same time the urine became turbid, and was of a high color. The pain left him at the end of three months, but the turbidity of the urine continued. After six months’ interval he had a similar attack — this time, he says, induced by drinking a * Keported by Mr. Frederick Hunter, Clinical Clerk. 796 DISEASES OF THE GENITO-URINARY SYSTEM. glass of spirits — whicli also lasted three months. After another interval of about sis months, the pain and urinary symptoms again returned, and have continued more or less sevei'e ever since. He was in the surgical hospital for three months, where he was frequently examined for stone, but none was found. At this time he was observed on several occasions to pass air by the urethra, the urine being of a gangrenous odor. He left the surgical hospital last May, and has been somewhat better since, the urine for some time having been clear and healthy. But having bathed in the sea a fort- night ago, he was seized with rigors, followed by fever, together with the former local symptoms, which have continued ever since. Symptoms on Admission, — The countenance is pale and sallow, expression de- jected ; body not emaciated, but with a general look of chronic disease. He com- plains of great pain and tenderness in the right lumbar region, which on examination presents a fulness, without great deformity, but well marked when compared with the opposite side. The hepatic dulness on percussion measures five inches vertically, the lower margin anteriorly being on a line with the umbilicus, and stretching across the abdomen into left hvpochondrium. He has never suffered from pains shooting down to the bladder, nor in the bladder itself. But there is occasional pain after micturition, and always frequent desire to pass urine — indeed every hour — although little is voided. The urine is turbid, of dirty yellow color; 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. IJ Tart. Antim. gr. ij ; Aqtice § viij ; Solve. Svmat § ss tertid qunque Jiord. Applicent. hirudines viii. laferi dolenti., ei postea foveatur. Progress of the Case. — September 26 ?/i. — The local pain has been relieved by the treatment, but it returns with severity at intervals. For some time the urine has been clear. He has had a .slight diarrhoea, which has been checked by a chalk and aromatic mixture ; and has occasionally taken at night Pulv. Doveri gr. viij. October Sd. — 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 odor. The appetite is gone; there is thirst and frequent vomiting. Pulse 120, soft. A saline antimordal mixture. Oct. ^th. — Anxious countenance ; pain continues, preventing sleep. Can take no nourishment. Much exhausted. Vomiting diminished. Pulv. Doveri ^Y. X. hora somni. Nutrients. Wine four ounces daily. Warm fomentations to the side Oct. \0th. — Local pain somewhat diminished. Complains of diarrhoea. Ijl Acid. Qallic. 3 ss ; Opif gr. xij ; Conf. Rosar. q. s. ; ft. pil. xij. Sumat unam sextd qudque hord. Oct. Ibth. — Since last report has gradually sunk, and died this morning. Sectio Cadaveris. — Forty-eight hours after death. Thorax. — Pericardium contained about a drachm of turbid serum, with a few floating flakes of lymph. Lungs and heart healthy. Abdomen. — The liver was considerably enlarged, and had undergone the waxy degeneration ; its substance being pale and dense, with a smooth surface on section. On attempting to remove it, the right lobe tvas found to be adherent to the colon ; and on separating this adhesion with the fingers, a quantity of pus escaped. This originated from a large abscess in the right kidney., containing about half a pint of pus, mixed with curdy matter. The superior wail was composed of the substance of the liver, a portion of the lower and posterior border of which organ was absorbed. The posterior wall rested on the quadratus lumborum muscle, and anteriorly it was in contact with the transverse colon and the pyloric end of the stomach. When opened from behind, the walls of the abscess were found to be covered with shreds of gangrenous tissue, of a dark greenish color, of gangrenous odor. Renal substance could only be detected at the lower part ; the rest of the kidney was converted 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 siz-e of a hazel nut. These calculi were embedded in pus, and partly projected into what might have been the pelvis of the kidney, but which was converted into a fibrous sac communi- cating with the ureter. The bladder presented at its neck the cicatrix ot an incision made in the usual situation for lithotomy. About two inches above this were three mucous excrescences the size of ))eas. in the centre of these was a depressed spot, through which a director readily passed backwards and upwards through the cellular- tissue into the rectum. The mucous surface of the rectum at this point was highly vascular, and covered with lymph in patches to the extent of four inches in depth NEPHRITIS AND PYELITIS. 797 round the gut. Left kidney weighed 13^ oz., and appeared healthy in structure. Other organs normal. Microscopic Examination. — The structure of the left kidney was quite natural. The liver presented the usual atrophied and translucent appearance in the cells, characteristic of the waxy degeneration, a few only containing a small number of fat granules. Commentary . — The local and general symptoms in this case were so clear, as to leave me in no doubt from the first that this man had a calculus emb:dded 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, blcody, 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 unmistakable group of phenomena diagnostic of calculous nephritis. Indeed, so certain was the fact, that more than once nephro- tomy was spoken of as a possible means of relieving him, every other organ with the exception of the liver being at one time apparently healthy. It was with great interest, therefore, that the dissection after death was watched, which fully confirmed the diagnosis. It also pointed out that the other kidney was enlarged and healthy, performing double duty without difficulty; that the liver was enlarged and waxy, and that a recto-vesical fistula existed, causing disease of the intestinal mucous membrane, to which the diarrhoea latterly might be attributed. In reference to an operation, it appeared to me at the time that it might easily have been effected after the method of Marchetti/^ as the two calculi were loose within cysts, and surrounded by pus. The enlarge- ment of the liver prevented the performance of such an operation being seriously entertained in this case. But here, as in ovariotomy, the great difficulty is to establish in the living subject an exact diagnosis, and this I had no difficulty in doing six weeks before his death, and when his general health was tolerably good. For such a disease nothing but palliatives are to be thought of. As the size of the stone cannot be known, diluents are indicated with the possibility of favoring its descent along the ureters to the bladder, a pract ce 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. Case CLXXVIII.f — Chronic Pyelitis^ and Cystic Kidneys — Dilatation of Ureters — Fungoid Ulceration of Urinary Bladder. History. — Jane Watson, set. 74, widow — admitted November 15th, 1852. As far as can be ascertained from the patient, whose mental faculties are very much impaired, she has been laboring 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 de- creased considerably in quantity, with frequent micturition, accompanied by pain. These symptoms lasted for about a month, after which the amount of water passed be- came 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, * An account of a gentleman being cut for the stone in the kidney, with a brief inquiry into the antiquity and practice of nephrotomy, by C. Bernard. — Phil. Trant.^ October 1696. \ Reported by Mr. Robert Francis M. Russell, Clinical Clerk. 798 DISEASES OF THE GENITO-URINART SYSTEM. and then becoming natural. Since the date of her first attack, she has complained of pain in the region of the right kidney, much increased at those periods when blood was observed in the urine. Symptoms on Admission. — On admission, she has a peculiar cachectic appearance, and is much emaciated. Tongue moist, cracked in the centre, great thirst, appetite impaired, bowels costive. She has considerable pain and tenderness on pressure in the right lumbar region, where there is also some fulness. The urine is passed in consid- erable quantity, specific gravity 1010, alkaline, highly coagulable on the addition of heat and nitric acid. It is quite turbid when passed, and deposits on standing a copi- ous yellowish gelatinous-like sediment, which, under the microscope, is seen to contain numerous pus corpuscles, granule cells, and casts of the tubes, crowded with gran- ules. When the bladder is about half empty, there is frequently a sudden stoppage of the flow of urine, Avhen she suffers from severe pain in the hypogastri'um, 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. Tinct. Hyoscyami 3 vi ; Tinct. Opii 3 ij ; Mucilaginis et Aquce aa. 3 vi. Sumat ter indies. Progress of the Case. — November \%th. — Continues much in the same state. Urine presents the same characters as before. Omittatur mistura Hyoscyami, Potassce Acetatis § ss ; 8p. jEtheris Nitrici 3 i'j \ Mucilaginis et Aquce aa 3 iij. M. Sumat 3 j quartd qudque hord. 1^ Sol. Mur. Morphioe 3j ; Mist. Camphorce 3 j. M. Sumat dimidium hora somni et alterurn post koras tres si opus sit. JVcmn fomentations to be applied to the loins. Nov. 21 — The w^arm fomentations were applied as ordered, and afforded considerable relief; she sleeps well at night after tak- ing 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 passed. Nov. IHh . — The quantity of urine is now greatly diminished ; presents the same characters as on the 2ls^. There are 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 shooting pains in the vulva, and the inner side of the thighs, extending down to the knees. She appears much exhausted ; pulse weak, 96. To have four ounces of wine. Nov. 28<^. — Is much in the same state ; the urine is still highly coagulable ; the sediment exam- ined by the microscope presents a large number, Is^, of finely molecular exudation casts ; 2i//?/, groups of broken down pus cells ; 3i/y, crystals of triple phosphate ; Ulily., granular cells ; 5c4Zy, blood corpuscles. December ^th . — Is now passing her fasces and urine involuntarily ; appetite leather improved ; pulse, 85, weak. The warm fomenta- tions have been continued since the 18th ult. To have six ounces of wine. Dec. %th. — Still passes everything in bed ; complains of great pain and tenderness in right lum- bar region; still takes food well; pulse 90, of better strength. Dec. \bth — Appetite very much impaired within the last two or three days ; still complains of pain over right kidney, and passes dejections involuntarily. Only an ounce of urine could be obtained for examination. It is still coagulable ; the sediment presenting, under the microscope, the same characters as on the 28th ult., with an increase in the number of blood corpu-scles ; pulse 100, very weak. Dec. 23 j. — 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 hard- ened deposits at apex of the left, which look like old tubercle. Bronchi contain much frothy mucus. The aorta through the. whole of its course (and both iliac arteries) con- tained a large amount of calcareous deposit, principally seated in the arch of the aorta, and the thoracic portion of that vessel. Abdomen. — Stomach and intestinal canal normal ; pancreas pale : spleen very small ; liver small, congested, firm, and dense. Lumbar glands considerably enlarged, NEPHEITIS AND PYELITIS. '^99 and contain a very great amount of yellowish opaque juice, evidently purulent, but no distinct abscesses. Both kidneiis 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 al- ways distinct ; cortical substance pale ; malpighian bodies and striae destitute of blood ; surface smooth, but more adherent to capsule than usual. On careful examination with the naked eye, a considerable number of cysts from the smallest visible size up to ^ inch diameter are observed in the cortical substance, especially near the surface. The bladder of normal size ; all its walls much thickened ; the mucous membrane presents a soft fungoid-looking ulcerated mass, in which no peculiar or character- istic structure could be observed. All parts of the mucous membrane were equally diseased. Microscopic Examination. — The cysts in the kidney can be traced down to very minute sizes (the smallest observed was about the 600 th of an inch in diameter), having the usual appearance of such cyst formations. The malpighian bodies shrunk, bloodless and opaque, without apparent morbid deposit, but with thickening of their membrane and nuclei. In some of the tubes similar thickening and epithelial engorge- ment, producing an appearance of opacity in the tubuli without any recognisable gran- ular deposit. When the tubes are washed out and examined separately, they appear (most of them) smooth. Epithelium small and compressed, but, generally, regularly disposed and normally developed. In a few places, traces of granular and molecular exudation, but to an insignificant extent. Commentary . — The complication of renal and vesical disease here met with, is by no means an uncommon one in aged persons. Its existence leads to obstruction of the ureter, at its entrance into the bladder, disten- tion of the ureter above, accumulation of urine in the pelvis of the kidney, and, as a consequence, inflammation and distention of its mucous lining walls, pressure on the secreting portion, and atrophy of its substance. Such a lesion, if it exist in both kidneys, must necessarily at last so inter- fere with their functions, as to be incompatible with life. The chronic disease of the bladder, on which the renal disease for the most part de- pends, only admits of palliative measures for its relief. Cystic disease of the Iddney 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 distention, and so causing cysts. 3d, In the enlarge- ment of the secreting cells of the organ, which here, as in the ovary, be- come distended with fluid, and by pressing upon, compress one another. 1. The obstructions found in the tubuli uriniferi are of various kinds, and may consist of coagulated exudation, of pus, of blood, of altered epi- thelium cells, or of different salts, such as urates, carbonates, phosphates, etc. etc. The bloody points so frequently observed on the surface of diseased kidneys, most frequently arise from extravasation of blood into the convoluted extremities of the tubes. Small calculi may be formed from mineral deposits, but more commonly the tubular cones present a diffused white appearance from their occurrence. That such a condition is a frequent source of cysts, may be easily proved by examination. The cysts so formed may be of different sizes, varying from that of a millet seed to that of an orange, and the destruction of the secreting portion of the kidney will, of course, be proportionate to their volume and number. The contents of such cysts are also of various kinds, such as serum, blood, 800 DISEASES OF THE GENITO-UEINAET SYSTEM. pus, fibrous exudation, colloid and fatty matter, fluid holding various crystals in suspension, whether fatty (cholesterine or margarine), or saline (phosphates, urates, etc.). I have frequently seen all the forms in the following figure (Fig. 474), and occasionally the radiated bodies repre- sented Fig. 321. 2. That numerous cysts may form from distention of the minute sacs surrounding the malpighian body, I have satisfied myself of by careful examination, and possess preparations demonstrating the fact. In this case, the cysts are generally numerous and scattered through the cortical substance. It would appear to arise from some obstruction at the com- mencement of the excreting duct, although I have never been able to detect any. Fluid collects outside the membrane in immediate con- tact with the tuft of vessels constituting the malpighian body, and inside another membrane continuous with the basement membrane of the latter. Indeed, it is in cases of this kind that we may satisfy ourselves that the membrane investing the tuft of vessels is really double, forming a shut serous sac, in the cavity of which the fluid accumulates. This fluid is invariably clear, various in quantity, but each cyst seldom exceeds a small pea in size. As it forms, it gradually presses on the vascular tuft, and causes its atrophy, and so impedes the secretory power of the organ. 3. The third form of cystic formation in the kidney evidently ori- ginates in the secreting cells themselves, as they may be seen, on a microscopic examination, to exist in clusters, varying in size from the 600th to the 16th of an inch in diameter. In such a case, the paren- chyma of the organ seems to be inflltrated with them, and strongly reminds the observer of a section of the ovary, loaded with Graafian vesicles. Many still retain their nucleus, whilst in others it has disap- peared. Mr. Simon of London, who first described this form of cystic Fig. 474. Structures occasionally seen in cysts of the kidney ; a and h, Structure- less transparent colloid masses ; c to Colloid bodies, composed of one or more nuclei, imbedded in albuminous matter ; h to Colloid masses, surrounded by con- centric laminae ; k, A colloid mass, with fatty granules arranged in an areolar manner. — {Wedl.) 350 dia^. bright’s disease. 801 formation, says, as explanatory of its formation, ‘‘ that certain diseases of the kidney (whereof subacute inflammation is by far the most fre- quent)- tend to produce a blocking of the tubes ; that this obstruction, directly or indirectly, produces rupture of the limitary membrane ; and that then, what should have been the intra-tubular cell-growth, continues, with certain modifications, as a parenchytic development.” One or all of these forms of cystic growth in the kidney may be as- sociated with the next lesion to be treated of, viz., Bright’s disease. PERSISTENT ALBUMINURIA, OR BRIGHT’S DISEASE. That albumen in urine was a symptom of certain dropsies, was first noticed by Dr. Wells of St. Thomas’s Hospital, f and Dr. Blackball of Exeter ; that it indicated especially renal dropsies, was the discovery of Dr. Bright, who has given us a careful account of the phenomena which characterise the disease that has since borne his name, as well as of the changes observed in the kidney after death. The subsequent observa- tions of Christison, Martin, Solon, Rayer, and others, as well as the more recent investigations of Gluge, Johnson, Simon, Frierichs, and others, have rendered it certain that the lesions of the kidney accom- panying albuminuria are various. Some are dependent on what may be considered an acute or chronic form of inflammation (see Nephritis), whilst others must be referred to what we now call the fatty and waxy degenerations. In selecting the following cases as illustrative of the disease, I have kept in view its natural progress, and endeavored to show how, by judicious treatment, it sometimes terminates in recovery ; how at other times it frequently becomes obstinate, 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 CLXXIX.;]; — Albuminuria — General Anasarca — (Edema of Lung — Recovery. History. — Elizabeth Brady, set. 30, cook, married — admitted March 19th, 1854. She states that her health was good until four weeks ago, when, after exposure to cold and wet, she was seized with pains in the chest, and cough, but without shivering. Three days afterwards her feet began to swell, and gradually the swelling extended upwards, involving her whole body. Symptoms on Admission. — On admission, chest well formed ; breathing slightly labored. On percussion, unusual resonance is perceived over the upper portion of both sides anteriorly. There is a 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 * Medico Chirurgical Transactions, vol. xxx. p. 152. \ Trans, of a Society for promoting Medical and Surgical Knowledge, vol. iii. pp. Ulj 16 L \ Reported by Mr. W. W. Clark, Clinical Clerk. 51 802 DISEASES OF THE GENITO-IJKINARY SYSTEM, anasarca ; li er lower extremities, however, being especially affected, and pitting easily on pressure. Progress op the Case. — March 21s ^. — Ordered to he hied at the arm to the exterd of timlve ounces. Pulv. Doveri Bi. Tales vi. One to he taken at hed-thne. March ^‘Id . — Fifteen ounces of blood were withdrawn from the arm, and the pulse shortly fell to 70. She expressed herself as greatly relieved. After taking the Dover’s powder she had a short sleep, but no diaphoresis was produced. The blood withdrawn presents no buffy coat ; her urine is voided in larger quantity, but still deposits a considerable sediment; pulse 90, soft and weak. Potass. Acet. 3i; Sp. MJth. Nit. 3 vi ; Syrup. Aurantii § i ; Aquce § iv. M. One ounce to he taken three times a day. Pulv. Oamhogice gr. v ; Potass. Bitart. 3 ij. j\f. To he taken at hed-time. March 23c?. — Her bowels have been well opened, and her general appearance is greatly improved, her faee being much less swollen ; urine less turbid, and in larger quantity. Intermittatur mist. Pil. Scillce et Digital, xii. One to he taken every sixth hour. March ‘iAth . — Her cough has abated greatly, and she feels herself much better. Repetat. Pidv. Gamh. et Potass. Bitart, vespere. Match 2%ih . — Urine deposits very little sediment on standing ; and, under the microscope, no tube casts can be detected; sp. gr. 1018. A slight coagulum is produced on applying heat and nitric acid. Her appetite is greatly improved. March ^l^th . — On examining her chest to-day, the dulness on percussion, which previously existed on the left side, cannot now be detected, and on auscultation over that portion the respiratory murmur is heard normal. Under the right clavicle the inspiration appears unusually harsh. Her urine presents the same character as at last report. Rcpetan- tur Pil. ScilUe et Digital, et Pulv. Potass. Bitart. 3 ss ter indies. April 3c?. She is now nearly convalescent, and has taken no medicine for two days. To have steak diet. May 8?A. — 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-casts on microscopic examination. Menstruation rather frequent, and, in the intervals of the catamenial periods, she is subject to a leucorrhoeal discharge. U Naphthce Medicinal. 3 i ; Tinct. Cardam. Co. § i ; Aqtice 3 V. M. A tahle-spoonful to he taken when the vomiting is trouhlesome. IJ Mo,g- nesice Carh. 3 ss ; Aq. Cinnam. § i ; Inf us. Sennce Co. 3 ij ; M. Ft. haust. hora somni sumendus. Intermittaniur alia. July 20?A. — Since last report her urine has remained entirely free of albumen. The oedema has now for the most part entirely disappeared, but still returns slightly after she has been for some time in the erect po- sition. General health good. Dismissed. Commentary . — On succeeding Dr. Cliristison in the charge of the clinical wards on the 1st of May 1854, I was informed that this was a case of Bright’s disease. On the 8th of the month, however, as stated in the report, on examining her urine, I found it to contain no albumen on the addition of heat or nitric acid, while the sediment, carefully collected, exhibited no tube-casts under the microscope. On looking into the history of the case, as recorded in the ward-book, and which is given above, it became clear that the woman had undoubtedly been laboring under albuminuria and chronic renal disease, which, well pronounced March 21st, had entirely disappeared at the beginning of May. But the oedema of the feet continued, with stomachic derange- ments ; the former symptom exhibiting a tendency to return, on assuming the erect position for any time ; and in consequence, she was not dismissed until the 20th of July. Before saying anything with regard to the treatment, it will be well to attend to the facts exhibited by some other cases. Case CLXXX.^ — Alhminuria — (Edema of loth feet and legs., left arm and hand — Recovery. History. — Robert Lindsay, set. 62 , carder of wool — admitted 21st Mai’ch 1854. Reported by Mi'. Robert Bird, Clinical Clerk. BRIGHT S DISEASE. 803 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 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 keej) within doors for several days at a time. He then became tolerable healthy, and con- tinued so until three weeks ago, when he noticed his left wrist somewhat swollen, and in the course of two days his lower extremities became likewise cedematous. He suf- fered from a dull heavy pain in the lumbar region, which has been present more or less ever since he underwent the operation ten years ago. His urine, at the time the swelling commenced, was scanty and high colored, and he was troubled with a slight cough. He says that about the time when his illness began, he was engaged in clean- ing machinery, and may have caught cold. He is not aware of any other cause which might have brought on his ailment. He acknowledges that formerly 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, pitting on pressure. There is also slight swelling of the left arm and hand. He comjilains of a dull pain in the lumbar region on both sides, but that on tlie 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; co- agulable by heat and nitric acid. He complains of frontal headache. Sleeps badly, being much disturbed by dreams and sudden startings. Tongue moist and clean ; complains of great thirst ; appetite imjiaired ; bowels regular; has a slight cough, with very little expectoration ; chest everywhere resonant on percussion. At the apices of both lungs anteriorly, and at the apex of the left posteriorly, sibilant rales are heard. He has suffered from palpitation for the last three weeks, but the cardiac sounds are normal. I^ Tinct. Ferri Mur. § i. Ten drops to be taken three times a-day. Pulv. Doveri gr. x. Mittant. tales vi. One to be taken morning and night. Progress of the Case. — March T^d. — This morning he had violent vomiting, but it has now abated, and he complains of great thirst. March 2^th. — Ordered pills of digitaline, each containing l-Hth of a grain. One to be taken three times a-day. March ^kth. — After taking the pills of digitaline twice, excessive purging came on ; their further use was therefore abandoned. The urine was very slightly increased in quantity. April Mh. — The use of digitaline was resumed four days ago, and now the coagulability of the urine has entirely disappeared. The oedema of his lower extremi- ties has abated greatly. The purging, caused by the digitaline, was counteracted by opium pills.. May 2>d. — Since last report the urine has been several times examined, and has been always found to be free of albumen. To-day only the slightest haze is caused by heat and nitric acid ; the urine is pale colored ; sp. gr. 1014, transparent, and without sediment on standing ; 84 oz. are passed in the twenty-four hours. The oedema has not entirely disappeared from the feet and ankles. He continues to take the digitaline pills. His general health is much improved. May 11th . — Two days ago he was ordered the following : — Tinct. Ferri Mur. % i. Fifteen drops to be taken thrice a-day. To-day he has passed 54 oz. of urine. The oedema of his feet and ankles is abating. A few minute flakes are produced on treating the urine by heat and nitric acid. May IMh . — 78 oz. of urine were voided during the last 24 hours. 1^ MEth. Nit. § iss ; Aq. Potass. ; Tinct. Digital, aa 3 ij. M. A tea- spoonful to be taken thrice a-day. Continue Tinct. Mur. Ferri. May l^th. — Amount of urine passed during the twenty-four hours is 100 oz. June %ld . — (Edema of legs almost entirely gone ; 68 oz. of urine passed during the last twenty-four hours ; sp. gr. 1014; quite unaffected by heat and nitric acid. June ‘■lUh . — His feet and ankles are slightly cedematous at night ; 60 oz. of urine passed during the last twenty-four hours; sp.gr. 1017. No coagulum produced by heat and nitric acid. Jidy ll^/<. — Dismissed quite well. Commentary. — In this case, also, we can have no doubt of the exist- ence of Bright’s disease, although on my succeeding Dr. Christison in the clinical wards I found no albumen in the urine, and that the patient was rapidly recovering. Digitaline had been tried, with the efect of producing excessive purging, and slight increase of the urine. The 804 DISEASES OF THE GENITO-UEINARY SYSTEM. albumen shortly afterwards disappeared from the fluid, but here, as in the last case, the oedema continued, and he subsequently became quite well. These two cases, therefore, indicate that purgatives and diuretics are sometimes very efficient in entirely removing the disease. Case CLXXXI.* — Albuminuria — (Edema — Ascites and General Ana- sarca — Coma and Convulsions — Recovery. History. — Alexander Strachan, aet. 36, a joiner — admitted October 26, 1858. He enjoyed good health up to the 2d October last, when, after exposure to cold and wet, he was seized with a rigor, followed by severe cough and slight expectoration. On the 6th he first remarked swelling of the lower extremities, and in the evening, on trying to make water, he, with some difficulty, passed about half a pint of brown, smoky- colored urine. On the following morning this presented a sediment of a light color and viscous consistence. He at this time suffered from constipation, and was ordered a dose of castor-oil by his medical attendant. On the 7th he had a copious ev'icuation from the bowels, but his legs continued to swell. On the 8th his water which was small in quantity, still presented a white, viscous sediment. The legs became more swollen, the abdomen now began to increase in size, and great difficulty of breathing came on. He continued in this state up till the day of his admission. Symptoms on Admission, — There is great oedema of both legs, ascites, and general anasarca. He has a good deal of cough and frothy expectoration ; but, with the ex- ception of occasional fine moist rale and sibilation posteriorly, the lungs are healthy. Cardiac dulness and sounds normal. Pulse 70, of moderate strength. He complains of a dull pain over the region of the kidneys. Urine of a dark, smoky color, highly albuminous, and depositing a whitish, tenacious sediment. Tube-casts and blood cor- puscles are very abundant, as determined by the microscope. Other symptoms nor- mal. To he dry cupped over the kidneys, and to take 3 j doses of Pulv. Jalapoi Comp, three times a day. Progress of the Case. — October 2^th. — The cough and expectoration have greatly diminished since he came into the house, but little impression has been made upon the dropsy. November 2d. — Ordered Pit. Digitalis et Scillce xij ; one three times a-day, in addition to the powders. November ^th. — Has passed quantities of urine varying from 20 to 44 oz. daily, although generally it has been deficient in quantity. The dropsical symptoms have undergone no change. This morning at four o’clock he was seized with convulsions and loss of consciousness. Had three more fits at intervals during the day. Urine of a smoky tint, containing tube-casts and blood corpuscles. Ordered to be cupped to 5 ounces over the region of the kidneys. To have 1] of the Bitartrate of Potass three times a-day. November %th. — Had three fits to-day, and been drowsy. November ^th. — The drowsiness is nearly gone to-day, and he is quite sensible, though complaining of an intense headache. Pulse 108, of fair strength. Urine 40 oz., sp. gr. 1016, albuminous and containing blood corpuscles. Dropsy of the legs has nearly disappeared, and the abdomen feels softer. It measures 36 inches round the most prominent part. November \0th. — ffidema of legs entirely gone; not the slight- est pitting on pressure. Complains of seeing objects distorted, and sometimes of a haze which appears before his vision. He continues to take the Squill and Digitalis pill, one four times a-day, and 3 j doses of bitartrate of potash. November Wih. — Six dry cupping-glasses were applied over the lumbar region this evening. The pupil of the eye was observed to be considerably dilated. November \2th. — Passed 68 oz. of urine free from albumen. November \Zth. — Passed 42 oz.; and November \Ath, 46 oz. of urine. To-day the left pupil was observed to be contracted, the right dilated. Sees whatever object he has been looking at magnified on the opposite wall. Novem- ber \Wi . — Since last report, has passed on the different days, 48, 60, 136, 132, and 98 oz. of urine. To-day it shows a mere trace of albumen. Abdomen much less tense, measures 34 inches. From the 19th to the 27th has been passing about 90bz. of urine daily. It has still a dim, smoky tint, reaction acid, sp. gr. 1018. Nitric acid imparts to it a red tint, and after boiling flakes of albumen appear. From this time he gradu- ally recovered. He was for some days troubled with muscae volitantes, but was dis- missed on the 1st of December at his own request, the dropsy having completely dis- appeared, and only the faintest trace of albumen existing in the urine. ^ Reported by Mr. George Shearer, Clinical Clerk. bright’s disease. 805 Commentary . — In this case the amount of general anasarca was very great, and purgatives and the squill and digitalis pill produced no effect, so that poisoning of the blood with urea caused coma and severe con- vulsions. These were of an epileptiform character, with foaming at the mouth, each paroxysm being of about ten minutes’ duration. From this state the patient was roused by the energetic action of the bitartrate of potash, which, by increasing the tlow of urine from the kidneys, rapidly diminished the head symptoms, and completely removed the dropsy. The following case, which is the most remarkable recovery I ever saw, still further points out the value of this drug in Bright’s dis- ease of the kidneys. Case CLXXXII.'^ — Third Attach of General Anasarca with Albuminuria — Enormous Dropsical Distention of the Abdomen^ Scrotum, and Dferior Extremities — Complete Recovery under the Action of Super- tartrate of Potash. History. — William Herdmann, set. 49, single, a lithographer — admitted March 31st, 1855. Patient admits that he has been a man of rather intemperate habits, al- though this has not been the case of late. Twelve years ago, without any premoni- tory symptoms, he was suddenly seized with general anasarca and with ascites. For this he entered the Infirmary, and after treatment was dismissed “ Cured.” Six years after the first, he suffered from another attack, which was also cured in the Infirmary. Within the last fortnight he has been again attacked by “dropsy,” which has been gradually increasing. Symptoms on Admission. — On admission, the quantity of urine passed is small, but he is not obliged to rise during the night to pass his water. No pain in the loins, or tenderness on pressure. Abdomen is considerably swollen, especially at the lower part. Circular measurement below umbilicus, 30^ inches. When he lies on his back, the anterior part of the abdomen is tympanitic, and the flanks dull on percus- sion. On turning him to either side, the one which is uppermost becomes clear on percussion, and the undermost remains dull. There is slight oedema of the ankles, but he notices, every morning, some puffiness in the cheeks, especially on the righf side (that on which he usually lies). Bowels rather costive ; appetite very bad ; tongue foul, and covered with thick brown fur ; considerable thirst ; complains of cough and shortness of breath ; expectorates a little frothy mucus. Percussion of chest anteri- orly resonant on both sides. On auscultation in front, there is heard on both sides harsh inspiration, attended with very prolonged expiration. Posteriorly, at both bases, there are loud sibilant and crepitating rales. Heart sounds indistinct ; no mur- mur ; pulse 68, of good strength ; sleeps well ; has complained a little of drowsiness for the last few days ; skin dry and harsh. very scanty ; has only passed 12 oz. since admission. The application of heat converts the whole quantity in the test- tube into a firm coagulum ; sp. gr. 1024. Casts of tubes and oil globules are found in the sediment. Descendat in balneum calidum vespere. Sumat. Pit. Scillce et Digita- lis j. ter in die. I^ Tr. Opii Ammoniatce ; Sp. Lavendulee Co. aa § ss ; Mist. Scillce § V. M. Sumat § j ter in die. Progress op the Case. — April ^th. — Has passed 16 oz. of urine during the last twenty-four hours. Swelling of abdomen increased ; it measures below umbilicus 33 inches. He is very thirsty. April Mh. — Only 9 oz. of urine passed since last report ; sp. gr. 1018 ; highly coagulable ; bowels costive ; tongue dry and furred ; cough still present, with expectoration of tough frothy mucus ; sibilant and crepitating rales still heard at bases of both lungs posteriorly. Repeat the warm baths. Injiciatur enema foetidum. Habeat Pule. Ipecac. Co. gr. x. hac nocte et repetatur eras mane. April %th. — Obtained little relief from the injection ; skin of chest, abdomen, and loins, pits upon pressure. Abdomen measures 34f inches in circumference ; passed only 9 oz. of urine since last report, of same character as before. Breath has a urinous odor, Contimient. Pil. Scillce et Digitalis et sumat Potass. Bitart. 3 j ter in die. Repetatut Reported by Mr. Robert Byers, Clinical Clerk. 806 DISEASES OF THE GENITO-UEIXAET SYSTEM. Pulv. Doveri. April \bth. — Urine passed daii}’’ has been from 8 to 15 oz., of sp. gr, about 1020, and highly coagulable. O^nittantur Pil. Scillce et Digitalis. To appl^ spongio piline constantly to the abdo^nen, sat^irated with a strong solution of In fus. Digitalis. April 22(/. — Urine not increased in quantity, varies from 9 to 15 oz. per diem ; abdomen measures 37^ inches. The Inf. Digitalis has produced a rash of a papular character over the surface of the abdomen. 5 ^P- -^th. Nitrici 3 vj ; Aq. Oiniiamomi ^ vss. M. Habeat | j ter in die. April 2bth . — Says that the last mix- ture 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. J/ay 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 Sd. — Urine 24 oz ; Habeat Potass. Bitart. Dj ter in die. Omittantur alia. May bth. — 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 ^ih. — Urine 20 oz. ; sp. gr. 1018 ; his condition at present seems almost hopeless. The abdomen is enormously distend- ed, with a peculiar diffuse indurated feel over the region of the epigastrium, which, however, is tympanitic on percussion. The scrotum, thighs, and legs are greatly en- larged ; appetite impaired ; the pulse 86, weak. To be dry cupped over the loins. To have Gin ? ij daily. May 9th. — No change. Habeat Potass. Bitart. 1 ter in die. May Wth. — Urine 34 oz, ; sp. gr. 1015; still highly coagulable; numerous casts of tubes are seen in the urine under the microscope. 3Iay Ibth. — Urine 38 oz. ; sp. gr. 1014; is less coagulable; complains of severe frontal headache. To continue with the Bitartrate of Potass. 3Iay 16///. — Urine 64 oz. ; sp. gr. 1010. Alay Vlth. — Urine 58 oz. ; sp. gr. 1013; no headache; bed-sore on sacrum; right side more swollen than left (he lies on his side) ; bowels costive. Habeat J^il. Cotocynth. Co. gr. x hord somni. 3Iay IS/A. — Urine 67 oz. ; oedema of limbs v'ery much diminished; swelling of abdomen less. Alay 2\st. — Urine 68 oz. ; sp. gr. 1010 ; appetite good ; pulse 96, full and strong, 31ay 22d. — Urine 1 20 oz, 31ay 23c/. — Urine 128 oz. ; sp. gr. 1014 ; it still contains albumen in considerable quantity ; the abdomen has greatly dimin- ished in size, and the thighs and legs are of natural appearance, though there is some pitting on pressure at the ankles ; every second day of late he has been attacked about noon with a severe frontal headache, B Quince Sul fihatis gr. iij ter die sumend. 3Iay 2\th. — Urine 107 oz. ; sp. gr. 1018; still contains much albumen; no headache. 3Iay 2bth. — Urine 126 oz. ; sp. gr. 1016; very slight headache to-day; has taken four of the quinine powders. Still takes the Bitartrate of Potash. May 28///. — Urine 100 oz. ; sp. gr. 1020. 3lay 30/A. — Urine 50 oz. May 31.s/. — Urine 80 oz. ; sp. gr. 1014; perf^ectly fiee from all trace of albumen ; oedema of legs and ascites have com- pletely disappeared ; no headache ; appetite good. June %th. — No return of the albu- men in urine ; quantity varies from 60 to 114 oz. daily. June 9th. — A slight trace of albumen in the urine to-day, and feet slightly cedematous. June 16/A. — Still a faint trace of albumen in the urine ; his ankles become cedematous if he sits up long. June \9th. — Urine 100 oz. in twenty-four hours; sp. gr. 1010; contains an exceed- ingly faint trace of albumen. June 27/A. — The quantity of urine passed in twenty- four hours averages 100 oz. ; sp. gr. varies from 1010 to 1015 ; his ankles after he has been long up pit slightly on pressure. July 2d. — Albumen has quite disappeared ; bandaging prevents his ankles from swelling. He sits up the entire day. The appetite is good. Urine passed daily about 40 oz. In fact he is quite well. July 3c?. — Dismissed cured. Commentary. — In this case the man described his dropsy as being the third attack of the kind he had experienced, although it was by far much more severe than the preceding ones. I found him in the ward at the same time with Cases CLXXIX and CLXXX., but unlike them, the treatment seemed to have been of no avail. The abdomen was enor- mously distended from fluid collected in the peritoneum and the scrotum ; the thighs and legs were also so greatly swollen from dropsy, that to all appearance the case was hopeless. The urine, when heated, presented almost a solid mass of albumen, as if it had been serum of the blood, and bright’s disease. 807 the sediment exhibited, under the microscope, numerous fatty cells and casts of the tubes, proving the disease to be renal. A singular circum- stance is, that from his admission in March, until May 11th, notwith- standing a diaphoretic, purgative, and diuretic treatment had been em- ployed, he continued to get worse, and the anasarca increased. In April, also, he had taken the bitartrate of potash in drachm doses without benefit. But after I resumed the same remedy in May, in half drachm doses, its diuretic effect was extraordinary. From the 11th to the 28th of May, the quantity of urine was greatly increased, and I ordered it to be measured daily. On some occasions 126 oz. of fluid were voided, and coincident with this diuretic effect, the enormously swollen abdomen, scrotum, and inferior extremities diminished in size, and gradually returned to their normal condition. On the 31st of May there was no albumen in the urine. The ankles still remained puffy, especially after sitting up for any time, but on the 3d of July he was dismissed perfectly well. The anasarca in this case had reached its ultimate limits, the scrotum was as large as an adult head, the prostration of the patient was extreme, and we daily feared the coming on of coma and sloughing sores on the back. Although dry cupping was tried over the loins on the 7th of May, I have m^’-self no doubt that the good effects are entirely to be at- tributed to the diuretic ordered on the 9th, and the increased discharge of fluid from the kidneys which followed. The cases now recorded, in which advanced Bright’s disease was per- fectly cured, exhibit the groundlessness of the fears entertained by some as to the use of diuretics in that disease. In all they were freely em- ployed, and it may be observed that improvement invariably coincided with the coming on of the increased flow of urine. The case of Herdmann (Case CLXXXII.) is extraordinary in this respect. Case CLXXIX. also, in which there was a permanent cure of albuminuria in connection with hepatic disease, may be consulted with advantage. Case CLXXXIII ."^ — Second Attack of Alhuminuria with Anasarca — Dis- missed relieved. tliSTORY. — Mary Donaghan, set. 43 — admitted July 12tli, 1854, out worker. She states that about three weeks ago, she came home from her usual employment in the open fields in good health, but awoke next morning with pain in the epigastric region, and found her legs, arms, body, and face, much swollen. She was not aware of having been exposed to unusual cold or wet previously, and had no shivering. She had no pain in the loins, and passed her urine in usual quantity. Two years ago, she was ad- mitted into this hospital, suffering in the same way as at present. The swelling of her body at that time, however, was much greater. Symptoms on Admission. — On admission, her lower extremities only are oedema- tous, pitting on pressure. Her skin is moist, and she perspires moderately. Urine passed in normal quantity. On standing, a thick white deposit subsides, which, under the microscope, is seen to consist of epithelial scales, numerous tube-casts filled with oily globules, and compound granular bodies. Urine deposits a considerable coagu- lum by heat and nitric acid, also an abundant precipitate of chlorides by nitrate of silver; sp. gr. 1012. She complains of pain on pressing firmly the left lumbar region. Her tongue is moist at the edges, and furred in the centre. She complains of thirst, and bad appetite. Epigastric region somewhat tender on pressure. Bowels consti- pated. B Pnlv. Potass. Bitart. | ss ; in pulv. xii divid. One to be taken three limes a-day. Progress of the Case. — July 23c?. — Conjunctivae somewhat inflamed. Two leech- es to be applied to external angles ot both eyes, 26i!A.— Conjunctivitis less acute. * Reported by Mr. James Thorburn, Clinical Clerk. 808 DISEASES OF THE GENITO-URINARY SYSTEM. Nit. Argent, gr. ij ; Aguce ^ i ; Nt. Collyrium. August Id. — Her eyes are now .learly well. Urine still very coagulable, and its general characteristics are much the same as on admission. The oedema of the legs is abating a little. August \Mh. — She has been sweating profusely for the last few days. The characters of the urine are much the same as last report. The oedema disappears almost entirely when she retains the re- cumbent posture for some time, but returns again wh.en she walks about. She con- tinues to use the powders of Potass. Bitart. August 21s^. — Urine pale colored; sp. gr. 1012. Yields a considerable coagulum on the application of heat and nitric acid. The swelling of her legs has abated very much. Scarcely any pitting can be produced, except after she has been walking about a good deal. Her general health is very good. She is able to be out of bed during the whole day, and is now anxious to be dismissed. August 21s^. — Dismissed relieved. Commentary. — In this case the same diuretic treatment we have previously seen to be so beneficial, produced great relief and rapid dis- appearance of the anasarca. No doubt every symptom would have soon disappeared, had she not insisted on leaving the Infirmary. Case CLXXXIV.* — Second Attack of Albuminuria after an interval of twenty-nine years., with Anasarca — Bronchitis — Dismissed relieved. History. — James M‘Kay, ast, 62, armorer — admitted January 6th, 1853. He states that he enjoyed excellent health till twenty-nine years ago, when he was admitted to the Royal Infirmary under Dr. Spens, for swelling of the limbs, trunk, and face, super- vening after exposure to cold and wet. He continued under treatment for nine days, when he was dismissed cured, and since then he continued free from any complaint, till about five weeks ago, when he observed that his urine was diminished in quantity, was of a high color, and deposited a thick white sediment. A few days after, he was exposed to cold, while perspiring, having freely indulged in spirituous liquors. This was followed by distinct rigor, lasting for a short time, and followed by general uneasi- ness and feverishness, with headache and feeling of soreness in the loins. Ten days after the rigor, swelling appeared in the feet and gradually increased, extending to the legs, thighs, and scrotum, but during the last few days the oedema has considerably diminished. He has been a good deal addicted to the use of ardent spirits for the greater part of his life. Symptoms on Admission. — On admission the skin is soft and dry ; the legs are somewhat oedematous, and pit on pressure. The urine is passed more frequently than usual, and in small quantities at a time ; the whole amount of urine voided is con- siderably under the normal standard ; it is of a pale color ; sp. gr. 1012 ; highly coagu- lable with heat and nitric acid ; no distinct sediment is deposited on standing. He has no pain at present in the situation of the kidneys or bladder ; tongue dry ; has no appetite, but troublesome thirst ; bowels regular ; pulse 96, natural ; heart’s sounds normal ; he has some cough and dyspnoea on exertion, but the chest is otherwise ’nor- mal ; other functions natural. To have warm bottles applied to the limbs and feet., with twelve grains of Dover's powder at nighty followed by a draught of twenty-five minims of Morphia if he does not sleep. Progress of the Case. — January 2th. — Slept towards morning after the morphia ; no sweating; urine coagulable as before; sp. gr. 1018; passed without pain or diffi- culty, and in good quantity, viz., 48 ounces. The oedema has quite disappeared from the limbs ; bowels costive. Ordered two Colocynth and Hyoscyamus pills. Jan. 12^A. — On the 10th, he was much in the same state ; no sweating ; appetite bad ; great thirst, for which he was ordered milk and lime water. Being no better last night, he was ordered the warm bath, followed by fifteen grains of Dover's powder. To-day he states that he felt more weak after the bath, had slight perspiration, which was confined to the face and legs. To have twelve grains of Dover's powder, with six of James' powder at bed-time. Jan. \4:ih. — The diaphoretic has been continued since last report, but no sweating has been produced ; passed, during the last twenty-four hours, 58 oz. of urine ; bowels are rather costive. Bitart. Potass. 3 iss ; Pulv. Gambog. gr. iv. M. To be taken immediately, and repeated in six hours if necessary. Jan. ifith. — The bowels were well opened on the 15th, the stools being of thin consistence after the second powder, which afforded considerable relief ; but they have not been opened since ; ap- petite still bad, but less thirst. The urine to-day is of nearly natural color ; sp. gr. 1022 ; quite as coagulable as before ; the quantity passed in the last twenty-four hours is * Reported by Mr. Wm. Calder, Clinical Clerk. BRIGHT S DISEASE. 809 68 oz., with a slight sediment of urate of ammonia. Ordered a scruple of Bitartrate of Potass three times a-day. Jan. \^th . — The quantity of urine passed yesterday was 60 oz., but to-day it has diminished to 36 ; he complained of much thirst, and was ordered cream of tartar water as a drink ; he did not sleep well during the night, and is somewhat incoherent in his remarks to-day, though quite sensible when promptly spoken to ; bowels still costive ; repeat the powder of Bitartrate of Potass and Gam- boge ; to have ten grains of DovePs powder after the bowels have been well opened. Jan. 20th. — Voided 130 oz. of urine during the last twenty-four hours ; has still considerable thirst ; pulse 80, of good strength. Expresses himself as feeling quite well. On standing for twenty- four hours, the urine deposits a slight sediment, in which casts of the urinary tubes are still visible, crowded with fatty granules. Jan. llth. — Feels better than he has done for several years, and wishes to return home. He is accoi-dingly ordered to be dismissed. Commentary. — In this case it was evident that improvement had commenced on his entering the clinical ward, the urine was passing copiously, and diuretics were not directly indicated. Under these circum- stances the diaphoretic plan of treatment was persevered in, and although not with the result of entirely freeing his urine of all trace of albumen, yet with such good efiect, that he insisted on leaving the house, which he did nearly well. In the last three cases it will be observed that great relief was experienced, although perfect recovery was not established. The dropsi- cal symptoms were removed, whilst the albuminuria remained, a condi- tion which constitutes the majority of those cases which enter into the hospital, and are dismissed as “ relieved.” Case CLXXXVI.* — Albuminuria^ with general Anasarca., terminating fatally — Waxy Kidneys, Spleen, and Liver, with Extensive Deposition of Tuhercle. History. — Sarah Wilson, set. 7 — admitted November 11th, 1853. Three years ago she suffered from scarlatina, and has ever since been a weakly child, with a capricious appetite. In the course of last summer, oedema of the feet and legs was first observed, together with diarrhoea, which has continued more or less ever since. Symptoms on Admission. — On admission, her countenance is puffy and pallid, and the whole surface blanched. Her feet and legs are oedematous, pitting on pressure. The urine is of a pale color ; sp. gr. 1006. On applying heat, and adding nitric acid, a coagulum is thrown down, which occupies a space in the test-tube equal to that of half the quantity of urine. She has never felt any pain in the lumbar region. Tongue moist, and covered by a slight fur ; no thirst ; appetite good. The abdomen is greatly distended, and there is distinct fluctuation. Pulse 86, weak and compressible ; cardiac sounds normal. She has no headache and sleeps well at night. Acet. Potass. 3 i; yEth. Nit. 3 ij ; Syrupi 3 i ; Aquce § v. M. A table-spoonful to be taken three times a-day. Progress of the Case. — November l^ith. — Diarrhoea continues and she lies in a very weak state. .8^ Alist. Cretce 3 iv. An ounce to be taken three or four times a-day. To have 1 oz. of gin daily. Nov. 25^/i. — Urine passed in great quantity ; sp. gr. 1002 ; * Reported by Mr. Peter W. Wallace, Clinical Clerk. bright’s disease. 811 not eo coagulable. The diarrhoea, which abated for a few days after last report, has again returned. Ordered an astringent mixture. Nov. 2>0th. — The puftiness of the face, -which, on some days after her admission, abated considerably, is now as bad as ever. Her urine has been passed involuntarily for the last three days ; the diarrhoea is less severe. Dec. l^th. — Since last report, the oedema has wholly disappeared. The faeces and urine are both passed invokintarily. The constant dribbling of the latter over the labia and nates has produced excoriation. She takes her food pretty well, but vomits it occasionally. Her pulse is very feeble, and her strength much im- paired. She is at present taking 2 oz. of gin, and an equal quantity of wine daily. For the last five or six days she has been very drowsy, sleeping almost constantly, although she can easily be aroused, and answers questions readily. Dec. IMh. — The oedema has not returned, but the drowsiness gradually increased until this morning, when she expired. Sectio Cadaveris. — Forty hours after death. Body greatly emaciated ; slight oedema of feet. Thorax, — The lungs., which looked quite healthy, presented to the touch some indurated points ; these, on being cut into, were found to consist of clusters of minute grey granulations, generally about the size of small marbles. At the apex of tlie right lung was a small cretaceous conci'etion. The heart weighed 3 oz., and was quite healthy. Abdomen. — There were adhesions between the upper surface of the liver and the diaphragm. The liver weighed 4 lb. There was a little hepatic congestion, but the intervening tissue was pale ; the whole presented the usual appearance of the waxy degeneration. The spleen weighed 2A ounces, specific gravity 1054. It felt firm, and presented on section a waxy appearance. Throughout its substance were numerous enlarged semi-translucent, grey malpighian bodies, closely aggregated together. Their average diameter was about the 16th of an inch. The kidneys enlarged, weighing each 6 1 oz. On stripping off the capsule they presented a mottled appearance from the presence of irregular vascularity, contrasting with the pale cortical substance. On section they presented a well-marked waxy appearance ; the cortical portion was of a pale yellowish color ; the striae generally absent or indistinct. At some places there was a number of minute opaque yellowish spots. On opening the intestines, tubercular ulcers were found ; they occurred in the lowmr third of the small intestine, presented the usual characters, and occupied the whole circumference of the gut. The mesenteric glands were much enlarged, and were infiltrated with tubercle. Microscopic Examination. — The liver was found to contain much fatty matter, both free and contained in the hepatic cells. But the majority of the cells were pale and very indistinct (see Fig. 295, p, 230), Thin sections of the cortical substance of the kidneys presented a very transparent appearance, particularly the malpighian bodies. At some places, there were collections of fatty granules, but this did not occur very frequently, and only in isolated points. The enlarged malpighian bodies in the spleen contained a translucent matter, closely resembling colloid, and which presented the blue reaction of cellulose on the application of iodine and sulphuric acid. Commentary. — This case presented all the symptoms of Bright’s disease, in a young girl who had been in a state of ill health for three years, in consequence of an attack of scarlatina. On dissection after death, the kidneys, liver, and spleen were found to have undergone that chronic condition now known as waxy, and which is very commonly associated, as in this case, with tubercle. The nature of the morbid alteration has been previously referred to (see p. 249), Case CLXXXVII.* — Albuminuria — Excessive amount of Urine — Phthisis Pulmonalis — Waxy Liver., Kidneys., and Spleen. History. — Thomas Keegan, set. 40 — admitted December 13th, 1848. Patient states that he was in the enjoyment of good health till last May, when he first experienced 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 mictu- * Reported by Mr. George Shearer, Clinical Clerk. 812 DISEASES OF THE GEXITO-UEINARY SYSTEM. rition continued undiininished till five months ago, when he experienced a dull aching pain in the small of the back. This pain in the loins afterwards 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 appetite, 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. Symptoms on Admission. — There was dulness on percussion, and cracked-pot sound over the upper third of left lung in front. Over this part there was heard tubular breathing and loud mucous rales ; over the right apex prolonged expiration. Posteri- orly percussion equal on both sides. Crepitation and sibilant rales on left side. There is frequent cough, with copious muco-purulent expectoration. Tongue dry, clean, red, and tremulous. Appetite good but thirst excessive. Drinks, as nearly as can be ascer- tained, a gallon of water daily. Bow-els regular. He is much emaciated ; skin dry. He has not perspired any for several weeks. No oedema or ascites. The urine acid, unu- sually 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 mi- croscope. There is slight tenderness on pressing firmly over the region of the kidneys. Progress of the Case. — December 15?A. — He passes from 100 to 130 oz. of urine daily. Has expectorated a considerable quantity of muco-purulent matter. His mouth and fauces were so dry this morning that blood fowled on dragging the tongue from the palate, to which it adhered by clammy glutinous secretion. There w’as a slight discharge of blood after blowing his nose also. December \ Wi. — Passed I'lG oz. of urine on the 16th, 128 oz. on the iVth, to-day 82 oz., and drinks large quantities of water. Ordered to be dry-cupped over the kidneys. To drink soda-water^ and milk and water instead of simple water. December '2S.dk. — Urine 112 oz. Ordered a table-spoonfd of Oleum Morrhuce three times a-da]p and the following mixture : — B Spt. jDtheris Nitrici 3 i ; Sol. Mur. Morph. 3 ss ; Mist. Camphorce § ij. M. Half the mixture at bed-time and the other half in three hours if the cough is troublesome. December 2\st . — Had a good sleep after the mixture, but felt drowsy and siek all day. Pupils contracted at morning visit. Passed 112 oz. of urine. 22(7. — Feels very well to-day. Passed a good night. Urine 64 oz. December 267A. — 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 26^A. — Passed 48 oz. of urine since yesterday. Has had no stool daring last tw'cnty-four hours. Complains of great sickness to-day, and vomited his dinner. Ordered Naphthce Medicin. ^ ss ; Tr. Card. Co. ? i ; M. A tea-spoonful occasionally in a glass of water. B Pulv. Jnlapce Co. 3 ss ; mitte tales xij ; one three times a day. Ordered also 4 oz. of gin daily. December 2Slth. — Passed a very uncomfortable night, wdth frequent moaning and sterto- rous breathing. At 1 p. m. his respiration became very slow and labored, a mucous rattle was heard in his throat, and at forty-five minutes past one he expired. Seeffo Cadaveris. — Forty-eight hours after death. Body a good deal emaciated. Thorax. — Very dense adhesions at the ap?ees 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 extremity communicated wdth a smaller one of an irregular form. These cavities were linecl 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 imlmonary tissue around them w as 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 this there was a second concre- tion. The middle and loxver lobes contained little tubercle. Bronchial glands enlarged^ indurated, and loaded with black pigment. Heart healthy. Abdomen. — The liver was much enlarged, and was of unusual firmness and density. On section it presented the waxy degeneration, xvell marked-, the surface of section being dry, of a somewhat mottled yellowish-red color, with a peculiar translucent appearance ; lobular structure very indistinct. The organ weighed 6 lbs. 6 oz. The bright’s disease. 813 spleen was enlarged, 8^ oz., and felt somewhat dense. On section it was found to be pretty abundantly studded with clear Malpighian bodies, resembling grains of boiled sago.* The kidneys were enlarged, weighing 15^ oz. On stripping off the capsule, the surface of the gland was found quite smooth, very pale, of a whitish-yellow color, and of unusual density. The surface was somewhat mottled, owing to some patches of vascuhuity, contrasting strongly with the generally anaemic condition. On section the cortical substance was found hypertrophied, and had a pale, translucent appear- ance. The medullary portion was moderately congested. Almost all the branches of the renal artery in each kidney contained whitish clots ; some of them were firm, others partially softened. Some chronic tubercular ulcers were found in the lower part of the small intestine, and in the upper part of the large intestine. Microscopic Examination. — On examining microscopically a little of the softened portions 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 vms examined, the minute arteries were found to be much thickened. The cells and other structures of the kidney presented the usual characters of waxy degeneration. Comnientarij . — After death both kidneys, the liver, and spleen exhibited a chronic state of waxy degeneration. Death was occasioned by exhaustion from the pulmonary disease, vomiting, and impeded nutrition. This case was published in the last edition under the head of Polydipsia, and was the first in which the passage of a large amount of urine during the progress of Bright’s disease attracted my attention. In the previous case, however, it will be observed that the urine also was passed in great quantity. Many other such cases have since entered the clinical wards, three of which follow. Case CLXXX VIII .'^ — Albuminuria with great increase of Urine-^ Waxg Kidneys^ Spleen^ and Liver. History. — Mary Muirhead, set. lY — admitted March 3, 1860. She states, that at the age of five she lost the power of her lower limbs, and that shortly afterwards an abscess formed on her back, between the shoulders, and ultimately burst, when she recovered the use of her limbs. Her spinal column is bent outwards, at an acute angle, opposite the second dorsal vertebra. She states that, excepting this abscess and the discharge from it, which continued nearly to the date of her admission, she has enjoyed general immunity from disease. Four years ago she had scarlatina, but has since been in her usual health. Her respiration was always difficult on exertion, and this has increased during the last three months, since which time she has had cough, at first short and dry, but more recently accompanied by sputum. The patient states that since January she has been subject to lumbar pains, at times so severe as to prevent her working. A month after this, or three weeks previous to admission, she observed that she was passing a much larger amount of urine than was natural, and at the same time her ankles became oedematous, and her face at times puffy. Her weakness in- creasing, she applied for and obtained admission to the Infirmary. Symptoms on Admission. — On admission heart sound healthy ; pulse 100, small and feeble. There was considerable harshness of respiratory murmurs all over the chest. Tongue clean, but rather dry ; thirst great; appetite good ; bowels regular; slight ascites ; the liver and spleen not enlarged ; legs slightly oedematous; skin pale and dry. Urine was copious, about 50 to *70 oz. per diem ; sp. gr. 1005 ; containing much albumen and few chlorides. A sediment was deposited on standing, which con- tained numerous hyaline tubecasts, involving here and there a cell which had under- gone fatty degeneration. Habeat Tr. Ferri Mur. tt^xv ter die. Steak diet. Milk. Progress of the Case. — Patient remained under observation without much change for two months, during which time her urine ranged from 50 to 150 oz. daily. On only two occasions during these two months did it fall below 50 oz. Tlu. ascites grad- ually increased. About the beginning of May she was seized with diarrhoea, which continued notwithstanding the employment of various astringents. The cough and dyspnoea increased, with advanced dropsy of the legs and abdomen. The daily amount * Reported by Mr. Wm. Ward Leadham, Clinical Clerk. 814 DISEASES OF THE GENITO-URIXAEY SYSTEM. of urine fell to 30 or 40 oz., continued albuminous, and contained casts w th more fatty renal cells than formerly. She died exhausted May 20th. lectio Cadaver is. — Thirty hours after death. The lungs were found free from tubercle, but the bronchi congested and full of mucus. Heart small, weighing less than four oz. ; spleen large and waxy ; liver large and waxy, weighing 1 lb, 15 oz, ; kidneys large, weighing together 13-| oz. The cor- tical substance was very pale, and presented all the characters of the waxy degenera- tion, There was no ulceration of the intestines. Commentary. — In this case it will be observed, that as a result of chronic spinal disease, followed by scarlatina, Bright’s disease appeared, accompanied by frequent desire to pass water, and that from 70 to 80 oz. of urine, which she voided daily on coming into the house, it subse- quently increased to 150 oz. I was much struck with this circumstance, and at once recognised its similitude to that of Keegan, previously reported, who died from waxy degeneratk)n of the kidneys and other organs. Although the notes of the examination after death are meagre,, the existence of the lesion cannot be doubted. Case CLXXXIX."^ — Albuminuria — Syphilitic Ulcerations of Throat — Enlarged Spleen and Liver — Leucocythemia — Waxy Degeneration of Kidneys.^ Liver, and Spleen. History. — Edward Burns, a laborer, set, 30, married — admitted January 12, 1860. Patient states that he has had very little sickness, and, in particular, never had syphilis ; but he confesses to have suffered fri^ii buboes, resulting from a strain. The prepuce is remarkably contracted, and his throat presents syphilitie-looking ulcerations. Symptoms on Admission. — His throat was ulcerated, his voice was husky, and he had a harsh cough, with occasional muco-purulent expectoration. At the apex of the right lung there was harshness of respiration, but no increase of vocal resonance ; cardiac sounds normal; pulse 80, small and feeble. Blood poor in corpuscles; the white rela- tively more numerous ; the red pale and flabby, with a tendency to tail, and form into rows like a string of beads rather than a rouleau of eoins. Tongue clean; appetite pretty good ; bowels open. Hepatic dulness extends from the sixth rib to the umbilicus. The spleen is also considerably enlarged. The urine is highly albuminous, of low spe- cific gravity, and contains a few waxy tube casts. Patient stated that he never observed anything particular about his urine ; but on its being, by Hr. Bennett’s direction, measured, it was found to amount to upwards of 160 oz. daily. It was always of low sp. gr., iuid contained no trace of sugar. There was no oedema of the legs, unless oc- casionally, when he had been working hard, and then his ankles became swollen at night. During the four months he I’emained in the house his general health improved, and his liver diminished slightly in size. The amount of urine varied from 140 to 230 oz. daily, and he drank from 60 to 120 oz. of fluids. Latterly the quantity discharged was from 90 to 120 oz. daily, and his blood presented a more healthy appearance. The treatment consisted of astringents and Argent. Nit., to the ulcerating of the fauces, wdiich healed, and of Tr. Ferri Mur. and lodid. Potassii internally, and oecasional dry cupping over the loins. He was dismissed, at his own request, April 30th. Presented himself Fh April 1861. — His general appearance is better than it was last year. He states that he is quite well, but that the daily amount of urine has not further diminished. It is highly albuminous, of low specific gravity, and contains casts. His tongue is clean ; his appetite good ; his bowels are moved twice a-day. The liver is much enlarged, measures eight inches vertically, and extends eonsiderably across the epigastrium to the left side. The spleen is also enlai’ged. The blood con- tains an excess of white corpuscles. Expiration is harsh and prolonged at the apices of both lungs. The heart-sounds are altered in tone, but not of a blowing charaeter. 13^/i Jiugust 1862. — The patient again presented himself. He is more emaciated. States that from increasing debility he has been unable to work for a month past. He still makes large quantities of urine, which is albuminous, but not so intensely as before. It deposits a sediment containing hyaline tube casts, with oil-granules here * Reported by Mr. Colville Browm, Clinical Clerk. height’s disease. 815 and there arranged in groups, as if resulting from disintegration of cells. There has been no dropsy of late. The liver, though still enlarged, is decidedly diminished since last report. He complains much of his breathing. 22(^ September 1863. — He complains much of difficulty of breathing, and of cough and headache when he attempts to stoop ; he has also dropsy ; and from all these symptoms feels himself unable to follow his usual work. The amount of urine is still large. He is obliged to rise three or four times every night in order to micturate. The urine is albuminous, and contains waxy casts. lie-cdmitted November 1863, complaining of a further aggravation of his symptoms, and died on the 9th, under the care of Dr. Sanders. Sectio Cadaveris. — Twenty-eight hours after death. The body was somewhat emaciated. Chest. — The heart was enlarged. The aorta was very atheromatous. The lungs were cedematous, and the bronchi congested and full of mucus. Abdomen. — The liver was about the natural size. On its surface were a number of nodples and cicatrices. At the bottom of some of the latter nodules of a pale color were visible. On section, numerous nodules were found scattered throughout the organ ; they were pale, dense, and had an appearance exactly resembling bees-wax ; their structure was much denser than that of the surrounding tissue. In some nodules there were streaks of fibrous tissue throughout the substance and round the margin, and the greater the proportion of that tissue the deeper were the cicatrices. In the nodules elevated above the surface there were no such streaks, or very few. In those situated at the bottom of deep cicatrices, the fibrous element was abundant, or even in excess of the glandular. On applying iodine to these masses, the whole of the waxy-looking material assumed a brownish-red color, but the fibrous streaks simply assumed a yellow tinge. Microscopic Examination. — Microscopically, the masses were found to present exactly the characters of waxy hepatic cells. They were composed entirely of these cells, enlarged, transparent, and finely granular. In some parts the cell elements were broken down, and a finely granular material containing some oil-globules was present. The fibrous tissue in the masses presented the characters of dense white areolar tissue ; and where it was most abundant the cells were most atrophied. Throughout the rest of the organ the cells were little affected with the waxy degeneration, but some of the small vessels showed it distinctly. The kidneys were somewhat contracted in the cortical substance, and presented a very well-marked instance of the waxy degeneration of the vessels and Malpighian bodies. There was some degree of waxy degeneration of the villi of the small intestine ; the bowels were otherwise natural. Commentary . — In this case, similar phenomena were observed as in the former cases, the amount of urine passed daily having increased to the extent of 230 oz. daily. A careful examination after death revealed the waxy degeneration. Case CXC ."^ — Enlarged Liver and Spleen — Leucocythemia^ and Fihrinosis of the Hood — Albuminuria — Waxy Kidneys. History. — Archibald March, set. 29, a shoemaker, married — admitted February 15, 1860. In April 1859, patient was in the Infirmary on account of enlargement of the liver and spleen, with slight leucocythemia. He was dismissed considerably Teheved ; but having felt, of late, great oppression on taking food, with occasional bloody vomitings and increasing general debility, he was readmitted. States that, some years since, he had syphilis, which was followed by eruptions, nodes, etc., and ultimately by the symptoms of which he now complains. Symptoms on Admission. — His general appearance is cachectic and sallow; his chest covered with brownish patches of pityriasis nigra, which have existed for some years. There is no oedema. Pulse is full, 82 per minute. Cardiac dulness 2y inches transversely. There is a soft blowing murmur, with the first sound, loudest at the biise. There is a slight relative increase of the colorless corpuscles of the blood, and the red corpuscles have a tendency to tail. (See Fig. 60, taken from this case ) Tongue is moist; appetite not good; thirst great. He vomits occasionally after eating. Bowels constipated. The liver measures nine inches in a line vertical to the * Reported by Messrs. Thos. Annandale and P. M. Braidwood Clinical Clerks. 816 DISEASES OF THE GENITO-UEINARY SYSTEM. nipple ; and there is great tenderness on pressure over the whole area of dulne*,s. The splenic dulness, laterally, is 6^ inches from above downwards. Urine was of a pale amber color ; specific gravity i009 ; no albumen. March 2>d. — It was ascertained that his urine amounted to 110 ounces daily, and it continued at a similarly high standard, sometimes falling as low as 90 and rising as high as 130 ounces. March lO^A. — A trace of albumen was observable. It steadily increased in amount ; and, soon after its appearance, a very few waxy or hyaline casts were to be detected by the microscope. Notwithstanding the increased flow of albumen, the patient, under a tonic treatment, with liberal diet, so far improved as to be able to leave the hospital, to resume work, on March 26th. He has been seen at intervals since. December 3c?. — His complexion sallow and cachectic as before ; abdomen free from tenderness ; liver measures, in line of right nipple, 7^ inches, and the spleen barely 5 inches at the side. He does not know exactly how much water he makes daily ; but thinks it is less than when he was in the Infirmary. It is distinctly albuminous. No dropsy. The glands of the neck on both sides have become enlarged within the last ten days. The blood is in the same condition as formerly. 4dh February 1861. — The liver and spleen have further dimin- ished in size. His appearance is somewhat less cachectic. For some days he has had a pain in the neighborhood of the umbilicus, and along the margin of the liver, aggra- vated on movement or on pressure, and after eating. The stools are of a dark color, and contain some bright red blood. He has no piles. The amount of urine continues high, about 120 oz. daily, and is albuminous. Sth October 1861. — The patient again presented himself ; his cachectic appearance is increased ; he complains of a severe pain in the lumbar region, and along the spermatic cords. His renal symptoms con- tinue unchanged, and the liver is still distinctly enlarged. Since that time he has re- peatedly been an inmate of the Royal Infirmary ; has occasionally worked at his occu- pation of shoemaking, and has of late acted pretty constantly as cook to the Mid- Lothian Militia stationed at Dalkeith. March 21s<, 1864. — He continues to make large quantities of water daily, usually upwards of 120 oz. It is still albuminous, but no tube casts have been discovered for some time. The hepatic dulness is diminished to about six inches ; the organ is still painful on pressure. He has no nausea, and his Dowels are regular ; but on several occasions lately he has had intense diarrhoea, some- times with bloody stools, and has vomited blood-colored matters. November 2c?, 1864. — Presented himself at the Royal Infirmary, saying, that he was greatly improved in health, and has been able to work continuously for some months past. The liver and spleen are still further diminished in size, the excess of colorless cells in the blood has disappeared, while the colorless corpuscles are healthy. In other respects the same. Commentary. — This man, who is still living, and who has been under my observation for upwards of five years, presented all the phenomena described in previous cases of waxy degeneration of the kidneys, liver, and spleen. The condition of his blood was very pecu- liar, not only presenting all the characters of leucocytheinia, but an amount of fibrin so great as to be deposited in fibres the moment it was placed on a glass side, and examined with the microscope — the colored corpuscles of the blood also were altered in form, presenting an oval shape, tails, etc., as previously figured. (See Fig. 60.) At one period, also, he probably had waxy degeneration of the intestinal mucous membrane. In 1860 we saw the albuminuria appear — the amount of urine passed daily increased to 130 oz. daily — and, from all the circum- stances of the case, there could be no doubt, that a most extensive waxy degeneration, with enlargement of the kidneys, liver, and spleen, existed. Notwithstanding the profound cachexia, weakness, and prolonged symp- toms which were unusually severe, he has latterly become much better. The liver and spleen have diminished one-third of their previous bulk, and he has so much improved in health as not only to declare himself well, but to continue his daily occupation without fatigue. The future progress of this interesting case will be watched with unceasing interest. The three previous cases strongly attracted ray attention, and that BRIGHT S DISEASE. 817 of the class, during the spring of 1860, in consequence of their simi- larity to that of Keegan, in which I first noticed the great increase of albuminous urine, in connection with waxy degeneration of the kidneys and other organs. Dr. Grainger Stewart, who was my resident physician at the time, has since then taken great pains to collect a con- siderable number of these cases, which he has published.* From many well-marked examples of waxy degeneration of the kidneys I have since examined, there can be no doubt that an increase of albuminous urine is a diagnostic symptom of great importance. A study of the five cases I have detailed will be seen to agree with the following description of the symptoms of this lesion by Dr. Stewart: — “An individual who has long sufifered from wasting disease, such as scrofula, caries, necrosis, or syphilis, or who, though without palpable disease, is of a feeble constitution, feels an increasing weakness, and begins to pass large quantities of urine, and to drink largely. He is, contrary to his usual custom, obliged to rise repeatedly during the night to make water, and on each occasion passes a considerable quantity. The amount of urine varies from 50 to upwards of 200 oz. daily, always bearing a relation to the amount of fluid drunk, generally nearly equalling it in amount, or sometimes even exceeding it. The feet and ankles become cedematous after a hard day’s work, but return to their natural condition during the night’s repose. In many cases there is observed a hardness and swelling in the hepatic and splenic regions, de- pendent on an increase of bulk of the liver or spleen. The patient feels a constant lassitude and unfitness for exertion. His urine gradually becomes albuminous, and a few waxy or hyaline tube casts are to be found in the very scanty sediment which it throws down. It is of low specific gravity — 1005 to 1015. The blood presents some peculiarities microscopically ; the white corpuscles being somewhat increased in num- ber, and the red presenting a flabby appearance, with a marked tendency to tail, — that is to say, instead of forming into rouleaux, like healthy corpuscles, they become stretched out into long, spindle-shaped bodies. The blood changes I have observed only when the degeneration affected the lymphatic or blood glands. The patient may continue in this state for months, or even years — may, indeed, undergo a temporary improvement — the liver and spleen becoming diminished in bulk, and the blood resum- ing a more healthy character ; but, sooner or later, for the most part, ascites or general dropsy gradually supervene, accompanied frequently by diarrhoea, which is at times found quite uncontrollable. The urine, now very albuminous, diminishes in quantity, so as at times to be almost or altogether suppressed ; effusions into the serous cavities or severe bronchitis ensues ; the patient becomes exhausted and sinks, or drowsiness comes on, and the disease terminates amid coma and convulsions.” I would refer you to the excellent remarks of Dr. Stewart as to the individual symptoms and pathology of this disease, only begging you to avoid the word amyloid as indicative of the lesion, for reasons detailed at length, p. 250. Case CXCI.f — Albuminuria^ with Phthisis Pulmonalis^ terminating fatally — Extensive Deposition of Tubercle and Colliquative Diarrhoea — Atrophied Fatty Kidney — Ulcerated Intestines, History. — John Montgomery, aet. 60, weaver — admitted November 19th, 1852. States that for several years past he has been exposed to great privations, and that he has been frequently troubled with bowel complaint during that time. The attacks have sometimes been severe, and of long duration, but have generally lasted for a few days only. About a month before admission, the diarrhoea became much aggravated, there having been sometimes as many as twelve stools in twenty-four hours. This has continted more or less since that time, reducing him greatly in flesh and strength. As far as he has observed, he has never passed blood by stool. He has also had a short * Edinburgh Medical Journal, 1861, p. 740; and 1864, p. 97. f Reported by Mr. W. M. Calder, Clinical Clerk. 62 818 DISEASES OF THE GENITO-UEINARY SYSTEM. dry cough, but ouly for a few weeks past, and unaccompanied with expectoration or dyspnoea. He was brought into the hospital in a state of great weakness and ex- haustion, having fallen down in the street, supposed to be in a state of intoxication. He states that he has not taken any spirits for some days past, although he has been much addicted to intemperance during the greater part of his life. Symptoms on Admission. — On admission, the tongue is very dry, but not furred ; but there are some sordes on the teeth and gums. He experiences difficulty in deglu- tition, as if there was some obstruction about upper part of sternum ; appetite bad ; troublesome thirst; no sickness or vomiting; no pain in epigastrium, but frequent griping pains in abdomen. Bowels are very loose : much straining and great tenesmus when at stool ; evacuations of an almost watery consistence and reddish-brown color. They present no appearance of blood, but contain a few shreds of mucus. Occasion- ally he passes nothing but a small quantity of frothy slime ; no haemorrhoids. On physical examination of the abdomen, the parietes are tense and retracted. The liver is slightly enlarged, the dulness measuring five inches from above downwards. Chest appears contracted, and does not expand freely. There is no comparative dulness on percussion. The respiration is feeble and the expiration prolonged; under the right clavicle it is of a somewhat tubular character. Vocal resonance is also increased over the same part. At the lower part of right side anteriorly, there is a fine fric- tion sound. Sputum in very small quantity; muco-purulent, 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. H Mur. Morph. 3 ij ; Tinct. Catechu 3 vj ; Mist. Cretce § vj. M. Su~ mat § j tertid qudque hard. Ordered to have 6 oz. of wine and steak diet. PnoGRESS OF THE Case. — November 2Qth. — Wandered a good deal during the night; is exceedingly weak to-day, but the diarrhoea is less severe. Nov. 22d. — Complains more of cough and pain in right side, striking across the chest to the left ; no dulness on percussion ; still friction on right side with fine moist rales ; marked increase of vocal resonance ; urine diminished in quantity ; of natural color, with slight floccu- lent precipitate on the application of heat and nitric acid. Diarrhoea stopped ; pulse 112, small and weak. Nov. 24th. — Was much weaker yesterday, and evidently sinking; too weak for examination of the chest; bowels were once opened; no urine voided since last report. Died this morning at four o’clock, comatose. Sectio Cadaveris. — Fifty-six hours after death. Body somewhat emaciated ; very little subcutaneous fat ; muscles well nourished. Thorax. — Heart normal ; adhesions of both pleurae over limited space of upper lobes. Both lungs contained many scattered groups of tubercle, chiefly miliary ; some fewT of them softened, and wdth small dry excavations at the apices; the pulmonary tissue around the tubercles mostly indurated and dark colored from carbonaceous in- filtration ; the bronchial glands dark and enlarged. Abdomen. — Stomach and jejunum and upper two-thirds of ileum normal. In lower third several scattered ulcers, not exceeding eight or tw’elve in number, from one- quarter to three-quarters of an inch in diameter ; some of them slightly congested 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-colored, the floor somewhat indurated. Spleen pale, peritoneal capsule thickened, the organ rather small, no dis- tinct morbid appearance. Liver slightly enlarged, presenting very distinctly, and in a considerable degree, the fatty degeneration. Kidneys unusually small (dimension of right three and a half inches long, one and three-quarter inches broad, three-quarters of an inch thick, left kidney of nearly the same size, weight not ascertained) ; capsule easily stripped off ; surface slightly uneven, not distinctly tuberculated ; venous vas- cularity of surface 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 w ith a lens, many very minute cysts were discovered in cortical sub- stance ; most of them required a power of half an inch focal distance to bring them into view. A similar powder, or even the naked eye, distinguished easily a number of opaque light gamboge yellow points in the cortical substance ; the largest w^as about one-fiftieth of an inch in diameter, accurately limited, and yielding, on being punctured, a fluid of the same color. In the cortical substance there were also some minute haemorrhagic petechiae, having the usual appearance of extravasation. bright’s disease. 819 Microscopic Examination. — With high magnifying powers, the tubuli uriniferi were seen in some places to be of normal character, with the exception of a very few granules in the epithelium ; on the contrary, in others, the tubes were crowded with fatty granules. The epithelium generally was normal in form and appearance in the tubes which had fewest granules. In many places the cortical substance of the kid- ney was studded with minute cysts, constituting the third form which they present (see p. 800), In the fluid squeezed from the yellow points, in the cortical substance, there was an immense number of fatty granules, partly loose, partly agglomerated into amorphous collections, partly composing distinct rounded granular masses up to the one-ninetieth of an inch in diameter, and partly contained in cells of a very fine deli- cate transparent character, presenting much of the appearance of a tesselated epithe- lium. The cells of this epithelium were more transparent, and generally one-third smaller than those usually found in renal tubules. Commentary. — In this, as in some former cases, the renal disease was associated with phthisis, but was more chronic, further advanced, and exhibited the ultimate eifects of the fatty rather than of the waxy de- generation, The report states that the urine was not highly coagulable, presenting only a slight cloud on the addition of heat and nitric acid. The fluids of the body, however, seemed to have been discharged to a great extent by means of stool. Before death, the urine was suppressed, causing coma. Drs. Christison and Peacock have pointed out how fre- quently Bright’s disease is a complication of phthisis, and I have not only confirmed that observation, but observed that this is, in most cases, connected with the waxy degeneration of the renal organs. In the cases previously given, we have seen various examples of the inflammatory, waxy, and fatty forms of Bright’s disease. It would be easy to multiply instances where, on dissection, all kinds of intermediate conditions of the kidneys had been observed ; but those now recorded, together with such as recovered or were relieved, present the leading characters illustrative of the pathology, diagnosis, and treatment of Bright’s disease. A few words on each of these topics may now be added with propriety. Pathology of Bright'’ s Disease. Many names have been proposed by various pathologists for the dis- ease called after Dr. Bright. Up to the present time, however, none of them has been sufficiently good to comprehend all those lesions which occasion renal dropsy, with persistent albuminuria. Hence we still retain the designation it has so appropriately borne, to express a disorder characterized by more or less dropsy, caused by 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 per- sistent albuminuria, it appears to me may now be classified under three heads — 1st, Inflammation, acute or chronic; 2d, Waxy degeneration; 3d, Fatty degeneration. 1. The Inflammatory Form. — This may be acute or chronic; the first is generally induced by all those causes which excite inflammation in other internal organs, and is ushered in by rigors and febrile symptoms, and accompanied by pains in the lumbar region, and the phenomena generally described as those peculiar to nephritis. (See Nephritis.) The chronic disease may follow the acute, may come on more slowly, as the 820 DISEASES OF THE GENITO-TJEINARY SYSTEM. result of the same causes, or proceed so imperceptibly from causes which have escaped observation, that the occurrence of dropsy, more or less extensive, may be the first symptom which excites attention. 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, different salts, and other morbid products, may be seen. These casts of the uriniferous tubes are finally molecular and fibrinous {exudative casts), or mingled with the fibrinous matter, there are epithelial cells and free nuclei of the tubes {desquamative casts). Other products, which vary according to the period of the disorder and the tissues in- volved, may also be present, to which we shall allude under the head of diagnosis. On examining the kidneys of individuals who have labored under this form of the disease, we find that in the acute stage they are more or less congested and tinged of various colors, from a bright red to a dusky brown. The surface is not unfrequently covered over with minute ecchymotic spots, dependent on the extravasation of blood into the tubes, in their convoluted portions. The excessive congestion and extravasation of blood, by obstructing the tubes and interfering with the secreting function of the organ, form the chief source of danger in 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 con- gestion (Case CLXXL), commensurate with the danger of the case. As the disease becomes more chronic, the intense uniform coloration dimi- nishes, leaving irregular arborizations, which mottle the surface — the blood extravasated is absorbed — the exudation, if not dislodged and passed in fragments by the urine, gradually disintegrates, and may or may not undergo the purulent or fatty transformation. This, by long- continued pressure, causes permanent obstruction of the tubes and 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 CXCI.) 2. The Waxy Form . — This form of the disease is generally chronic, and for the most part accompanies scrofulous, syphilitic, and other cachectic complications. Dropsy, and a peculiarly sallow and emaci- ated look, constitute its chief symptoms ; and the urine, as the disease slowly progresses, becomes first increased in quantity, and then more and more suppressed, death taking place by exhaustion or coma. The urinary sediment is usually small, and presents hyaline casts of the tubes {waxy casts) ^ with a few epithelial cells, unusually colorless and transparent. Not unfrequently, 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, though mixed up with the various other lesions which usually accompany it, may now in the majority of cases be distinctly determined, the description given by Dr. Stewart serving for the most part to render it recognizable (p. 817). On examining kidneys which have undergone the waxy degeneration, we generally find that they are more dense to the feel than natural, some- times smaller, at others larger than usual, and of a color resembling height’s disease. 821 various shades of dirty bees’ wax, or of a light fawn tint. On section the surface is smooth, and the edges more or less translucent ; a circumstance dependent on the diminished vascularity which everywhere prevails, and a pecu- liar transparency which all the struc- tures of the organs have undergone. A thin slice, when magnified under a power of 250 diam. linear, exhibits the vessels of the Malpighian bodies more transparent and refractive than usual (Fig. 475). The tubules are colorless^ often destitute of epithelium, and of a peculiar whiteness. Such cells as are discovered have their nuclei more or less atrophied, and closely resemble 475. those seen in the liver when similarly affected (see Fig. 319, p. 249), Indeed, this change in the kidney is frequently associated with a similar transformation of the liver, spleen, and intestinal mucous mem- brane. The nature of this waxy degeneration of tissue is unknown, although probably it is some change in the chemical composition of the structure affected, whereby it is rendered albuminoid. It is in no way amyloid, as previously pointed out (p. 250). But whatever be the es- sential nature of this peculiar degeneration, there can be little doubt that the waxy tissues are rendered more permeable by fluids, and hence the excessive discharge of urine and of matter from the intestinal mucous membrane when so affected. (Cases CLXXXVI. to CXC.) The Fatty Form. — This, as we have seen, may be a result of in- flammation, but it is not unfre- quently produced independent of it. Here, again, the progress of the disease is chronic, is not so frequently associated with scrofula and tubercle, but occurs rather in individuals more ad- vanced in life, suffering from cardiac and bronchitic disorders, or who are addicted to intem- perance. It is also frequently associated with fatty degenera- tion of the heart and liver. Dropsy and persistent albuminuria Fig. 476, are constant symptoms, and the sediment is ’.oaded with casts of the tubes containing oil granules {fatty casts) and granule cells. Fig. 475. Waxy degeneration of a Malpighian body, with a few granule cells.— ( Wedl.) 300 dtam. Fig. 476. Structures in a fatty kidney, a and 6, Tubes filled with fatty granules, having in one of them the transparent basement membrane visible, c. Transverse section of a similar tube, d. Fatty epithelium of the tubes, e, Amorphous fatty matter in the tube.s. f Crystals of uric acid in a tubule. — ( Wedl.) 350 diain. 822 DISEASES OF THE GENITO-URINAEY SYSTEM. On examining the kidneys of individuals who have died of this form of the disease, we observe the tubes more or less obstructed by fatty granules, which have gradually accumulated in the epithelial cells of the tubes. These separate, and even burst, liberating their contents, and in this way obstruct the tubes, and compress the secreting and surrounding textures (Fig. 476, a and 1). Gradually the vessels are so compressed, that the organ afiected looks bloodless, and though, on the whole, enlarged, is of a light fawn or dirty white color. The fibrous texture is occasionally hypertrophied, causing contractions round the convoluted tubes, thus producing irregularities on the surface. Occasionally, also, large accumulations of the fatty granules take place, causing the tubes to burst, and presenting to the naked eye light fawn- colored spots or granulations, more or less numerous, which are scattered over and through the cortical substance. It is easy to conceive how such accumulations of fat, and consequent pressure and obstruction, must at length so interfere with the kidneys, as to be incompatible wdth the performance of their functions (Case CXCI.) On scraping the surface of a fatty kidney, and adding a drop of water, we are enabled to see, under a magnifying power, fragments and cells such are given Figs. 476, 477. The}’’ exhibit portions of uriniferous tubes loaded with free fat granules and epithelial cells, also containing similar fat granules. On Fisr. 477. making a thin section of a fatty kidney, we not unfrequently see the Fig 478. Fig. 479. tubes in situ loaded with similar granules, and the fibrous tissue so in- 477. Portion of fatty tube, with fatty epithelial cells, scraped from the sur- face of a fatty kidney. Fig. 478. Longitudinal section of a fatty kidney, showing the tubes loaded with fatty granules. Fig. 479. Transverse section to the former one, (i.) Malpighian body. — son.) 260 diam. bright’s disease. 823 creased and thickened between them, as to occasion a lesion identical in many respects with the so-called cirrhosis of the liver, to which an atrophied and granular kidney is strictly analogous. Sections of the cortical substance of such kidneys are represented Figs. 478, 479. The above is a condensed description of what appears to me the three pathological forms of Bright’s disease of the kidney. These lesions, although they are met with separately and distinct, may, however, be more or less conjoined. One part of a kidney may be congested or inflamed, whilst another is fatty ; or we may have the fatty and waxy conditions united together. It is only in this way that we can account for the various shades of alteration which the kidney may at different times present during the continuance of persistent albumin- uria with dropsy. All these alterations, by interfering with the secret- ing functions of the cells, more or less disorder the excretory power of the kidneys, and, if continued, ultimately tend to overload the blood with the effete elements which ought to be discharged with the urine. At the same time, by causing more or less congestion of the vessels, or by pressure on the Malpighian bodies, and obstruction of the tubules, a serous effusion takes place, the albumen of which, passing into the urine, communicates to it that property of coagulability which constitutes its pathognomonic character. Diagnosis of Brighfs Disease. The diagnosis of Bright’s disease of the kidney is dependent on three kinds of observation: — 1st, Symptoms; 2d, Chemical — and 3d, Microscopical — examination of the urine. 1. Diagnostic Symptoms. — In the acute forms, pain in the lumbar regions, high-colored urine, and other indications of nephritis, followed by dropsy ; and in the more chronic forms, the occurrence of dropsy, frequently without the local renal symptoms, are the chief diagnostic symptoms. A constant desire to pass urine, and the passage of a large quantity of that fluid should also excite apprehension. But these symptoms must always be very vague until, by a chemical examination of the urine, the presence of albumen is determined. Chemical Examination of the Urine. — In testing the urine, you should be careful to employ both heat and nitric acid. Heat alone frequently separates earthy salts, which to the eye may resemble a slight cloud of albumen; and nitric acid alone frequently throws down a precipitate of uric acid, where urate of ammonia is in excess. But if the coagulum produced by heat also resist the action of nitric acid, we may be pretty sure that the urine contains albumen. The mere presence of albumen in the urine does not constitute Bright’s disease. It may accompany cystitis or haematuria — may follow the action of a blister affecting the kidneys, or result from mercurialism, errors in diet, or con- firmed dyspepsia. In all such cases, however, it is temporary, and does not present the diagnostic character of persistence. 824 DISEASES OF THE GENITO-UEINAKY SYSTEM. Microscopical ^Examination of the Urine, — The method I have found best for determining the form and structure of the organic matter dis- charged in the urine, is to allow the fluid to repose for twelve hours, then pour ofi' the supernatant liquid, and put the turbid sediment into a test-tube. Allow this to repose for another twelve hours, when the concentrated precipitate containing the organic matters collects at the bottom, and can now easily be brought into the field of the microscope. Or some ounces of the urine may be put into a conical glass, like an ale glass, and the precipitate allowed to deposit itself, as recommended by Dr. Johnson. From thence it can easily be obtained by pouring off the supernatant fluid, or by removing the sediment with a pipette for microscopic examination. The objects so brought into view are various, comprising different salts, cells, fungi, and casts of tubes (see pp. 103 to 107, and Figs. 102 to 114), the discrimination of which necessitates a knowledge of histology. The diagnostic elements, however, in Bright's disease, may be considered to be the separated casts of the tubuli uriniferi. These are of four kinds. 1. Exudative Casts, — These casts consist of the coagulated exuda- tion, or fibrin, which, in the inflammatory form, is poured into the tubes, so as to present a mould of their interior. They are analogous to similar casts which occur in the minute bronchi, in all cases of pneumonia, and are recognised under the microscope by their uniform molecular structure. They mostly occur in acute cases, are frequently associated with blood corpuscles, and not unfrequently with desquamative casts and epithelial cells. Figs. 108 Z>, and 480. 2. Desquamative Casts . — These casts consist of mass- es of the epithelium lining the tubules, sometimes closely aggregated together side by side, at others ag- glutinated by means of the molecular exudation former- ly alluded to. They result from a separation of the lining cell membrane from the interior of the tube, in patches of greater or less extent and may be associated in acute cases with exudations, and in chronic cases with the fatty or waxy transformations next to be mentioned. — See Figs. 108 rt, p. 105, and 481. 3. Fatty Casts. — These casts consist also of patches of epithelium, which, however, have previously under- gone the fatty transformation, by the accumulation of a greater or less number of fatty granules in their cells. Occasionally the cells burst and fill the tubes with fatty granules, among which no epithelium can be distin- guished. — (See Fig. 109, p. 105, and Fig. 476.) At others the cells are less changed, the fatty accumulation as it were only commencing, as in Fig. 482. These fatty casts are often associated with fragments of desquamative ones, with a few cells, more or less fatty, and frequently with the next kind of cast to be noticed (Fig. 482). Waxy Casts . — These casts present an exceedingly diaphanous and Fig. 480. Exudative casts with epithelial cell and mass of coagulated exudation. Fig. 481. Desquamative casts with blood corpuscles, naked nuclei, and cells. Fig. 480. Fig. 481. bright’s disease. 825 Fig. 483. structureless substance, which, according to Dr. Johnson, is secreted by the basement membrane, after the destruction of its epithelial cells. But may it not consist of the basement membrane itself which has undergone some chemical transformation, the nature of which has yet to be ascertained ? The waxy are frequently associated with the two kinds of casts last described, but especially with the fatty ones (Figs. 482, 483). Not unfrequently all stages of transformation may be seen in the same demonstration, between one tube containing epithelial cells, more or less fatty, and another, which being empty, presents the translucent or waxy appearance. (Figs. 476, 483.) The exact signification of all these various kinds of casts has yet to be fully determined by clinical investigation. But it appears to me that the exudative casts indicate the most acute form of lesion — the desqua- mative a sub-acute, the fatty a chronic lesion, and the waxy a lesion destructive of the tubular textures. But as all these difierent changes may be going on in the kidney at the same moment, so we may find these various casts mingled with one another in various proportions, combined with other structural elements. The predominance in number of one kind of cast over another, will, however, serve to indicate to the pathologist, with tolerable correctness, the nature of the change which is going on in the renal organs. They undergo great variety in size, often being much smaller than any kind of uriniferous tubes, a circum- stance indicating considerable contraction of their calibres. Treatment of Bright's Disease. The acute forms of Bright’s disease should be combated externally by cupping over the loins, and warm fomentation.s — internally by diaphoretics, and later by diuretics. I have seldom found it necessary to have recourse to general bleeding, and then only as a palliative to relieve pulmonary congestion. The chronic forms, in addition to appro- priate remedies, require attention to diet and exercise. A non-fatty diet is evidently indicated in the fatty degeneration of the kidney. Fixercise, change of air, and sea voyages are also beneficial. Care also should be taken that the surface be kept warm, and cutaneous transpiration favored. The complications and sequelae must be managed according to circumstances, and the general indications special to individual diseases. In this place I shall only allude to the effects of two classes of remedies, namely, diaphoretics and diuretics. Diaphoretics . — The connection which necessarily exists between the kidneys and the skin as excretory organs, is well known. In health. Fig. 482. Fatty casts with granule cell. Fig. 483. Waxy casts of various sizes. 826 DISEASES OF THE GENITO-URINAIIY SYSTEM. impeded function in the one, is to a certain extent, compensated for by increased function in the other ; and diseases in the skin, especially scar- latina, or other causes which tend to check cutaneous transpiration, are peculiarly liable to induce renal disorders. Such being the case, it seems highly judicious, in our efforts to cure, to excite, by all means in our power, the functions of the skin in cases of Bright’s disease of the kidney ,* and with this view, Dover’s powder, keeping the surface warm, hot air baths, warm water baths, and a warm climate, are among the means which have been proved to be most useful. They are more especially indicated in the waxy form of the urine with increased amount of urine and slight dropsy. When, however, the urine is diminished, and dropsy a leading symptom, it frequently happens that these remedies are of no avail, and then we must have recourse to the next class of remedies. Diuretics . — It has been thought that in the acute inflammatory cases, where the kidney is more or less congested and loaded with exudation, diuretics, by stimulating the organs and exciting them to increased action, would add to, rather than diminish, the excitement. But when it is considered that the dropsy is induced by obstruction in the secreting tubes, which presents a mechanical obstacle to the outward flow of fluid, it seems probable that, by increasing that flow, the accumulations pro- ducing the obstruction may be washed out. Besides, by augmenting the amount of fluid from the Malp)ighian bodies through such tubes as still remain pervious, a compensation is frequently to be found for the dimin- ished flow which takes place in the obstructed ones. Certain it is, that 1 have given diuretics in all stages of the disease with the best effects, as soon as it became manifest that the remedies formerly alluded to were of no avail. Nor have I seen any bad results from the practice. Besides, in acute cases with diminution of urine and rapid dropsy, no other course is left open to us, as diaphoretics under such circumstances are seldom effectual. The whole class of diuretics may be tried in Bright’s disease, in com- bination with other remedies ; but the most valuable, so far as I have been able to determine, is the bitartrate of potass, which I have fre- quently seen to produce a most powerful effect, when every other had failed. The spongio-piline, saturated in a strong solution of infusion of digitalis applied externally, and digitaline administered internally in minute doses, botli recommended by Dr. Christison, are useful. But here again I have seen the cream of tartar operate after both these had failed. Sometimes also, after it has been given without effect at an early period of the disease, it has succeeded remarkably well at a later one. Of this, the case of Ilerdmanu (Case CLXXXII) is a remarkable example, which warrants our having recourse to the remedy again and again after certain intervals, should it not act. It is very possible that the casts which obstruct the tubes may be more loosened at one time than at another, and that a powerful diuretic may, in consequence, have a greater effect in washing out the obstructions and restoring the functions of the organs. At all events, I have rarely seen other diuretics succeed, when repeated attempts by means of the bitartrate of potass had failed. SECTION IX. DISEASES OF THE INTEGUMENTARY SYSTEM. Notwithstanding the great advances which have been made in our knowledge of diseases of the skin, it cannot be denied that very inexact notions prevail regarding this class of disorders. I do not here allude to the eruptive fevers which, from their frequency and danger, necessarily demand the attention of every professional man, so much as to the lighter and more chronic disorders to which the skin is subject. Ignorance, however, here, although it seldom occasions danger to human life, pro- duces great inconveniences, exasperates the progress of other maladies, renders life miserable, and frequently destroys those social relations and ties which constitute happiness. A lady was seized with an eruption on the genital organs, which rendered the slightest contact unbearable. Her husband suspected that she labored under syphilis, and accused her of infidelity. A medical man, who was consulted, pronounced her disease venereal — a separation took place between the parties ; the lady always maintaining her inno- cence, but anxious to escape the unfounded suspicions and ill-treatment of her husband. Mercury and an anti-venereal treatment was continued for some time, but the disease increased in intensity. At length another physician, skilled in the diagnosis of skin diseases, was consulted, who pronounced it to be an ec%ema rubrum^ quite unconnected with syphilis ; and on the application of appropriate remedies, a speedy cure confirmed his diagnosis. A lady in the country sent one of her servants into town, to obtain advice for an eruption which had broken out on her body, and which she was afraid might be communicated to her children. The practitioner consulted was much puzzled, and asked me to see the patient, who, ac- cording to him, was laboring under a rare form of skin disease. I found a herpes zoster extending round one half the trunk, and told him it would disappear spontaneously in a few days, which it did. Nothing is more common in practice than to meet with cases among servants, where prurigo has been mistaken for itch, causing great alarm to the family, and much injury to the servant. The various diseases of the scalp also are continually confounded together. Indeed, examples might easily be accumulated, proving the inconvenience which an un- acquaintance with skin diseases may occasion both to patient and practi- tioner. A young medical man is especially liable to be consulted in cases of trifling skin eruptions ; and nothing is so likely to establish his credit, as the ready diagnosis and skilful management of such disorders, 828 DISEASES OF THE INTEGUMENTARY SYSTEM. especially when (as frequently happens) they have been of long standing, and baffled the efforts of older practitioners. Conceiving, then, that this subject deserves more careful consideration than it usually meets with in a clinical course, I propose directing your attention to the classification, general diagnosis, and treatment of these disorders as an introduction to the study of individual cases in the wards. CLASSIFICATION OF SKIN DISEASES. Skin diseases are so various in appearance and in their nature, that many experienced practitioners have endeavored to facilitate their study by arranging them in groups. There are three kinds of classifications which deserve notice — 1st, The artificial classification of Willan, Bateman, and others; 2d, The natural arrangement of Alibert and others; and 3d, A pathological arrangement founded on the supposed morbid lesions. Of these, the best, and the one which most facilitates the study of cutaneous diseases, is certainly that of Willan. No doubt it has its faults and inconveuiences, but many of them have been removed by Biett. This classification is founded upon the character presented by the erup- tion, which,* when once known, determines the disease. It is an old saying, that it is much easier to play the critic and to find fault, than to construct something better. This remark may be well applied to those who have ventured to set aside the principles on which Willan’s arrange- ment is founded, and to bring forward others. No natural classification can ever be followed by the student, as it presupposes a considerable knowledge of the subject. The pathological arrangement again is decidedly faulty. The morbid anatomy and pathology of many skin diseases are unknown ; how, then, can we found a classification upon them ? Indeed, the very foundation on which such classifications are based, is continually undergoing changes as pathology advances. On the whole, therefore, the arrangement best suited to the student and for practical purposes is that of Willan and Bateman, with the modi- fications subsequently to be noticed. Definitions . — Before we can proceed to refer any particular disease to its appropriate class, we must be acquainted with the characteristic appearances which distinguish the different orders. They are as fol- lows : — 1. Exanthema (Bash). — Variously-formed, irregular-sized, superficial red patches, which disappear under pressure, and terminate in des- quamation. 2. Vesmila (Vesicle). — A small, acuminated, or orbicular elevation of the cuticle, containing lymph, which, at first clear and colorless, be- comes often opaque or pearl-colored. It is succeeded either by scurf or a laminated scab. 3. BuUa (Bleb). — This differs from the vesicle in its size, a large portion of the cuticle being detached from the skin by the interposition of a watery fluid, usuall}^ transparent. 4. P'ustula (Pustule). — A circumscribed elevation of the cuticle, con- CLASSIFICATION OF SKIN DISEASES. 829 taining pus. It is succeeded by an elevated scab, which may or may not be followed by a cicatrix. 5. Papula (Pimple). — A small, solid, acuminated elevation of the cuticle, in appearance an enlarged papilla of the skin, commonly termi- nating in scurf, and sometimes, though seldom, in slight ulceration of its summit. 6. Squama (Scale). — A lamina of morbid cuticle, hard, thickened, whitish, and opaque, covering either small papular red elevations, or larger deep-red, dry surfaces. 7. Tuherculum (Tubercle). — A small hard, indolent, primary eleva- tion of the skin, sometimes suppurating partially, sometimes ulcerating at its summit. 8. Macula (Spot). — A permanent discoloration of some portion of the skin, often with a change of its structure. These stains may be white or dark-colored. The different appearances thus described characterise the eight orders of Willan and Bateman — viz., 1. Exanthemata; 2. Vesiculm; 8. Bullae; 4. Pustulae; 5. Papulae; 6. Squamae; 7. Tubercula; 8. Maculae. The principal modifications made by Biett consist in removing from these groups certain diseases which have no affinity with them, and forming them into extra orders of themselves. Thus he makes altogether fifteen orders, as seen in the following classification given by his pupils Schedel and Cazenave, which also indicate the subdivisions into which each order is divided : — Order I. — Exanthemata. Vaccinia. Framboesia. Rubeola. Ecthyma. Cheloidea. Scarlatina. Impetigo. Order VIII. — Maculce. Erythema. Acne. Lentigo. Erysipelas. Mentagra. Eph elides. Roseola. Porrigo. Naevi and Vintiligo. Urticaria. Equinia. Order IX. — Purpura. Order II. — VesiculcB. Order V. — Papulce. “ X. — Pellagra. Eczema. Lichen. “ XI. — Radesyge. Herpes. Prurigo. “ XII. — Lepra Astra- Scabies. Order VI. — Squamce. chanica. Miliaria. Psoriasis. « XIII.— TAe Aleppo Varicella. Pityriasis. Evil., or Malum Order III. — Bailee. Ichthyosis. Alepporuyn. Pemphigus. Order VII. — Tubercula. “ XIV. — Elephantiasis Rupia. Lepra Tuberculosa, Arahica. Order IV. — Pustulce. Lupus. “ XV. — Syphilidee or Variola. Molluscum. Syphilitic Erup- tions. Even this classification is very complicated, and appears to me to admit of still further modifications, which will render the subject more simple and practical at the bed-side. I shall point out to you, in the first instance, the reasons which have induced me to make these modifi- cations, and then give, in a tabular form, the classification which we shall in future adopt. In the orders Exanthemata and Pustulce we find several diseases which are characterised by excessive fever, so that they have long been spoken of under the term of eruptive fevers, as well as under that of febrile eruptions. With them, in short, fever is the characteristic, and 830 DISEASES OF THE INTEGUMEXTAKY SYSTEM. they are influenced by laws of a peculiar character, altogether different from those which regulate the production of other cutaneous affections. I propose, then, to remove these disorders from the category of skin dis- eases altogether, and to leave only three in the first order, namely, ery- thema, roseola, and urticaria. I am aware that, strictly speaking, these may be accompanied by slight fever, which may also occur in several other skin diseases. But I do not pretend to form a classification which is perfect, or even pathological, but one which some experience in the teaching of these diseases has convinced me is useful and practical for the student. In the order Vesiculm we find five diseases. I propose cutting out miliaria, as being very unimportant, and a trifling sequela of fevers. Varicella I believe to be a modified small-pox, and I omit it for the same reasons as I do variola. Scabies, on the other hand, though dependent upon the presence of an insect, the Acarus Scahiei, presents such distinct characters as to warrant its retention. I propose expunging the order Bnllce altogether. "We find in it two diseases. The first of these, pemphigus or pompholyx, is a vesicular dis- ease in every point, appearing sometimes in successive crops, and form- ing a laminated scab. Kupia, on the other hand, is evidently a pustular disease, forming a prominent scab, producing ulceration, and leaving a cicatrix. I shall therefore add pemphigus to the order vesiculge, and rupia to that of the pustulm. From the for the reasons formerly stated, I expunge variola, vaccinia, and equinia. Mentagra, so far as I have been able to study it in this country, has always consisted of eczema or impetigo on the chin of the male. In syphilitic cases it is more or less tubercular, and it has been described also as consisting of a vegetable parasite. Although I have never seen the appearance figured % Cazenave (Plate 1C), I can understand that such a mentagra might really consist of vegetable fungi. At all events, mentagra is not a special pustular disease. Porrigo means any eruption on the head, whether vesicular, pustular, or squamous. Favus, to which it has long been applied, is undoubtedly a parasite, and ought, with others of a like nature, to constitute a distinct class. More- over, it is neither vesicular nor pustular. Hence the class of pustulac will with us contain only impetigo, ecthyma, acne, and rupia. The orders Papulm and Squamm remain the same. The strophulus of many English writers is certainly only lichen occurring in the child ; and what has been called lepra, as distinguished from psoriasis, is the latter disease presenting an annular form. From the class Tubercuh I cut out framboesia, as being a disease un- known in this country, together with cheloidea, which, as I understand it, means either cancer or tubercle of the skin. As regards the order Maculcd^ I place purpura in it, as did M illan, because, although sometimes it may depend on constitutional causes of an obscure nature, and at others be allied to scurvy, it still, in an arbi- trary classification of this kind, constitutes an undoubted spot or macula. All the other orders of Biett I shall take the liberty of expunging— pellagra, lepra Astrachanica, and malum Alepporura, are unknown in this country. I agree with Hebra, in thinking that Radesyge is only a modi- DIAGNOSIS OF SKIN DISEASES. 831 fied form of lupus. The elephantiasis Arabica is an hypertrophy of the areolar tissue or chorion, and belongs more to the subject of fibrous growths than that of skin diseases. Syphilitic diseases I do not regard as a distinct order, but as any of the ordinary skin alfections, more or less modified by a peculiar state of the constitution. Whilst I have cut out many diseases from the eight orders originally established by Willan, and subsequently modified by Biett, I find it ne- cessary to add two orders, which the advance of pathology and histology shows ought to be considered apart. I allude to those which depend on the presence of parasitic animals and plants, and which may be called respectively Dermatozoa and Dermatophyta. It has now been shown by M. Boiirguignon, that scabies is dependent on the presence of an acarus, but that the insect is only indirectly the cause of the eruption. Hence I put acarus among the dermatozoa, although it certainly forms, when present, a constituent of itch. Among the dermatophytes will be placed favus and mentagra — both removed from the class pustulae. Other dis- eases, such as plica Polonica, and pityriasis, have been considered as parasitic ; but the former is unknown in this country, and the latter, when it presents epiphytes among the scales, constitutes a form of favus. The classification, then, we shall in future adopt is as follows: Order I. — Exanthemata. Erythema. Roseola. Urticaria. Order II. — Vesiculce. Eczema. Herpes. Scabies. Pemphigus. Order III. — PustulcB. Impetigo. Ecthyma. Acne. Rupia. Order IV. — Papulce. Lichen. Prurigo. Order V. — Equaince. Psoriasis. Pityriasis. Ichthyosis. Order VI. — Tabercula. Lepra Tuberculosa. Lupus. Molluscum. Order VI. — Maculae. Lentigo. Ephelides. Ngevi. Purpura. Order VIII. — Dermatozoa. Entozoon folliculo- rum. Acarus. Pediculus. Order IX, — Dermatophyta. Achorion Schonleinii (Favus). Achorion Grubii (Mentagra).* DIAGNOSIS OF SKIN DISEASES. The recognition of skin diseases, and the separating of one class from another, is of essential importance to a proper treatment. On this point I fully agree with a w^riter, who says, “ The treatment of a great many cutaneous diseases is but of secondary importance compared with their differential diagnosis. Many of them will get well without any treat- ment, provided they are allowed to pursue their natural course ; and, on the contrary, a mild and simple eruption, by being mi.staken, from a similarity of external appearance, for one of a severe or rebellious char- * It has been objected to the words porrigophyte and mentagraphyte, introduced by Gruby, that they are unclassical ; and as the celebrated botanist Link, after care- fully examining these vegetations, has described the former as a new genus, under the head of Achorion (from acAor, the old term given to a favus crust by Willan), I have tUought it best to adopt that term. To mark the variety in favus, he has added the name of its discoverer, Schonlein ; and I have ventured, at all events provisionally, to distinguish the one described as existing in mentagra, by adding to it also that of its discoverer, Gruby. 832 DISEASES OF THE INTEGUMENTARY SYSTEM. acter, and treated accordingly, may be aggravated and prolonged for an indefinite period.’’ — (Burgess.) This diflerential diagnosis, however, to the inexperienced, is a matter of great difficulty, because not only is con- siderable tact generally necessary to discover the original element each disease presents, such as rash, vesicle, pustule, scale, and so on ; but often this is impossible. Under such circumstances the diagnosis is fre- quently derived from the scab, or other appearances presented, such as the cicatrix. The whole subject has been rendered very confused and complicated by systematic writers, who have often given different names to the same disease, or unnecessarily divided them into forms and va- rieties. I advise you not to pay any attention to these forms and varie- ties for the present, and to confine your efforts only to the detection of the diseases enumerated in the table under each order; and with a view of facilitating your endeavors, the following short diagnostic characters and definitions should be attended to. I. Exanthemata. 1. Erythema . — A slight continuous redness of the skin in patches of various shapes and sizes. 2. Boseola . — Circumscribed rose-red patches, of a circular, serrated, or annular form. 3. Urticaria . — Prominent red patches of irregular form, the centre of which is often paler than the surrounding skin. II. Vesiculje. Eczema . — Very minute vesicles in patches, presenting a shining ap- pearance, yielding a fluid which dries into a laminated or furfuraceous crust. The skin is a bright red color. Herpes . — Clusters of vesicles, varying in size from a millet seed to that of a pea, surrounded by a bright red areola. They yield a fluid which dries into a thin incrustation, that drops off between the eighth and fifteenth day. Scabies . — Isolated vesicles of an acuminated form, commonly seated between the fingers and flexor surfaces of the arms and abdomen — never on the face. Pemphigus . — Large vesicles or blebs (bullae) surrounded by an ery- thematous circle, the fluid of which forms, when dry, a laminated crust. When chronic, they appear in successive crops, and the disease is called pompholyx. III. Pustule. Impetigo . — Small pustules, commonly occurring in groups, and form- ing an elevated crust. Ecthyma . — Large isolated pustules, depressed or umbilicated in the centre, and leaving a cicatrix. Acne . — Isolated pustules situated on a hardened base, which form and disappear slowly. They only occur on the face and shoulders. Pupia . — Large pustules, followed by thick prominent crusts, and pro- ducing ulcerations of various depths. DIAGNOSIS OF SKIN DISEASES. 833 IV. Papula. ZicJien . — Minute papulae occurring in clusters or patches. Prurigo . — Larger and isolated papulae generally seated on the exten- sor surfaces of the body. V. Squamje. Psoriasis. — Whitish laminated scales slightly raised above the red- dened surface of the skin. Lepra is poriasis occurring in rings. Pityriasis. — Very minute scales, like those of bran, seated on a red- dened surface. Ichthyosis. — Induration of the epidermis, and formation of square or angular prominences, not seated on a reddened surface. VI. Tubercula. Lepra Tuberculosa. — (Elephantiasis of the Greeks). — Tubercles vary- ing in size, preceded by erythema and increased sensibility of the skin, and followed by ulceration of their summits. Lupus. — Induration or tubercular swelling of the skin, which may or may not ulcerate. In the former case, ulceration may occur at the sum- mit or at the base of the tubercles, and frequently extends in the form of a circle more or less complete. Molluscum. — Pedunculated, globular, or flattish tubercles, accom- panied by no erythema or increased sensibility, occurring in groups. They are filled with atheromatous matter. VII. Macula. Lentigo or Frechle. — Brownish-yellow or fawn-colored spots on the face, bosom, hands, or neck. Ephelis. — Large patches of a yellowish-brown color, accompanied by slight desquamation of the cuticle. Nceci or Moles. — Spots of various colors or forms, sometimes elevated above the skin. They are congenital. Purpura. — Bed or claret-colored spots or patches, which do not dis- appear under pressure of the finger. VIII. Dermatozoa.. These minute animals require a lens of considerable power to ascer- tain their characters, which need not be particularised here, as they will be subsequently described and figured. (See p. 830, et seq.) IX. Bermatophyta. These minute plants require a high magnifying power to distinguish them with exactitude. But they communicate peculiar characters to certain cutaneous diseases, as follows • Favus. — Bright yellow, umbilicated crusts, surrounding individual 53 834 DISEASES OF THE. INTEGUMENTARY SYSTEM. hairs, which agglomerate together to form an elevated friable crust, of a peculiar musty or mousey smell. Mentagra. — Grayish or yellowish dry crusts, of irregular form, origi- nating in the hair follicles of the beard. In forming your diagnosis, therefore, you will be guided principally by three characters : — 1st, The primitive and essential appearance — that is, whether a rash, vesicle, pustule, and so on. 2d, The crust — whether laminated or prominent, composed of epidermis only, etc. 8d, Ulcera- tion, — whether present or absent; and if so, the kind of cicatrix. These and other characters I shall point out at the bed-side, so as to familiarise you with their appearances. You will remember that the classification formed by Willan is wholly artificial. It is like the Linnsean classification of plants. The difiiculty for the learner is to recognise the essential character, the more so as many diseases pass through various stages before this is formed. Thus herpes presents — 1st, a rash; 2d, papules ; 3d, vesicles ; 4th, pustules; yet the disease is considered vesicular. Ecthyma passes through the same stages, yet it is considered pustular. In the vesicular disease, however, the crust is laminated, — in the pustular, it is more or less prominent. Again, it not unfrequently happens that two or more diseases are combined together in one eruption. Thus it is very common to meet eczema and impetigo combined, when the disease is called Eczema im'peti- ginodes. Favus occasionally causes considerable irritation, producing a pustular or impetiginous margin around it. The vesicles of scabies are often accompanied by the pustules of ecthyma, and so on. In very chronic skin diseases, it may happen that it is impossible to say what the original disorder was, whether vesicular, pustular, scaly, or papular. In such cases the skin assumes a red color, the dermis is thickened, the epidermis rough and indurated, and a morbid state is oc- casioned, in which all trace of the original disease is lost, and what remains is a condition common to various disorders. As regards varieties, little need be said, and as I formerly stated, I advise you to postpone their study until you are acquainted with the diseases themselves. Even then an acquaintance with them is of secon- ' dary importance. These varieties have been formed on account of the most varied circumstances, such as, — 1st, Duration, most of them may be acute or chronic ; 2d, Obstinacy, the terms inveterata^ acrius^ etc.; 3d, Intensity, hence the terms mitis^ maligna^ etc.; 4th, SrruA- TiON, hence the terms capitis, facialis, lahialis, pafmaris, etc. ; 5th, Form, hence the terms circinatus, scutulata, iris, gyrata, larvalis,figu- rata, tuherosa, guttata, etc.; 6th, Consittution, hence the terms cachec- tica, scorbutica, syphilitica, etc.; 7th, Age, hence the terms inf antilis, senilis, etc. ; 8th, Color, hence the terras album, nigrum, rubrum, versicolor, etc ; 9th, Density, hence the terms sparsa, diffusa, concen- iricus, etc. ; 10th, Feel, hence the terms Iccve, indurata ; 11th, Sensa- tion PRODUCED, hence the terms formicans, pruritus, uriicans, etc. ; 12th, Geographical distribution, hence the terms tropicus, Mgyptiana, Nor- wegiana, etc. DIAGNOSIS OF SKIN DISEASES. 835 PORRIGO. There was a period in the history of skin diseases when they were arranged in two great divisions — viz., those affecting the scalp, and those affecting the rest of the cutaneous surface. All the disorders compre- hended ill the hrst of these divisions received the name of Porrigo, a word said by some to be derived from jporrum, on account of the scales or concretions of the scalp resembling the layers of an onion ; by others it is derived from porrigo^ to spread. Willan described six kinds of Por- rigo, viz., P. larvaXis, P. furfurans, P. scutulata^ P. favosa^ P. lupi- nosa^ and P. deoalvans. It is now ascertained that none of these dis- eases are necessarily peculiar to the scalp, — and that, although they are more or less modified by being connected with and affecting the hairs of that region, they may also occur on other parts of the skin. There can be little doubt, however, that the employment of the term Porrigo, as well as the corresponding word Teigne in France, has thrown great con- fusion over the subject of eruptions on the scalp. But, as this term is still in pretty general use, it will be well to explain to you what diseases these different kinds of Porrigo really are. Porrigo larvalis (larva, a mask) is really Impetigo, or Eczema impe- tiginodes, of the scalp. The former is recognised by crusts more or less prominent or nodulated ; the latter, by the circumstance that, in addition to these nodules, there is between them a laminated or brittle crust, spread more or less equally over the surface. They are both ver}^ com- mon in infants and children and the disease sometimes extends over the face, concealing the features, hence the term larvalis. A very charac- teristic representation of Impetigo capitis is given in Willan and Bate- man, Plate xli., erroneously called Porrigo favosa. (See also the disease on the face, ibid., Plate xxxvii. ; Alihert, Planches 13 and 15.) Porrigo furfurans (furfur, bran) is really Pityriasis of the scalp, although Psoriasis of that region has also received the same appellation. There is also a peculiar form of Eczema, or Eczema impetiginodes, in which the crust is friable, and breaks up, or crumbles into minute frag- ments, to which the term furfurans has been erroneously applied. The true Porrigo furfurans (Pityriasis) is well represented, Willan and Bate- man, Plate xxxviii. ; Alihert, Planches 14 and 15. It is often a form of favus. (See Favus.) Porrigo scutulata (scutulum, a small shield). — The nature of this dis- ease has been much disputed. By some it is said to be Favus (Erasmus Wilson), by others a form of Herpes (Cazenave). The disease is de- scribed by Willan and Bateman, and more recently by Burgess, as con- sisting of oval or rounded, slightly elevated patches, covered with furfur, and having stunted or filamentous hair projecting from the sur- face. It is a form of skin eruption exceedingly rare in Edinburgh. It seems to be represented, Willan and Bateman, Plate xxxix. ; Willis (Trichosis scutulata). Porrigo favosa (favus, a honeycomb) is a disease, the true nature of 836 DISEASES OF THE IXTEGUMENTAET SYSTEM. which has been only lately determined. It consists essentially of an exudation on the skin, in which fungi or phytaceous plants grow. Hound, isolated, bright yellow crusts are formed, which, when compressed toge- ther, assume an hexagonal shape — hence the term favosa. It is well represented, Willis (Trichosis lupinosa) ; Erasmus Wilson, Fasciculus I., Alibert, Planche 17. Porrigo lupinosa {lupinum, the lupine). — This is the same disease as the last. The round or oval crusts, when isolated and at an early stage, present a concavity and form resembling that of the lupine seed — hence its name. Porrigo decalvans {calvus, bald). — Baldness is so common among the aged that it can scarcely be called a disease ; but when it occurs in young persons, and is circumscribed, it constitutes the Porrigo decalvans of Willan. It is said by Gruby to depend on a vegetable parasite grow- ing in the hair. It is well represented, Willan and Bateman, Plate xl. ; Willis (Trichosis decalvans). From this analysis of the different kinds of the so-called Porrigo, you observe that there is nothing peculiar with regard to them. With the exception of baldness, none essentially belong to the hairy scalp. True favus is far more common on the head than elsewhere ; but I have fre- quently seen it on various parts of the cutaneous surface, and occasion- ally on the cheeks or shoulders, without being on the scalp at all. It follows that, instead of the term Porrigo, you should designate the disease as Eczema, Impetigo, Pityriasis, Psoriasis, or Favus of the scalp, as the case may be. Notwithstanding I have endeavored to place this subject before you in as simple and uncomplicated a form as possible, I am conscious that at first you will still experience considerable difficulty in the diagnosis of skin affections. This can only be removed by practical experience at the bed-side, and by constantly exercising your powers of observation in detecting the essential elements which their varied forms present. At the same time, I think the modified classification and short characters I have given, will materially assist your studies in this important depart- ment of practical medicine. It must be remembered, however, that they only refer to those cutaneous diseases which you are liable to meet with in this country. Should you ever be called upon to practise in the tropics, or in other places where peculiar skin disorders prevail, it will, of course, be your duty to study them in an especial manner. Here, as they cannot be made the subject of clinical observation, they are alto- gether removed from our consideration. THE TREATMENT OF SKIN DISEASES. Since the addition of a ward for skin diseases to the clinical depart- ment of the Royal Infirmary, I have had ample opportunities of deter- mining what are the more common forms of cutaneous eruption met with THE TREATMENT OF SKIN DISEASES. 837 in Edinburgh, and of trying various kinds of remedies. As the illus- tration of so many forms of integumentary disease by reports of cases is in this work impossible, I propose now to give a condensed account of the treatment I have found most successful. Exanthemata. Few cases laboring under erythema, roseola, or urticaria, enter the Infirmary ; and in such as occasionally present these eruptions during their residence there, the mildest remedies suffice for their removal. In the severer cases, a saturnine lotion to diminish local irritation, with a saline purgative, generally suffices for the cure. Vesiculje. Eczema is by far the most common disease met with, both in its acute and chronic forms. The local treatment I have found most effica- cious is that which I first recommended in 1849. It consists in keep- ing the affected part moist, with lint or linen saturated in a very weak alkaline solution, consisting of 3 ss of the common carbonate of soda dissolved in a pint of water. For this purpose it is necessary to cover the moistened lint with oil silk, or gutta-percha sheeting, which should well overlap the lint below, so as to prevent evaporation. The usual effect is soon to remove all local irritation, and especially the itching or smarting so distressing to the patient. It also keeps the surface clean, and prevents the accumulation of those scabs and crusts which in them- selves often tend to keep up the disease. After a time, even the indu- rated parts begin to soften, the margins of the eruption lose their fiery red color, and merge into that of the healthy skin, and finally the whole surface assumes its normal character. In private practice, it is often a matter of great difficulty to secure a proper application of the lotion. Individuals are slow to accept the idea that constant moisture of the part is absolutely necessary for the treatment, and hence vigilant superintendence and frequent visits are requisite, in order to watch the progress of the case. Even in the hos- pital constant care is necessary, to see that nurses properly cover the eruption ; and when, as sometimes happens, this task is given to the pa- tients themselves, it almost always fails. Then there are some portions of the surface which it is very difficult to keep moist and well covered, such as the face and axillae. But, by carefully adapting lint and gutta- percha sheeting, attaching strings to the edges of the latter, so as to keep the whole in its place, I have never failed in ultimately carrying out my object. In the Infirmary I treat vesicular eruptions of the face in this way by means of a mask, having apertures for the eyes, nostrils, and moutffi If the eruption be very general, long soaking in slightly alkaline baths is useful. In addition to stating what I have found to be beneficial, it is im- portant to say what I have, on careful trial, ascertained to be useless or injurious. Perhaps no remedy is more generally employed in this and a variety of other skin diseases than citrine ointment — an applica- * Monthly Journal of Medical Science, August 1849. 838 DISEASES Ob’ THE INTEGIIMENTAKY SYSTEM. tion that I have always found to irritate and make eczematous eruptions worse. At the same time, there are some very chronic forms of the dis- ease which I have been told are cured by this preparation, but what these are I have never been able to ascertain. Indeed, all greasy appli- cations whatever, in acute cases, are useless, and the patients themselves say, are very “ heating.” I have tried the freezing process recommended by Dr. Arnott, but the salt of the frigorific mixture, and the cold itself, has caused apparently so much agony, that I have been deterred from using it, especially when the emollient moist alkaline application is so efficacious. In some rebellious chronic cases I have occasionally found the oil of cade a useful remedy, and in others the oxide of zinc ointment. They are most beneficial after a prolonged use of the moist alkaline applica- tion In the same way, friction with the hand or a soft flesh-brush fa- vors the disappearance of the chronic induration and vascularity of chronic eczema of the inferior extremities, which should be kept as much as possible in the recumbent position. These stimulating appli- cations, whilst useful in the very chronic and non-irritativc forms of the disease, or to remove what an emollient treatment fails to accomplish, are most injur' ous in the acute forms. llerpes . — This disease generally runs its course in about fourteen days, and requires no treatmen't whatever further than an acetate of lead lotion to allay the smarting. It is not very common. Scabies occuis very frequently, and is cured by a host of remedies. A strong lather, made of common soft soap and warm water, twice a day, answers very well. The question with scabies, is not what remedy is useful, but which will cure it in the shortest period. The most exten- sive experience at St. Louis has shown, that the sulphur and alkaline, or Helmerinch’s ointment, cures itch, on an average,- in seven days. That sulphur, however, is not the active remedy, I have satisfled myself by experiment. Soft soap, as we have seen, which contains alkali, and even simple lard, if pains be taken to keep the parts constantly covered with it, will cure the disease as soon as sulphur ointment. I have tried the Stavesacre ointment, recommended by M. Bourguignon, in only a few cases, but found it to answer very well. Its superiority, however, over other applications, I am not yet prepared to admit. (See Dermatozoa.) P emphigus . — This is rather a rare disease, and when chronic, coming out in successive crops, is very rebellious. I have cured several acute, and some tolerably chronic cases, in from one to three weeks, by the weak alkaline wash, applied as in the case of eczema, combined with generous diet. Pustule. Impetigo . — This affection in all its forms is very common, and is best treated by the weak alkaline wash, exactly the same as in eczema. In the chronic forms which attack the chin of men, constituting one of the varieties of mentagra, the same treatment cures the most rebellious cases, if the moisture be constantly preserved. For this purpose the hair must be cautiously cut short with sharp scissors, and the razor care- fully avoided. If the side of the cheek covered by the whisker be THE TREATMENT OF SKIN DISEASES. 839 attacked, removal of the hair from thence also is essential to the treat- ment. A bag or covering accurately adapted to the part affected must be made of gutta-percha sheeting, and tied on with strings. This may be covered with a piece of black silk, to allow the individual to go about and carry on his usual occupations. In this way I have fre- quently seen chronic impetigo of the chin, of from eight to ten years’ standing, which has resisted all kinds of ointments and heroic remedies, completely removed in a few weeks. But then the surface must be kept constantly moist, a circumstance requiring great care and determination on the part of the patient. When it becomes necessary to shave, flour and warm water, or paste, should be used, and not soap. Alkalies, applied from time to time only, as in the form of wash or soap, always irritate, although, when employed continuously, they are soothing. Ecthyma is not a common disease, and usually presents itself con- joined with Eczema or Impetigo, and is treated successfully in the same manner as those diseases. The E. cachecticum requires, in addition to the alkaline wash locally, a generous diet. Acne is a disease frequently requiring constitutional rather than local remedies. Although not uncommon in private, it is rare in hos- pital practice. Careful regulation of the diet, abstinence from wine and stimulating articles of food, watering-places, baths, etc. etc., constitute the appropriate treatment. Bupia . — This disease I have never seen occur but in individuals who have been subjected to the influence of mercurial poisoning. Hydriodate of potassium and tonic remedies, with careful avoidance of mercury in all its forms, is the general treatment I have found most successful. If the pustules be few in number, the scabs may be removed by poulticing, and the sores treated locally with water-dressing or red wash. But if they are numerous, great caution should be exercised in exposing so many ulcerated surfaces, and it is better to let the crusts remain. Papula. Lichen and Prurigo . — In both these affections, constant inunction with lard is as beneficial as constant moisture in the eczematous and impetiginous disorders. In the prurigo of aged persons, the Vng. JIgd. Precip. Alb. is a useful application, although the disease is not unfre- quently so rebellious as only to admit of palliation. The chronic papu- lar diseases often constitute the despair of the physician. Squama. Psoriasis^ and that modification of it known as lepra^ is a very com- mon disease, and has been uniformly treated by me externally with pitch ointment. I have satisfied myself, by caref^ul trials, that it is the pitch applied to the part that is the beneficial agent, as I have given pitch pills and infusion of pitch largely internally, without benefit. With the hope of obtaining a less disagreeable remedy, I have frequently tried creasote, and naphtha ointment, and washes, but also without 840 DISEASES OF THE INTEGFMENTAEY SYSTEM. benefit. Lastly, I have caused simple lard to be rubbed in for a length* ened time, but without doing the slightest good. The oil of cade is occasionally useful, especially in psoriasis of the scalp. Internally, I give five drops of Fowler’s solution, and as many of the tr. cantharidis. It is rare that the internal treatment alone produces any effect on a case of psoriasis of any standing. If a case resists this conjoined external and internal treatment, I have always found it incurable. Some years ago I carefully treated a series of cases internally with Donovan’s solu- tion, without producing the slightest benefit. True Fityriam frequently disappears of itself. In chronic cases the treatment by pitch is useful, and sometimes the application of the Ung. Zinci Oxyd. or Ung. Hyd. Precip. Alb. The form of pityriasis that is dependent on a vegetable fungus is identical with favus. (See Favus.) Ichthyosis. — I have treated several chronic cases of ichthyosis. But while in some cases the skin has become a little softer from a course of pitch treatment, no permanent cure was effected. Tueerculjs. Lupus is the only kind of tubercular skin disease I have seen in the skin ward of the Infirmary, and that is pretty common. It is a constitutional disorder, and must be treated by cod-liver oil, and all those remedies useful for scrofula, of which it is a local manifestation. The external treatment is surgical, consisting of the occasional applica- tion of caustics, red lotion, water-dressing, ointments, etc., according to the appearance of the sore. I agree with Hebra in thinking lupus and the radesyge of the Norwegians to be the same disease. Many years ago I found lupus of the legs and thighs to exist among the fisher- women of Newhaven, who assisted their husbands in hauling in their boats, or who were accustomed to wade for any length of time in salt water. Macula. Lentigo I have never found to be benefited by any kind of treatment, local or general. It is evidently connected with season and the intensity of the sun’s rays, as it often disappears in winter and returns in summer. Bphelis and Ncevi are alike incurable. Bronzing from exposure to the sun, as in hot climates, frequently disappears on returning to a tem- perate latitude. Purpura is a. constitutional disorder, for the most part allied to scurvy. It consists ot an alteration of the blood, with tendency to dis- integration of the colored corpuscles and ditfusion of haematozine. Un- der such circumstances, ecchymoses occur in the skin, sometimes con- fined to round spots, varying in size, at others existing in patches. It is for the most part associated with weakness, and requires rest and time to permit absorption of the extravasated blood, conjoined with tonics, anti-scorbutics, and generous diet. In sea scurvy, lemon juice and fresh vegetables are the true remedies. (See Scorbutus.) Scalp diseases must be treated according as they depend on eczema, THE TREATMENT OF SKIN DISEASES. 841 impetigo, psoriasis, or favus — in all cases first removing the crusts with poultices, then keeping the head shaved, and, lastly, applying alkaline washes, pitch ointment, or oil, according to the directions formerly given. Ringworm is a disease I have never seen in Edinburgh, and of what it consists I am ignorant. Some writers apparently consider it to be favus, and others a form of herpes. On two or three occasions I have seen a scaly disease of the scalp, in the form of a ring — that is lepra, which I have cured by pitch ointment, or oil of cade. Dr. Andrew Wood in- formed me some time ago, that he banished it from the Heriot’s Hos- pital school of this city by condensing on the eruption the fumes of coarse brown paper, and thus causing an empyrrheumatic oil, or kind of tar, to fall upon the part. This at one time led me to suppose that it might be a scaly disease, and a form of lepra or psoriasis. On the whole, I am inclined to think it a form of favus, which has commonly been mistaken for a scaly disease of the scalp. (See Favus.) So-called Syphilitic diseases of the skin are, in my opinion, the various disorders already alluded to, modified by occurring in individ- uals who have suffered for periods more or less long from the poisonous action of mercury. A longer time will be required for their cure, but the same remedies locally, conjoined with hydriodate of potassium in small doses, with bitter infusions, tonics, and a regulated diet, offer the best chance of success. The great difiiculty in the treatment of skin diseases generally con- sists in their having been mismanaged in the early stages — a circum- stance I attribute to the little care with which, until a recent period, clinical students have studied them. Many chronic cases of eczema are continually coming under my notice, which, in their acute forms, have been treated by citrine ointment, or other irritating applications, that almost invariably exasperate the disorder. I shall not easily forget the case of one gentleman, covered all over with acute eczema, who had suffered excessive torture from its having been mistaken for psoriasis, and rubbed for some time with pitch ointment. In the same way I have seen a simple herpes, which would have readily got well if left to itself, converted into an ulcerated sore by the use of mercurial ointment. Nothing is more common than to confound chronic eczema of the scalp with favus, although the microscope furnishes us with the most exact means of diagnosis. I have seen one case in which a chronic eczema of the cheek was cut out by a surgeon, under the idea that the disease was malignant. I presume that acne must frequently have been mistaken for tubercular disease. In no other way can I account for some very dis- tressing cases, where the patients’ faces have been painted over with but- ter of antimony. I need scarcely say, that the correct application of the remedies I have spoken of can only be secured by an accurate discrim- ination, in the first instance, of the diseases to which they are applicable. The general constitutional treatment in all these cases seldom de- mands aperient or lowering remedies except in young and robust indi- viduals with febrile symptoms. In the great majority of cases, cod- liver oil, good diet, and tonics are required. In a few instances sedatives, both locally and internally, are necessary to overcome exces- sive itching or irritation. These the judicious practitioner will readily 842 DISEASES OF THE INTEGUMENTAKY SYSTEM. understand how to apply according to circumstances. Baths in all their various forms are useful in skin diseases, althougli, since I have applied a kind of constant local bath in the form of moist application, formerly alluded to (See Treatment of Eczema), they are comparatively seldom used by me in the Infirmary. The natural baths and mineral springs of watering-places in Great Britain, France, and Germany, are undoubtedly beneficial in appropriate chronic cases. DERMATOZOA. The skin may be attacked by certain animal parasites. Of these the pedicula, or lice, are too well known to need description. But we may shortly allude to the Acarus scabici, and the Entozoon follicu- lorum. Acarus Scabiei. This insect has been proved by the researches of M. Bourguignon* to be the undoubted cause of itch. The male is about a third smaller than the female. He has suckers on two of his hind feet, and possesses on the abdominal surface genital organs, all of which characters are * Traite entomologique et pathologique de la gale de I’homme. 4to. Paris, 1852. Fig. 484. Dorsal surface of the female Acarus Scabiei. Fig. 485. Ventral surface of the same. Fig. 486. Ventral surface of the male Acarus. — {Bourguignon.) 100 diam. DERMATOZOA. 843 absent in the female. She, on the other hand, in addition to her size, and the negative marks alluded to, is characterised by the three kinds of horny spines which are scattered over the back. The suckers, or ambulacria, are organs of locomotion ; the mandibles enable it to cut the epidermis, and extract fluid from the tissue, which passes through a delicate oesophagus, the internal termination of which is unknown, the body of the animal being apparently filled with an unorganized, very finely molecular pulp. A short delicate tube may also sometimes be observed at the anus — a supposed rectum. No respiratory apparatus can be discovered, although the creature may be seen to swallow minute bubbles of air, which pass down the oesophagus, and, like the nutritive juices, ditfuse themselves through the interior. At all events, animal juice and air are both necessary to the life of the Acarus. The disease called scabies has been conclusively shown by M. Bourguignon to be entirely owing to the presence of the insect, and to be communicated from one person to another, eight times out of ten, by their sleeping together. The female seldom quits her burrow but at night, and if impregnated, not even then, unless disturbed mechani- cally, as by scratching. Once in motion, she crawls over the surface with great rapidity, and readily passes from one person to another, where the skins are in contact. Communication is not readily occa- sioned by holding the hands of those atfected, or by coming in contact with them during the day. The disease cannot be communicated by inoculating with the serum of the vesicles, by the pus of the pustules, or by any principle contained in the dead body of the insect itself. Neither can the Acarus of one species of animal, as of the horse or sheep, inhabit the body of a difierent one. Still the disease is not purely local, inas- much as papular, vesicular, or pustular eruptions often occur in parts which the Acarus has not infested, so that they seem to originate from some cause independent of its mere presence. The Acarus has a predilection for youth and a tender skin, and has a hatred of hair bulbs. Hence why it frequents young persons more commonly than old ones, and why in children it occurs indis- criminately all over the body, while in adults it is most often found between the fingers and toes, inside of the thighs and genital organs. Seventy times out of a hundred, scabies is confined to the hands, and in the other thirty, occurs also on the trunk and genitals. The only proof of the existence of itch is the presence of the Acarus, and this is easily to be detected by a microscope adapted for the purpose by M. Bourguig- non. It consists of a body with eye-piece and lenses magnifying seventy diameters linear, with a condensing lens, the whole placed on a movable arm with several joints, attached to a firm stand. With this instrument the entire surface of the body may be explored, and the movements and doings of the insects observed with the utmost facility. The associated papules, vesicles, and pustules are, in the opinion of M. Bourguignon, in no way diagnostic. M. Biett made a series of experiments at the Hopital St. Louis, to determine what substance would cure itch in the shortest space of time. He employed forty-one difierent applications and modes of treatment. The result was, that frictions with the following ointment occasioned 844 DISEASES OF THE INTEGUMENTARY SYSTEM. recovery on the average in the smallest number of days : — Take of sub- limed sulphur, two parts ; of subcarbonate of potash, one part ; and of lard, eight parts. M. Albin Grass endeavored to ascertain what substances would most quickly destroy the Acarus just removed from its burrow. It survived three hours in water ; two in olive oil ; one in a solution of acetate of lead ; four-fifths of an hour in warm water ; twenty minutes in vinegar and an alkaline solution ; twelve minutes in a solution of sulphuret of potash ; nine minutes in turpentine ; and from four to six minutes in a solution of the hydriodate of potash. It survived sixteen hours in the vapor of sulphur under a watch-glass ; and one hour in the flowers of sulphur. According to these researches, therefore, hydrio- date of potash would be the best remedy. He removed three living insects from a patient who had taken three sulphur baths, whereas, after a single application of Helmerinch’s ointment, that is, where sulphur and potash are combined, he frequently found them dead. M. Bourguignon with his microscope watched with great care the effect of the frictions made at St. Louis with the sulphuro-alkaline ointment. After the first day, in which there had been two frictions and a simple bath, the Acari were in no way disturbed. In two days, after four frictions, they were still active, but burrowed deep in their grooves. In three days they still lived, but were unusually flat ; but their eggs could be hatched by artificial heat, and produced larvae, possessing great activity. In four days the insects in the superficial parts were shrivelled up and dead ; the deeper ones, though living, tres malades. Many of the eggs now aborted. In five days all the insects were dead ; and in six even the eggs had lost their vitality. The eruptions, on the other hand, often remained stationary, and not unfrequently became worse from the irritation of the ointment and frictions, but after a time they disappear also. Hence it is common at St. Louis, after seven or eight days’ friction, to send out the patients though still covered with eruption, and in most cases they get well. About three in ten, however, return with the disease again established, a circumstance that Mons. B. attributes to the fact, that the frictions, which were only applied to the superior and inferior extremities, had not destroyed the insects which were present on the trunk. M. Bourguignon, on considering the structure of these Acari, and the facility with which a poisoning fluid could penetrate their delicate integument, was led to make a series of observations to determine how long they would live after the application of various toxic solutions. He found those which possessed the most energetic action on these creatures were solutions of the ioduret of potassium and of the ioduret of sulphur, which killed them in eight minutes. A solution of the alcoholic extract of staphisagria was the next in virulence, destroying the animals in fifteen minutes. The hands of an itch patient were immersed in a solution of the two former for two hours, so as strongly to impregnate and color the integuments. On examining the insects immediately afterwards, they were as lively as ever, but on the next day they were all dead, and the eggs destroyed. The epidermis was greatly shrivelled, and in three days complete desquamation occurred, carrying DERMATOZOA. 845 with it Acari, grooves, and eggs, and leaving the cutis raw and tender. The action on the skin was evidently too strong. A bath of a solution of the alcoholic extract of staphisagria was then made, and immediately after a two hours’ immersion of the hands, all the insects were found dead, and, with one exception, the eggs destroyed. So far from irritat- ing the integument, this application at once caused the itching to cease, and produced such calmative effects, that M. B. proposes it as a local] remedy for inflammation. The eruptions also appeared to be rapidly cured by it. After various experiments, he adopted an ointment of the staphisagria as the most generally useful preparation, prepared as fol- lows : — Recent grains of staphisagria in powder, 300 grammes ; boiling lard, 500 grammes. Digest for 24 hours at the temperature of 100° in a sand bath and strain. Four days of friction with this ointment, in- stead of seven with sulphuro-alkaline ointment, not only destroys the insects and their egg?, but completely cures and prevents the integu- mentary irritation and eruptions. Entozoon Folliculorum. This insect inhabits the sebaceous follicles of the skin, and is very common in the face, more especially when the seat of acne. In the Fig. 487. Pig. 488. follicles of the nose they are present in the majority of living persons. Fig. 48 Y. Three follicles of the skin of the dog containing entozoa. 100 diam. Fig. 488. Cul-de-sac of a sebaceous follicle, containing three animalcules in different positions, and two eggs — (after Oruhy). 350 diam. 846 DISEASES OF THE INTEGUMENTAEY SYSTEM. and, according to Simon, are almost universal in dead bodies. He frequently found them living six days after the death of the individual in whom they were found. The animal measures from l-135th to l-64th of an inch in length, and from l-155th to l-555th of an inch in breadth. It is composed of a head, a thorax, and abdomen. The head represents in form a truncated cone, flattened from above downwards, and directed obliquely downwards from the anterior part of the trunk. The existence of an eye has not been determined. The head is furnished with two maxillary palpi, which admit of extensive motion. The thorax is the broadest part of the animal, and is composed of four segments. In each of these, on each side are two legs — eight in all. The abdomen varies in length, is annulated in structure, and admits of certain movements. Inter- nally Dr. Erasmus Wilson has traced out an alimentary canal, and its termination in an anus, together with a brownish mass which he considers to be the liver. No sexual differences have been discovered in them, and they possess no respiratory organs. The animalcule is easily found by com- pressing with two fingers the skin we wish to examine, until the sebaceous matter is squeezed out, in the form of a little worm. This matter should be placed in a drop of oil previously heated, then separated with needles, and examined with a microscope magnifying 250 diameters. Their move- ments are slow, whilst the conformation of their articulations only permits them to move forwards and backwards, like lobsters (Gruby). They are nourished by the seba- ceous secretion of the follicles. They most commonly occupy the excre- tory duct of the follicles, which are often dilated in the places where they are lodged. Their head is always directed towards the base of the gland. When there are many together, they are placed back to back, and their feet are applied against the walls of the duct. When very numerous, they are compressed closely together, and are found deeper in the ducts. They rarely exist, however, at the base of the gland. In young persons they generally vary in number from two to four ; in an aged individual, they may be from ten to twenty. (Gruby). Though this entozoon may occasionally be associated with acne, it seldom gives rise to great inconvenience. According to Erasmus Wilson, Fi". 489. Hair and its follicle, in which may be seen the animalcules descending towards the root of the hair, and cul-de-sac of the follicles. — {Gruby.) 100 diam. DEKMATOPHYTA. 847 the difficulty seems not to be to find these creatures, but to find any individual, with the exception of newly-born children, in whom they do not exist'. DEKMATOPHYTA. The growth of parasitic fungi on the surface of the skin has now been observed under a variety of circumstances, and constitutes occasion- ally in man three forms of skin disease — viz., taenia favosa, and certain forms of pityriasis and of mentagra. The latter is very rare in this country ; and I have never seen a case of it. All these disorders, however, may be classified under the head of favus, under which I shall consider them. Favus. Case CXCIL* — Favus of the Scalp in an Adult — Incurahle. History. — Isabella Fergusson, set. 22, a somewhat stout servant girl, with fair skin, and scrofulous aspect, was admitted into the clinical ward of the Royal Infir- mary, May 6th, 1849. She states that there has been an eruption on her head for the last twelve years. Four months ago the catamenia ceased, since which time she has been subject to occasional headache, constipation, and slight dyspepsia. Symptoms on Admission. — Nearly the whole of the scalp is covered with a thick yellow friable crust, of uneven surface, and irregular margin, emitting a highly offen- sive odor, like cat’s m*ine, 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 were removed by poultices, and an ointment composed of ammon. mur. § j ; and ung. sulphuris § j, applied locally. Dr. Bennett first took charge of the case on the 14th of June. The head was then again covered with favus crusts, some isolated, others compressed together .and forming an elevated scab. A small portion, examined under the microscope, presented the branches and sporules of the cryptogamic plant so characteristic of the disease. The crusts were again removed hg poultices of linseed meal^ the head shaved, ana cod-liver oil ordered to be applied to the scalp morning and evening — the whole to he covered with an oil-silk cap. This treatment was continued for six weeks, but on suspending it the favus crusts returned. During the months of August and September, iodine and pitch ointments were applied : portions of the scalp were even blistered, but without effect. Progress of the Case. — At the commencement of October, the scalp being at the time perfectly clean and closely shaved, all local treatment was suspended, and the reappearance of the disease carefully watched. In three days the entire surface pre- sented a scaly eruption, the epidermis being raised, cracked, and broken up over the whole scalp, which was exceedingly dry and harsh. The furfuraceous condition of the scalp continued, becoming more and more dense, until the fourteenth day, when there were first perceived minute bright sulphur-colored spots in it. These, on being examined microscopically, were seen to be composed of fine molecular matter, mingled with epidermic scales, from which delicate branched tubes were apparently growing. The crusts were now once more removed by repeated poulticing, and cod-liver oil applied as formerly The scalp continued free 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 8^/i of December. During this period, no local application was made to the scalp, with the exception of the cold douche to alleviate the head symptoms, delirium and coma hav- ing been severe. The surface latterly once more became covered with furfuraceous scales ; and on the Wth December the bright yellow minute spots again made their appearance. As her strength improved, the favus crusts increased in size and num- ber, and the progress of this very singular disease was again very carefully watched. Each individual crust, at first the size of a small pin’s head, gradually flattened out, * Reported by Mr. William Johnston, Clinical Clerk. 848 DISEASES OP THE INTEGUMENTARY SYSTEM. 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 diame- ter. 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 foi’m of the honey-comb. Gradually the concavity disappeared. Each crust presented an external dark ring, and an internal lighter centre, which became considerably elevated. Tlie 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 \1th January ^ when the cure appearing to be hopeless she was dismissed. She was enjoined to continue the use of the oil, which, whilst applied, and covered with the oil-silk cap, had the power of preventing the formation of fresh crasts on the scalp. Case CXCIII.^ — Fatus of the Scalp of three years' standing — Cured. History. — Margaret Bryer, set. 12, of scrofulous and cachectic appearance, was ad- mitted June 19th, 1849, with favus crust on the scalp. The crusts are most numer- ous and dense on the crown of the head ; but others, isolated or in small groups, are scattered over the temples, forehead, and occiput. The scalp is bald here and there in patches, varying in diameter from half an inch to an inch. On examining the crusts microscopically, they are seen to contain the cryptcgamic branches and sporules pathognomonic of favus. The disease is of three years’ standing, and is attributed to the use of a comb, belonging to another girl who had a sore head. The crusts have been several times removed by means of pitch plasters and a variety of ointments, but have always returned. Progress of the Case. — At first, the crusts were removed and the scalp kept moist by means of an alkaline lotion, which succeeded in removing the irritation. Early in July she was ordered § ss of cod-liver oil three times a day. The oil was also directed to be applied to the shaved scalp twice daily., which was to he Tcept constantly covered with an oil-silk cap. This treatment was persevered in until Augxist lO^A, when she w'as dismissed cured. This girl was re-admitted September hth., and remained in the In- firmary five days, under observation. Up to this time the disease had not re-appeared, so that, when dismissed on the lO^A, a permanent cure was undoubtedly produced. Case C'K.CIY Favus caught in the Ward from Case Cured. History. — Margaret Cameron, aet. 6, an ill-nourished, cachectic-looking child — admitted July 23d, 1849, on account of an eruption on the scalp. In some places the hair was matted together by a recent pustular eruption ; groups of impetiginous pustules and eczematous vesicles being scattered here and there. In others, where the disease was 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 microscopic demonstrations of the scabs. Poultices were ordered to the scalp., to remove the crusts ; and afterwards an alkaline wash., with cod- liver oil internally. Progress op 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 microscope. It appeared that the girl was a great favorite with Isabella Fergusson (Case CXCII.), 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 im- proved ; and the crusts were ordered to be removed 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 treat- ment 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 w^eek elapsed without any return of favus ; and, her health being now good, she was discharged, December Uh. * Reported by Dr. J. Smith, Clinical Clerk. \ Reported by Mr. Alexander Struthers, Clinical Clerk. FAVUS. 849 Case CXC V.* — Favus of the Scalp of four years'^ standing^ cured hy a Sulphurous Acid Lotion. History. — Helen Goodall, aet. 15 — admitted November 3d, 1853. She has been affected with favus of the scalp for four years, and frequently been in the Infirmary, and subjected to various kinds of treatment, under different physicians, without any permanent benefit. On admission, a great part of the scalp was bald, from destruc- tion of the hair bulbs, but the other portions were covered with a prominent yellow friable crust, of mousey odor, crowded with pediculi. On the ^th 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 23c?, leaving the scalp partly bald, but quite clean. On the \UK 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 bth. Case CXCVI.f — Limited Favus of the Cheehy cured hy Cauterization with Nitrate of Silver. History. — James Scott, set. 15, a painter, applied for advice, January 2Yth, 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 ex- ternal 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. The whole was then well cauterized with nitrate of silver^ and was cured at once. Commentary . — Of the five cases of favus now given, the first was that of an adult, and was of twelve years’ standing. By means of poultices and excluding the air, with oily applications, the scalp could easily be freed from the eruption and kept so ; but as soon as these means were discontinued, the disease returned. The second and third cases were permanently cured by the constant application of oil to the 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 fourth case was cured by using a sulphu- rous acid lotion instead of oil — a practice recommended by Br. Jenner, in consequence of the powerful effect possessed by this acid in destroy- ing vegetable growths. In the fifth case, the disease was limited, and was at once destroyed by means of caustic. It is rare that favus can be watched through its entire progress in the wards of a hospital — first, because the disease commonly lasts months, often years, and charitable institutions cannot support individuals so long; and, secondly, because it always happens, that when urgent cases demand admission, and beds are required, these are just the parties who are discharged to make room for them. At the same time, the disease is so common in Edinburgh, that the wards are seldom free of one or more examples of it in various stages. Besides, by poulticing off the crusts, and allowing the eruption to come back, its commencement and progress may be studied in any individual case. 54 * Reported by Mr. P. W. Wallace, Clinical Clerk, f Reported by Mr. Hugh Balfour, Clinical Clerk. 850 DISEASES OF THE INTEGTJMENTAEY SYSTEM. History of Favus as a Vegetable Parasite — (Achorion Schonleinii 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 higher animals, and even in man himself, were connected with the growth of parasitic plants of a low type. Schdnlein,t of Berlin, was the first to detect them in favus crusts — an observation confirmed by Bemak,J Fuchs, and Langenbeck.^ Grruby|| 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 myself, and further extended in 1842. H In 1845 I succeeded in inoculating the disease in the human subject. Since then they have been made the subject of further investigation by Lebert,^* Remak,tt Robin, 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 Rayer, 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 for- mation of pustules is not essential to the disease, although they are often present. Hence the mistake of those pathologists who classified favus amongst the pustulas. M. Gruby says that they are never present, which is equally erroneous, although they appear to be a secondary result, attributable to the irritation the disease produces in some individuals.^i^ On the other hand, I have never seen this affection produced without having 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 * Del. Mai. del Segno Calcinaccio o Muscardino. Milano, 1837. f Muller’s Archives. 1836. f Medicinishe Zeitung. 1840. § Comptes Rendus de la Polyclinique de Gottingen. II Comptes Rendus, tom. xiii. pp. 72 and 309. 1841. ^ On Parasitic Vegetable Structures found Growing in Living Animals. Edin- burgh Philosophical Transactions, vol. xv. p. 277. 1842. Monthly Journal, June 1842. ** Physiologie Pathologique, tom. ii. 1845. +f Diagnostiche und Pathogenische Untersuchungen. 1845. iff Des Vegetaux qui croissent sur THomme, etc. 1847. §§ This explanation of the origin of pustules and purulent matter, when present, has been adopted by Lebert, Rcmak, and Simon. FAVUS. 851 from day 'to day how the disease returns, it will he seen that the first morbid change is increased vascularity of the skin, accompanied with a desquamation of the cuticle; and that in a period varying from twelve to fourteen days, small spots of a bright yellow color, like that of sulphur, may be detected. These gradually augment in size, but even at the earliest period may be observed, with a lens, to have a central depression, through which a hair may generally be observed to pass. The crust or capsule niay 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 lupinosa, and Porrigo 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 a he Fig. 490. 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 ob- served in them. At first, also, the whole capsule appears of a homo- geneous bright yellow, but when further developed, its centre assumes a whiter color. This arises from the aggregation of the sporules of the plant, which are more abundant in this situation. As the development Fig. 490. a, Isolated crusts of Favus, presenting the lupine seed like depression in different stages of growth (so-called Porrigo lupinosa ) ; some are arranged in groups of twos and threes. 6, A larger group of these crusts, somewhat compressed at the sides, like a honeycomb {Porrigo favosa), c. Another group, which occurred on the shoulder of a young girl. No hairs passed through the centre of these crusts, c?, Large isolated crusts in an advanced state of growth, the external ring is cracked, and the friable centre is enlarged and elevated, e, Numerous crusts aggregated together, so as to form an irregular elevated mass. Traces of the original form may be observed in the cracked rings round the margin. {Natural size.) 852 DISEASES OF THE INTEGUMENTARY SYSTEM. proceeds, this central whitish yellow mass assumes a mealy, powdery con- sistence, and encroaches upon the edges of the capsule, which gradually disappear, whilst its upper concave form becomes convex, as Gruby pointed out. In general, an inflammatory ring is seen round the crust, which, as the capsule becomes elevated above the skin, enlarges, and assumes a deeper color, indicative of the increased local irritation. At length the whole cracks or splits up; all regular form is lost; a dense thick crust covers the scalp ; an odor, like the urine of cats or mice, is evolved ; and, in chronic cases, vermin deposit their eggs in the inter- stices, and crawl in large numbers over the surface. I have satisfied myself that occasionally the disease, instead of pre- senting distinct capsules round hair bulbs, becomes diffused under the epidermis, which then assumes the appearance of pityriasis, and not un- frequently 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, and perfectly globular instead of oval. In others I have seen the sporules three or four times larger than those of ordinary favus, with in- cluded nuclei, multiplying fissiparously. Hence the so-called parasitic pityriasis of the scalp I believe to be a modification of favus, and con- sider it a good rule, in all chronic eruptions on the head, to examine the crusts microscopically. The other local symptoms are merely those which result from the greater or less degree of irritation produced in different persons by the changes above referred to. At first, scarcely any uneasiness is felt ; perhaps occasional slight itching of the part. As the disease pro- gresses, 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 suppura- tion 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 odor exhaled is insupportable to those who surround the individual, and the ichorous discharge, vermin, and crusts, which cover the affected parts, present a most disgusting appear- ance. Although the disease most commonly attacks the hairy scalp, it may occur on the forehead, temples, cheeks, nose, chin, ears, shoulders, arms, abdomen, lumbar region, sacrum, knees, and legs. Alibert gives a plate in which it is figured in all these situations. I have myself seen it on the cheek, shoulders, back, arms, and inferior extremities, and in some of these situations I could detect no hairs perforating the capsules. (Fig. 490, c.) The constitutional symptoms are of the utmost importance, but, generally speaking, receive little attention from practitioners. In most of the individuals affected, who have come undhr my notice, the general health has been greatly deranged, and a scrofulous or cachectic constitution more or less evident. In some the facies scrofulosa of authors has- been well marked ; in others there were engorgements of FAVUS. 853 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 gener- ality of individuals who die laboring under favus, perish from phthisis, or other forms of tubercular disease. The beautiful plates published by Alibert are in this respect far from being true to nature ; for whilst the capsules and crusts are accurately drawn, the individuals affected seem to be ideal personages, enjoying the most robust health, and possessing even the utmost beauty of form and feature. In the generality of cases, on the contrary, the patient is thin, the countenance is of a dirty yellow color, and the whole aspect betrays depression of the vital powers. The appetite is often impaired, the alvine evacuations irregular, and the func- tions of digestion and nutrition are impeded. Numerous writers have observed the physical and mental development of the individual to be retarded; and Alibert gives instances where the epoch of puberty was considerably delayed. By those not well accustomed to the diagnosis of skin diseases, favus has often been confounded with other eruptions of the scalp, more especially eczema and impetigo, or the combination of these diseases known as the eczema impetiginodes. In none of these eruptions, how- ever, 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 Pity- riasis. On examination of the scurf, however, the epidermic scales will be found associated with the Achorion Schonleinii, in various stages of development. Causes. Alibert considered the disease hereditary, and gives cases confirma- tory 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 puberty, it is more rare, although sometimes present ; and in a few instances it has been observed in persons advanced in years. In almost all the cases which have come under my notice, the individuals have been exposed to causes which depress the vital powers, and are well- known excitants of tuberculous disease. Close questioning will usually elicit that they are of a scrofulous family ; have been exposed for some time to infected or corrupted air ; inhabited small rooms, or confined streets, or dwellings situated in unhealthy situations ; that the aliment has not been very nutritive, etc. etc. Hence, why the disease is com- mon in workhouses and jails, and most prevalent amongst the poorer classes of the population, and individuals who obtain a precarious existence. * In 1842 I discovered Favus on the face of a common house mouse, in which animal the same cryptogamic vegetations were to be detected as in man. Dr. Carter confirmed this observation in a communication he brought before the Royal Medical Society of this city, during the session 1856-57. Prof Gluge of Brussels also described and figured the same fact (Bulletins de 1’ Academic royale de Belgique. 2me serie. Tom. iii., No. 12). 854 DISEASES OF THE INTEGUMENTARY SYSTEM. Almost every writer on the disease considers it to be contagious. Bateman, Gruersent, and others, speak of its spreading amongst school- boys, from the employment of the same towels, combs, caps, etc. Gibert has seen it propagated in the wards of St. Louis from the same cause. It has been observed, he says, two or three times to be com- municated by young people kissing each other, when it has appeared in the chin or neighborhood 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, how- ever, he evidently doubts it, says that much exaggeration has been made use of on this subject, and states that the amour-propre of parents usually induces them to ascribe the origin of so disgusting a disease to external communication. He further observes, “ Mes fdeves ont souvent tente d’inoculer en notre presence, le produit de I’incrustation faveuse, sous plusieurs formes, et en variant les precedes. Le plus souvent il n’est rien resulte, dans d’autres cas est survenue une inflammation passagere, qui s’est bientot evanouie — parfois une suppuration semblable qui pour- rait s’etablir par tout irritant mechanique, ou par I’insertion d’une sub- stance etrangere dans le tegument.”^ Gruby also, on discovering its vegetable nature, inoculated thirty phanerogamous plants, twenty-four silk-worms, six reptiles, four birds, and eight mainmifera, but only pro- duced the disease once, and then in a plant. The human arm was inoculated five times, but, independent of a slight inflammation and sup- puration, no efi’ect was produced. Twenty-two 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 fre- quently 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 produced ; 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. Remak of Berlin communicated 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, ap- peared, and in a few days more a dry yellow favus scab formed itself upon the spot, which, examined microscopically, presented the mycoder- matous vegetations characteristic of favus.f Mentioning this fact to my polyclinical class, at the Royal Dispensary, in the summer of 1845, one of the gentlemen in attendance volunteered to permit his arm to be ino- culated. A boy, called John Bangb, ast. 8, laboring under the disease, was at the time the subject of lecture, and a portion of the crust, taken directly from this boy’s head, was rubbed upon Mr. M.’s arm, so as to produce erythematous redness, and to raise the epidermis. Portions of the crust were then fastened on the part by strips of adhesive plaster. * Traite des Maladies de la Peau, fol., p. 443. f Medicinische Zeitung, August 3, 1 842. FAVUS. 855 The results were regularly examined at the meetings of the class every Tuesday and Friday. The friction produced considerable soreness, and, in a few places, superficial suppuration. Three weeks, however, elapsed, and there was no appearance of favus. At this time, there still remained on the arm a superficial open sore about the size of a pea, and Mr. M. suggested that a portion of the crust should be fastened directly on the sore. This was done, and the whole covered by a circular piece of adhe- sive plaster about the size of a crown-piece. In a few days, the skin surrounding the inoculated part appeared red, indurated, and covered with epidermic scales. In ten days, there were first perceived upon it minute bright yellow-colored spots, which, on examination with a lens, were at once recognised to be spots of favus. On examination with the microscope, they were found to be composed of a minute granular matter, in which a few of the cryptogamic jointed tubes could be perceived. In three days more, the yellow spots assumed a distinct cupped shape, per- forated by a hair ; and in addition to tubes, numerous sporules could be detected. The arm was shown to Dr. Alison ; and all who witnessed the experiment being satisfied of its success, I advised Mr. M. to destroy each favus spot with nitrate of silver. With a view of making some further observations, however, he retained them for some time. The capsules were then squeezed out, and have not since returned. Mr. M. had light hair, blue eyes, a white and very delicate skin. There is every reason to believe that the strips of plaster employed in the first attempt shifted their position, and that the crust was only properly retained by the cir- cular 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 CXCIV.) It must also be evident that it does not readily spread to healthy persons, and that there must be either a predisposition 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 condition. Pathology. We have seen, when describing the symptoms and mode of develop- ment of the disease, that it is not essentially pustular, and that the pustules occasionally present are accidental. On the other hand, it has been shown that the peculiar favus-crust is composed of a capsule of epidermic scales, lined by a finely granular mass ; that from this mass millions of cryptogamic plants spring up and fructify ; and that the pre- sence of these vegetables constitutes the pathognomonic character of the disease. In order to examine the natural position of these vegetables micro- scopically, it is necessary to make a thin section of the capsule com- pletely through, embracing the outer layer of epidermis, amorphous mass, and light friable matter found in the centre. It will then be found, on pressing this slightly between glasses, and examining it with a magni- fying power of 300 diameters, that the cylindrical tubes (thalli) spring from the sides of the capsule, proceed inwards, give off branches dicho- 856 DISEASES OF THE INTEGUMENTARY SYSTEM. tomously, which, when fully developed, contain, at their terminations {\nycelia)^ a greater or smaller number of round or oval globules {spori- dia). These tubes are from the joo ^ millimetre in thickness, jointed at regular intervals, and often contain molecules, varying from Toooo ToVo ** millimetre in diameter. The longitudinal diameter of the sporules is generally from To o> transverse from 3 0 0 I'O 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 yU of a millimetre. The mycelia and sporules merous near the external layer. There may frequently be seen swellings on the sides of the jointed tubes, which are apparently commencing rami- fications. On examining the hairs which pass through the favus crusts, it will Fig. 493. often be found that they present their healthy structure. At other times, however, they evidently contain long jointed branches, similar Fig. 491, Branches of the Achorion Schmnleinii in an early stage of development growing from a molecular matter, and mingled with epidermic scales, from a very minute favus-crust. Fig. 492. Fragments of the branches more highly developed, with numerous spo- rules and molecular matter, from the centre of an advanced favus-crust. 300 diam. Fig. 493. a, A light hair containing branches of the Achorion Schoenleinii (magni- fied 300 diameters linear). The wood-cutter has made the branches too beaded. 6, A darker colored hair, containing branches of the plant. 800 diam. FAVUS. 857 to those in the crust, running in the long axis of the hair, which is exceedingly brittle. I have generally found these abundant in very chronic cases ; and on adding water, the fluid may be seen running into these tubes by imbibition, leaving here and there bubbles of air, more or less long. There can be very little doubt that the tubes and sporules, after a 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 vegeta- tions 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 organization is common to animals as well as plants ; and hence “ to speak of Porrigo favosa^ or any similar disease, as produced by the growth of a vegetable within the animal body, appears to the author a very arbitrary assumption.” Mr. Erasmus Wilson, in his work on “ Diseases of the Skin ” (p. 430), as well as in a special “ Treatise on Ringworm,” is also opposed to the idea of favus owing its essential characters to a vegetable growth. He considers that the peculiar branches and oval bodies previously described are mere modifications of epidermic cells, which in some cases he is of opinion may be transformed into pus cells — in others, into those observed in favus. The branches of the plant he calls “ cellated stems,” and the sporules, secondary cells ; and argues, that mere resemblance to a vegetable formation is not sufficient to constitute a plant. He says, “ The statement of the origin of the vegetable formations by roots implanted in the cortex of the crust is un- founded ; the secondary cells bear no analogy to sporules or seeds ; and it is somewhat unreasonable to assign to an organism so simple as a cell the production of seeds, and reproduction thereby, when each cell is en- dowed with a separate life, and separate power of reproduction. Lastly, M. Cazenave,^ although he acknowledges himself to be no histologist, says he has sought for the sporules many times, and believes himself authorised to conclude that their detection is not always so easy as is supposed (p. 225). Finally, he denies that favus is a vegetable parasite, and maintains it to be a peculiar secretion, originating in the sebaceous glands, (p. 236). With the exception of Mr. Wilson, who appears carefully to have examined the favus crust, the opposition to the vegetable nature of this production seems to have originated in very imperfect notions as to its intimate structure on the one hand, and that of certain cryptogamic plants on the other. For if long hollow filaments, with partitions at inter- vals, containing molecules witbin their cells, springing from an unorga- * Medical Gazette, December 1841, p. 415. f Principles of Physiology, p. 453. X On Ringworm, 1847, p. 23. § Traite des Maladies Cuir Chevelu, 1850. 858 DISEASES OF THE INTEGUMENTARY SYSTEM. nized granular mass, and giving off toward their extremities round oval bodies, or sporules, arranged in bead-like rows, be not vegetable, what are they ? The animal tissues present nothing similar, while numerous plants, long known to botanists, present the same identical structure. But not only must they be referred to the vegetable kingdom, but to a considerably elevated position among the cryptogamic plants. The protococcus nivalis and torula cerevisice^ universally considered as plants, together with the sarcina ventriculi^ described by Goodsir, are immeasur- ably beneath them in complexity of structure ; and many of the mucores or moulds growing in damp places are, as I have satisfied myself by re- peated 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 'penicilvum, glaucum of Link, the aspergillus penicillatus., acrosporium monilioides^ sporotormm minutum^ nostoc cccruleum^ 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 structure described, and now by every one acknowledged to exist in the favus crusts, really belong to the vegetable kingdom, we should remember that they are not the only formations of this kind which have been found to grow parasitically in living ani- mals. In my original paper,"* 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 mol- lusca, insects, reptiles, fishes, birds, and mammiferous animals. These observations have subsequently been confirmed by numerous pathologists and naturalists. 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. l)r. Greville, to whom I exhibited them, was quite satisfied of the fact. Brogniart, according to Gruby, and Messrs. Link and Klotzsch, to whom they were shown by Bemak, expressed a similar opinion. Brogniart considers them to belong to the genus Mycoderma of Persoon. J. Muller 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 generic name of Achorion (from achor, the old term for favus), and added to it the designation of the discoverer Schonlein. The following is his description of the plant : — “ Achorion Schcenleini nohis orhiculare., Jlavum^ coriaceum, cuti humanae praesertim capitis insidens ; rhizopodion molle, pellucidum, jioccosum Jloccis tenuissimis., vix articnlatis., ramosissimis., anastomoticis (?) ; t mg celmm Jloccis crassioribus, subramosis., distincte articulatis, articulis inaeqnalibus irregulan- bus in sporidia aheuntibus ; sporidia rotunda^ ovalia vel irregularia., in uno vel pluribus later (bus germinantia.'^ The mode of development from sporules has now been determined with considerable exactitude. Bemak made small grooves on the cut surface of a fresh apple ; placed portions of the favus crust in them ; * Edin. Philosophical Trans. 1842. f I have never seen any anastomosis. FAVUS. 859 tlien laid the apple, with the cut surface turned upwards, in moist sand ; and covered the whole with a glass bell. Under these circumstances, he found that the sporules developed themselves, and he examined them frequently up to the sixth day, when the surface of the apple became of a brown color, 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 Fig. 494. that the sporules of the Achorion undergo development in the same man- ner as those in other crypt ogamic plants. That is, the membrane which surrounds them throws out one or more prolongations, which are con- verted into tubes ; and these, in turn, present, generally towards their extremities, a number of sporules, which at length are pushed out, or are disintegrated, and so become free. Figs. 494 and 495 represent the changes observed in the sporules germinating on the surface of the ap- ple; and Fig. 496 shows the thalli, mycelia, and sporules seen in the crusts, produced by inoculation, on E-emak’s arm. The method of reproduction and formation of sporules may be ob- served with great facility in any well-developed favus crust, especially under powers varying from 500 to 800 diameters linear. Thalli, with variable-sized cells, may be observed branching at the extremities, with sporules forming within them. These are conjoined with separated my- celia, containing well-developed sporules, many of which are also free, as in Fig. 497. It follows, therefore, that all the circumstances connected with the development and mode of reproduction of the Achorion Schoenleini have been fully ascertained. The seat of favus has been much disputed by authors. By some it has been located in the piliferous bulbs or follicles (Duncan, Baudelocque, Bayer), by others in the sebaceous glands (Sauvages, Underwood, Mur- ray, Mahon, and lately by Cazenave), and a third party in the reticular tissue of the skin (Bateman, Gallot, Thomson). According to Gruby the plants grow in the cells of the epidermis, the true skin is compressed, Fig. 494. Sporules developing on the surface of an apple, after three days. Fig. 495. The same after four days. Fig. 496. The same more fully developed on the human arm, after inoculation, a, Thalli, with pale walls ; 6, containing sporules (mycelia) ; c, mycelium separated from the thallus : f sporules separated from the mycelium — {after Remak). 300 diam. 860 DISEASES OF THE IXTEGUMENTAEY SYSTEM. not destroyed, and the bulbs and roots of the hairs and sebaceous fob licles are only secondarily affected. I have made observations to determine the correctness of this state- ment, and have found that the whole inferior surface of the capsule is formed of epidermic scales, thickly matted together. These are lined by finely molecular matter, from which the plants appear to spring, and which unites the branches and sporules together in a mass. Superiorly, however, the epidermic scales are not so dense; and I have always found them more or less broken up, and not continuous. This observation is valuable, as indicating the probable mode in which these plants, or the sporules producing them, are deposited on the scalp. It will be seen that the appearance of the peculiar porrigo capsule was invariably pre- ceded by a desquamation of the cuticle, that is, a separation or splitting up of the numerous external epidermic scales which constitute its outer- most layer. Hence it is more probable that the sporules, or matters from which the vegetations are developed, insinuate themselves between the crevices, and under the portion of epidermis thus partially separated, than that they spring up originally 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- bably albuminous, and allied to the molecular character of all broken down or disintegrated organic material in which fungi grow. We have seen that, previous to the return of the favus crusts, the head is al- ways covered with brokeu-up epidermis, more or less disintegrated. Ex- periments have shown that the plants will not grow on the healthy skin, and that inoculation suc('.eeds 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 Fig. 497. Thalli, mycelia, and sporidia of the Achorion Schoenlemii showing the mode of reproduction. 800 dia7n. FAVUS. 861 the scalp) has been the seat of some other eruption (Case CXCIV.) or is not particularly clean. Mr. Erichsen considers, “ That the matter of favus is a modification of tubercle — that it is a tubercular disease of the skin. By tubercular I do not mean a disease like lupus, characterised by small firm tumors, but a disease, the nature of which consists in the deposition of that her etolog oils formation called tubercle.” This view of the nature of favus I have long held ; and it was distinctly stated by me, when treating of the pathology of scrofula, in a work published in 1841.^ The favus crust, however, is not constituted wholly of the tubercular matter. The peculiar exudation only constitutes the soil from which the mycodermatous vegetations spring, as I shall now endeavor to show. Gruby describes the mycodermata of favus as springing from an amorphous mass, of which the periphery of the capsule is composed. This mass undoubtedly exists, and, according to my observations, is com- posed of a finely molecular matter, identical in structure with certain forms of tubercle, or recently coagulated exudation. The cheesy matter, for instance, so frequently found on the secreting surface of serous mem- branes, and in tubercular cavities and other structures in chronic cases of tuberculosis, or general tendency to tubercular 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 myself repeatedly examined this tubercular matter, and been unable to detect any difference between it and the mass in which the vegetations of favus appear to grow. Chemical analysis of this form of tubercle demonstrates it to be composed principally of albumen, with a minute proportion of earthy salts ; sometimes there is combined with it a small quantity of fibrin or gelatine. If this general result be compared with the analysis, by Thenard, of favus matter, the identity between it and tubercle must appear highly probable. He found in 100 parts, coagu- lated albumen, 70 ; gelatine, 17 ; phosphate of lime, 5 ; water and loss, 8 parts. Thus the evidence furnished by morphology and chemistry agrees in determining the molecular matter found in the crusts of favus and in tubercle to be analogous, Remak found that, although the sporules underwent developmental changes on the cut surface of an apple, as well as in animal fluids 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 gradually disintegrated, and infusorial formations commenced. Hence the Achorion grows under the same circumstances only as all other moulds. Putrefac- tion of animal or vegetable substances is unfavorable to its production; 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 confervse readily occur, is beneflcial to the development of favus. Hence why inoculation in healthy tissues fails, and why certain exudations in peculiar states of the constitution, or disintegrated matters which have * Treatise on the Oleum Jecoris Asselli, p. 94. 862 DISEASES OF THE INTEGUMENTAEY SYSTEM. undergone particular chemical clianges, probably from acid secretions of the skin, are necessary to the production of the disease. I believe, therefore, that the pathology of favus is best understood by considering it essentially to be a form of abnormal nutrition, with exudation of a matter analogous to, if not identical with, that of tubercle, which constitutes a soil for the germination of cryptogamic plants, the presence of which is pathognomonic of the disease. Hence is explained the frequency of its occurrence in scrofulous persons, and among cachectic or ill-fed children; the impossibility of inoculating the disease in healthy tissues, or the necessity for there being scaly, pustular, or vesicular eruptions on the integuments, previous to com tagion. But as experiments have proved the possibility of inoculation in healthy persons, it follows that the material in which the vegetations grow, may at the commencement, in a molecular exudation, be formed primarily or 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 which the parasite derives its nourishment, and in which it grows. Treatment, Almost every species of treatment has been had recourse to, in order to remove this disagreeable and intractable disease ; and there can be no doubt that cases have recovered under the use of all and each of the methods recommended. In some instances, favus wears itself out, or rather, as the development of the frame proceeds, and the constitutional strength improves, the conditions necessary for its production and maintenance are removed, and it consequently disappears. In every case, howeves- it must be our object to get rid of the disease permanently as soon as possible, and this is only to be done by removing the pathological 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- ment by means of the Calotte. This consisted in spreading a very adhesive plaster inside a cap, which closely fitted the shaven scalp. The hair was then allowed to grow and insinuate itself amongst the substance of the plaster — when the whole was forcibly torn ofif. In this way portions of the scalp were sometimes separated — at others, pieces of the plaster remained firmly attached, and gave great trouble. A modification of this plan consisted in covering the head with the plaster in strips, which were removed separately from before backwards, and from behind forwards, so as to tear out the hairs. Even this plan failed. The practice I saw adopted in Berlin, in 1841, consisted in plucking out the hairs individually with a pair of pincers ; but this tedious and painful method, also, was found to be of little service. It has been revived of late years by Bazin and Hardy in Paris, and has also been practised in Glasgow by Drs. Anderson and Buchanan, at the skin Dispensary there. According to the former, so called paracitides require to be used after FAVUS. 863 depillation, to destroy the fungus, removal of the hair bulbs being a means for enabling the medicine to reach the germs. The success of this practice has yet to be established. ^ In Paris the old treatment by the calotte was put aside for the milder empiric treatment of the frcres Mahon. Between the years 1807 and 1813, 439 girls and 469 boys, affected with favus, were cured by them at the Bureau Central des Hopitaux, and the mean duration of the treatment was 56 applications. These applications are generally made every other day, so that the average length of treatment by this much boasted and successful method is three mouths and a half. T have endeavored to show, however, that in many cases it is a constitutional disease, and dependent upon the causes which induce scrofulous diseases in general. The treatment, therefore, in such ought to be constitutional, and directed to removing the tendency to tubercular exudation, on which the malady depends. No doubt, however, a local treatment in this, as in all 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 ; 2dly, 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 if the views of its patho- logy [ have brought forward be correct, and it is in its nature allied to tubercular affections, a treatment exactly opposite ought to be pursued. The development of vegetable life may also be prevented by the applica- tion 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 affected, and its albuminous constituents proportionally increased ; that the albumen at length becomes effused 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 effusion into the textures increases, the fatty constituents of the frame diminish. It has been shown, by numerous facts, that under such circumstances the internal and external exhibition of cod-liver oil has been attended with the most marked advantage, and often been made the means of cure when all other remedies have failed. The action of the oil appears to be the same in favus as in other forms of scrofulous disease, and its use should be combined with appropriate diet and exercise, and with reference to the same indications and contra-indications. The local treatment I have employed for several years, is directed in conformity with the pathological views previously detailed, to the exclusion of atmospheric air, so as to prevent vegetable growth. For 864 DISEASES OF THE INTEGUMENTARY SYSTEM. this purpose, I direct, in the first instance, that the afiected scalp should be poulticed for several days, until the favus crusts are thoroughly softened, and fall off. Then the head is to be carefully shaved, after which it will be found to present a shining clear surface. Lastly, cod-liver oil should be applied with a soft brush, or dossil of lint, over the affected surface morning and night, and the head covered with an oil-silk cap to prevent evaporation, and further exclude the atmospheric air. Every now and then, as the oil accumulates and becomes inspissated, it should be removed by gently washing it with soft soap and water. Common lard, or any other oil, does very well, but it is not so penetrating as cod-liver oil. In one case I found a sulphurous acid lotion succeed, and in another a solution of carbolic acid seemed to answer. But further trials of these remedies, as well as of a saturated solution of sulphuretted hydrogen, failed. I believe, therefore, that cod- liver oil, both internally and externally, constitutes the best treatment. I have found the average duration of this treatment to be six weeks, which contrasts very favorably with the results of MM. Mahon’s practice at the Hopital St. Louis. Some cases seem to be incurable, and these are most frequent among adults ; but even in them, so long as the scalp is kept moist with oil, and the air is excluded, the eruption will not return. In young subjects, in whom general as well as local treatment is admissible, and in whom a scrofulous disposition is manifest, the prognosis is more favorable, and the disease may be permanently eradicated (Cases CXCIII. to CXCV.) Whenever favus is recent and of limited extent, it may at once be destroyed by cauteriza- tion with nitrate of silver (Case CXCVI.) Lebert is of opinion that poultices and oily applications soften the favi and distribute the sporules over the skin. He therefore insists on removing the crusts dry, by means of a small spatula, sewing needles, or other instruments. He says that nothing is more easy than to detach them entire ; for, although pushed into the skin, they are not held there by any adhesion. But I think it will be found that, however dexterous a person may be in removing the crusts, the majority 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 by 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 impetiginous pustules. Parasitic Pityriasis. Case CXCYII .* — Parasitic Pityriasis — Incurable. History. — Charlotte Clerk, set. 18 — admitted June 20th, 1867 — a Hindoo girl from Bombay. She has had an eruption on her head ever since she can remember. On admission the hair was found clipped short ; the scalp was bald in patches, especially * Reported by Mr. TV. Guy, Clinical Clerk. PARASITIC PITYRIASIS. 865 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 diffused friable yellowish matter, which, on examination under the microscope, presents the thalli and sporules of favus. July i6th . — To detei’mine 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 forming distinct favus crusts, but causing a scaly eruption over the surface, together with a few pustules of impetigo. On removing the scales a friable yellow mass can be generally seen below, presenting on examination the vegetable structure of the Achorion Schbnleinii. 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 IBS'/, 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 cir- cumstance was the baldness. I microscopically, in order to arrive at an exact diagnosis. In this case the fungus was essentially the same as that of favus, although it presented modifications as to the size of the sporules and thalli. As in Case CXCII. , all the remedies tried were of no avail. Case CXCVIII .* — Pityriasis Versicolor — with the Mierosporon Furfur of Fichstddt — Cured hy Pitch Ointment. History. — Margaret Nicol, aet. 29, unmarried — admitted 24th October, 1864. The patient was always well till three weeks ago, when, on expo- sure to cold two days after men- struation she was seized with pain of a sharp cutting character, situ- ated deep in the hypogastric region, accompanied with a bloody dis- charge, which ceased after four days. Symptoms on Admission. — The pain continues, and is aggravated by deep pressure over the pubes. Pain on micturition. No uterine discharge. Uterus considerably enlarged, and cervix tender on pressure. On the lower two-thirds of the chest anteriorly, and the upper two-thirds of the abdomen, are irregularly-shaped patches of a yellowish brown color, covered h minute dry scales, which, when submitted to microscopic examination, are found * Reported by Mr. W. T. P. Wolston, Clinical Clerk. Fig. 498. Thalli and sporules from chronic pityriasis of the scalp. 250 diam. Fig. 499. Mierosporon Furfur, in pityriasis versicolor {Anderson). 350 diam. 55 had previously seen two similar cases, and was in no way surprised to find that the disease was a parasitic one. All chronic scalp eruptions, especially if there be Alopecia, should be examined 866 DISEASES OF THE INTEGUMENTARY SYSTEM. to contain multitudes of the sporules and thalli of the microsporon furfur. Tongue furred ; bowels constipated. Other functions normal. Ordered poultices to be ap- plied continuously to the abdomen. Progress of the Case. — November 10th . — Uterine pain very much diminished. Ordered to apply pitch ointment to the patches of pityriasis. Nov. 10th . — Uterine enlargement and pain quite gone. Color of the pityriasis much faded. December Is^. — Dismissed cured. Commentary . — The general form of this vegetable parasite, first discovered by Eichstadt in 1846, is different from that of favus, con- sisting of masses of globular sporules seldom exceeding the eight- thousandth of an inch in diameter, mingled with short branching thalli, just large enough to contain them (See Fig. 499). Dr. T. M. Anderson of Glasgow has published several cases strongly confirmatory of the contagiousness of the disease.* Cleanliness and unguents are the best remedies. The above case readily yielded to the common pitch ointment. In a case which closely resembled chronic eczema of the scalp, I found masses of similar sporules on the hairs, with numerous Fig. 500. others infiltrated among the fibres of the bulbs, rendering the whole structure very brittle. ^ Parasitic Affections of the Skin, p. 94. Fig. 500. Portion of the root of a hair plucked from a crust of chronic eczema of the scalp, easily made to split up, and presenting within its substance and sheath numerous minute globular sporules. 250 diam. SECTION X. DISEASES OE THE BLOOD. The diseases of the blood have strongly engaged the attention of modern pathologists, who, putting aside the vague speculation which the ancients held regarding this important fluid, have sought to investigate the sub- ject by the aid of facts derived from chemical, microscopical, and clinical researches. The general results of these have been sketched, pp. 131 to 133. The alterations of the blood give rise to many of the most impor- tant disorders which affect the body, besides being necessarily associated more or less with every morbid change connected with alterations of nutrition. It is the principal idiopathic or essential forms of blood dis- ease which will be treated of in this place. LEUCOCYTHEMIA. On the 19th of March, 1845, 1 examined the body of a man who died under the care of Professor Christison, in the Koyal Infirmary, laboring under hypertrophy of the spleen and liver, and whose blood was covered 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 uncon- nected with any form of inflammation. It was published in the Edin- burgh Med. and Surg. Journal, October 1st, 1845, vol. Ixiv., p. 413. Dr. Craigie, who was present at the dissection, recognised its similarity to one he had had under his care four years previously, the blood of which had been examined microscopically by Dr. John Reid, who found “that it contained globules of purulent matter and lymph.” An account of it appeared in the same number 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 November 1845, of Froriep’s “Notizen” (No. 780), under the name of “ Leukhemia,” or white blood. On the 31st of December 1845, a man was received into St. George’s Hospital, London, in whom Dr. Fuller detected, both before and after death, the increased number of colorless 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 1846. Since then several similar cases have been met with, in which this morbid condition of the blood has been deter- 868 DISEASES OF THE BLOOD. mined to exist, by an accurate examination with the microscope ; and a reference to the records of medicine has shown the previous occurrence of like cases. In these last, the blood, with two exceptions, was not physically proved to contain an unusual number of colorless corpuscles, although 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. Craigie 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 Beid found that the blood “ contained globules of purulent matter and lymph.”* ^ The term “ Leukhemia,” or white blood, given to this disease by Virchow, is faulty, because, in the first place, as was correctly stated by Dr. Parkes, the blood is not white, but presents its usual red tinge when drawn from the arm. The colorless clots occasionally observed after death will certainly not warrant the application of this term to the blood generally, as they are frequently present without the morbid condition under consideration. Besides, the same name (white blood) has been given with more propriety to the fatty blood, examined by Drs. Traill, Christison, and others, which presents a milky, opalescent appearance. At 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 colorless corpuscles, and this is done by the term Leucocythemia — from XevKos, white ; kvtos, cell ; and aljjia, blood : literally, white cell blood — which expresses the simple fact, or pathological state, and involves no theory. Throughout England and Prance this name has been universally adopted. Case CXCIX.f — Leucocythemia discovered after death — Hypertrophy of the Spleen, Liver, and Lymphatic Glands — Absence of Phlebitis and of Purulent Collections in any part of the body. History. — John Monteith, aged 28, a slater — admitted into the clinical ward of the Koyal Infirmary, February 27, 1845, under the care of Dr. Christison. He is of dark complexion, usually healthy and temperate ; states that twenty months ago he was affected with great listlessness on exertion, which has continued to this time. In June last he noticed a tumor 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 tumors have appeared in his neck, axillae, and groins, at first attended with a sharp pain, which has^now, however, disappeared from all of them. Before he noticed the tumor, 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 tumor ; he has used chiefly purgative medicines, especially croton oil ; employed friction with a lini- ment, and had the tumor blistered. Symptoms on Admission. — On admission, there is a large tumor, extending from the ribs to the groin, and from the spinal column to the umbilicus, lying on the left side. It is painful on pressure near its upper part only. Percussion is dull over the tumor ; * Gazette Hebdomadaire, March 21, 1856, and Edin. Med. and Surg. Journal, October 1845. •)• This case occurred in the clinical ward of Professor Christison, who treated it. The body after death was most carefully inspected by me as pathologist .to the Royal Infirmary, and parts were removed for careful subsequent examination, and for pre- servation, the appearances being altogether of a kind quite new to me. The case, for reasons which will appear in the sequel, is here given as it was originally published in the Edinburgh Journal for 1st October 1845. LEUCOCYTHEMIA. 869 pulse 90 ; states that for three months past he has not lost in strength. There is slight oedema of the legs. To have two pilh of iodide of iron morning and evening. Phogress of the Case. — March l.< — Urine of yesterday somewhat turbid when just passed, natural in color, acid to litmus ; sp. gr. 1013. Sediment presents cubic crystals under the microscope, disappears almost entirely on the addition of aqua potassa), but is unaffected by nitric acid. The filtered urine is not affected by aqua potassae, and yields only a slight white haze when boiled. March ^th. — (Edema of legs increased. They have been bandaged with flannel rollers. Potassce (Jarhonath 3i; Spiritus ^theris Nitrici 3 iv ; Aquce Menthce Aquce fontis M, Surnat unciarn ter in die. March 10(A. — Tormina and considerable diarrhoea; urine notin- creased. Habeat haustum Olei Ricini § ss statim ; et exacts quatuor horis, Opii gr. ii. March \2>th. — Attacked this morning with heat of skin; thirst; pulse 110, full, very compressible. The diarrhoea, which had been checked, returned yesterday ; none this morning after taking an opium pill. Urine 100 ounces. Omittantur medicam.enta. Sumat statim Pulveris Ipecacuanhce et Opii gr. x, et repetatur dosis singulis scmihoris ad tertiam vicem. March lUh. — No sweating from the powders ; diarrhoea still rather troublesome, pulse 100, softer; tongue dry ai d brown; febrile expression of counte- nance, resembling that of typhus. Aqicce Acetatis Ammonice 3 vi ; Solutionis Morphice 3i; Aquce fontis § iij ; Syrupi §J. Sttmat unciarn quarto, qudque hord. Habeat decoctum hordei pro potu. March \Uh. — Died suddenly in the morning. Sectio Cadaveris. — March \S)ih {^fonr days after death). Externally, the body presented a considerable prominence of the ensiform cartilage and false ribs on both sides. The ab- domen was contracted ; considerable dulness on percussion on left side, which had previously been marked out by a line formed with nitrate of silver. No ascites or oedema of the limbs. Blood. — The blood throughout the body was much changed. In the right cavities of the heart, pul- monary artery, venae cavae, vena azygos, external and internal iliac veins, and many of the smaller veins leading into them, it was firmly coagulated, and formed a mould of their size and form internally. In the cavities of the heart and venae Fig. 50l. cavae, the blood, when removed, was seen to have separated into a red or inferior, and a yellow or superior, portion. The red portion was of a brick-red color ; it did not present the dark purple smooth and glossy appearance of a healthy coagu- lum, but was dull and somewhat granular on section, and when squeezed readily broke down into a gru- mous pulp. The yellow portion was of a light yellow color, opaque and dull, in no way resembling the gelatinous appearance of a healthy decolorised clot. XVhen squeezed out of the veins, as was sometimes accidentally done where they were divided, it resem- bled thick creamy pus. In some portions of the Fig. 502. veins, the clot was wholly formed of red coagulum. In others it was divided into red and yellow. In a few places the yellow formed only Fig. 501. Portion of clot from the vena cava, showing the divisions into red and white coagula. Half the real size. Fig. 502. • 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 colorless coagula even in the most depending portions of the clot. Half the real size. 870 DISEASES OF THE BLOOD. a streak or superficial layer upon the red, or covered the latter with spots of various sizes. Whether this coagulum existed in all the veins, could only hnve 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 healthv 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 full, also the longitudinal, the lateral, and other sinuses at the base of the cra- nium, 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. 503). In the aorta and external arteries were a few small clots, resembling those found in the veins. These vessels, however, were comparatively empty. Tie 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 readily slipped 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 de- scribed. Others, again, were half filled with red and half with yellow coagu- lum, the passage of the one into the other being clearly perceived. Both hemispheres, with the longitudinal si- nus and falx in situ^ were removed by a section across the brain, as low" down as the division of the cranium would permit. The brain was then discovered to be very soft uniformly, — a circum- stance accounted for by the time w hich had elapsed since death. The part re- moved w"as put aside, in order to be preserved and hardened in spirit. The lateral ventricles were found healthy, contained no serum, and the choroid plexus was perfectly normal. At the base of the brain the basilar artery w as seen distended with the yellow coagu- lum, as were also a few of the arteries, but to a very slight extent. The sub- stance of the brain itself was through- out healthy. All the sinuses at the base of the cranium gorged w"ith the red coagulum. Chest. — A few chronic adhesions Fig 503 . united the pleurae on both sides, which were easily tom through. Both lungs were slightly engorged posteriorly and inferi- orly. The anterior margin of the left lung emphysematous, but to no great extent. On section, the yellow coagulum of the blood was observed to occupy all the 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 coagu- lum, 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 w'as found composed of the yellow, and the two inferior thirds of the red clot formerly described. The right ventricle and pulmonary artery were similarly dis- Fig. 503. Appearance of the upper surface of the hemispheres after removing the dura mater, showing the remarkably white appearance of the coagula in the veins and longitudinal sinus. Half the real size. LEUCOCYTHEMIA. 871 tended ; portions of the clot closely embraced the columnae carnese, 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 color, 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 structure. The liver enormously enlarged from simple hypertrophy. Its structure throughout healthy. Gall-bladder enlarged, and distended with a clear pale yellow bile. The whole weighed ten pounds twelve ounces. The spleen also enormously enlarged from simple hyper- trophy. It was of a spindle shape, largest in the centre, tapering towards the extremi- ties. 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 thick- ened, opaque, and dense over a space about the size of the hand. Both kidneys healthy. The stomach and intestines healthy throughout. About four inches from the anus the superior haemorrhoidal veins were distended on both sides external to the rectum. They formed two chains of tumors, 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 lymph- atic 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 en- larged, but of a dark purple color, and in some places black from pigmentary deposit. The mesenteric glands were of a whitish color, 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 color, also enlarged, forming a chain on each side and in front of the abdominal aorta, more especially at its bifhrcation into the iliacs. No collection of pus could be found in any of the tissues. Microscopic Examination. — The yellow coagulum of the blood was composed of Fig. 504. coagulated fibrin in filaments, intermixed with numerous colorless corpuscles, which Fig. 504. Colorless corpuscles, mingled with a few colored ones, from the white clot of the blood in Case CXCIX. Fig. 505. The same bodies, mingled with a larger number of yellow blood cor- puscles in the red clot. Fig. 506, Change produced on the colorless corpuscles on the addition of acetic acid, the yellow corpuscles being dissolved. Fig. 507. Cells in the fluid squeezed from the lymphatic glands, after the addition of acetic acid. Fig. 508. Blood-vessels giving off a capillary from the pia mater ; the latter is seen filled with colorless corpuscles ; the former partly with colorless, mingled with colored corpuscles. 250 diam. 872 DISEASES OF THE BLOOD. could be readily squeezed out from it when pressed between glasses. Where the yel- low coagulum was unusually soft, the corpuscles were more numerous, and the fibrin was broken down into a diffluent mass, partly molecular and granular, partly composed of the debris of the filaments broken into pieces of various lengths. The corpuscles varied in size from the 80th to the 120th of a millimetre in diameter ; they were round their cell-wall granular, and presented all the appearance of pus corpuscles (Fig. 604)! W ater caused them to swell and lose their granular appearance, and acetic acid dis- solved the cell-wall and caused a distinct nucleus to appear. This nucleus was com- posed 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 corpuscles of laudable purulent matter (Fig. 506). The red portion of the coagulum contained a smaller number of these colorless corpuscles mixed with a multitude of normal yellow corpuscles (Fig. 505). The colorless 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 coro- nary veins, hemorrhoidal tumors, 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 cor- puscles (Fig. 508). 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 numerous molecules, gi-anular and imperfect cells. These were intermingled with bundles of filamentous tissue. The enlarged lumbar glands, on being pressed, exuded a fluid that was crowded with corpuscles ; some resembling the colorless corpuscles already alluded to ; others oval and round, containing a distinct nucleus (Fig. 60'7). The ultimate textures of the muscles, brain, nerves, etc., were carefully examined, and found normal. Commentary . — I have reprinted this case from the original paper pub- lished by me in the Edinburgh Medical and Surgical Journal for October 1st, 1845, in order to show that it contains a careful and minute descrip- tion of the facts which I discovered on examining the body, March 19th. Figs. 501 to 503 are copied from some of the preparations still in my possession, taken from the body. A cast of the spleen is in the Univer- sity museum. Numerous drawings were also made from microscopic demonstrations; some of which are represented Figs. 504 to 508. In the remarks originally appended I observed : — “ The points con- nected with this case that require discussion are — 1st, The connection be- tween the symptoms and morbid appearances; 2d, Were the corpuscles 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 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 coagulation of the blood and the formation of pus, it is difficult to say. Whether the hypertro- phy of these organs exercises a peculiar influence on the blood, or whether the change in that fluid be caused in connection with chronic diseases in general, as has lately been pointed out by M. Bouchut, further observa- tions alone can determine.” LEUCOCYTHEMIA. 8'3‘3 Concerning the second point, I said, The only bodies with which they can be confounded are the colorless corpuscles of the blood itself, the corpuscles described by Gulliver as existing in softened fibrin and those found in lymph. With regard to the colorless corpuscles of the blood, we know of no instance where they existed in the amount, or ever presented the appearance described.” I then, after considering the structure of softened fibrin, came to the conclusion that 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 un- derstood by pyaemia, 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 in- flamed ? There was none. Piorry and others have spoken of an inflam- mation 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 re- quire no labored 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 satisfactori- ly 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 mo- ment’s reflection will make it evident that all our ideas of, and facts con- nected with, inflammation are associated with some local change in the economy. The constitutional disturbances connected with it are invari- ably 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 independent of inflam- mation 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 after- wards Professor Virchow published a similar case, and said they were the colorless corpuscles of the blood, he merely adopted another opinion regarding them from what I had done. But I submit, this does not en- title him 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, to meet with two other cases, before I was enabled to resume the inquiry by meeting with the following one : — Case CG.f — Leucocythemia detected during Life — Hypertrophy of the Spleen — Ascites, History. — Barney Tinlay, set. 17, farm-servant — admitted into the clinical ward of the Royal Infirmary, January 25, 1850. With the exception of an attack of scar- let fever, which he experienced about three years ago, he enjoyed perfect health * See note on the discovery of Leucocythemia at the end of this article, f Reported by Mr. Hugh M. Balfour, Clinical Clerk. 874 DISEASES OF THE BLOOD. until twelve months since, when he first noticed a tumor in the abdomen, accom- panied by some pain. The tumor since this period has gradually increased in size, and latterly he has been unable to walk fast on account of dyspnoea. For the last two or three years ho 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 on Admission. — On admission, his complexion is pale, the conjunctivie are unusually blanched, and his whole appearance is very cachectic. On examining the abdomen, a hard tumor can be felt occupying the whole left side. Superiorly, it can be felt emerging from the false ribs about two inches to the left of the ensiform cartilage. It then passes dowmwards 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 vertebrae. Its anterior margin presents a semi-circu- lar convexity, whieh is smooth, with a distinct notch in its upper third, and is appa- rently about half an inch thick, as with the fingers a fold of integument may be pressed somewhat below it. The tumor is completely dull on percussion throughout, and is in several parts painful on 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 percussion, found to be of the 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 assum- ing the erect posture. Heart sounds natural. He has occasional epistaxis and hemorrhage from the gums. Respiratory and urinary systems healthy. The appearance of the blood drawn from the extremity of the huger, when magnified 250 diameters linear, is represented 509. The colored corpuscles ^for the most part have collected together in rolls, the numerous colorless corpuscles filling up the intervening space. Acetic acid dis- solved the colored bodies, and ren- dered the cell-wall of the colorless ones very transparent — bringing 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 depression in their centre. Here and there the nucleus was crescentic, or in the form of a horse-shoe. (Fig. 510.) ProcxRess op the January 27^A.— He has 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 l^s pain. R Ferri. Citratis 3i; Tinct. Card. Comp. I i ; Inf ns. Calumhce I vii . M. Fiat mistvra ; sumat § i ter in die. R SulpJi. Quince gr. iij ; Pidv. Catechu extr. gr. iv ; 01. Carui m. i. M. liant pil. ij. Mitlantur tales xij, et Sig. sumat ij, mane et vespere. Jan. ZOth. Diarrhoea now entirely ceased. R Fulv. Quince Sulph. gr. iij \ Ferri Carb. Sacch. gr. vij. M. Fiant pil. ij ; Mittantur tales vi ; sumat unam., ter in die. Intermittantur alia. Yester- day 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. of the blood 1041*5 Sp. Grav. of the Serum 1026*5 Composition of 100 parts — Fibrin 6 Serous Solids 72 Globules 67-6 Fig. 510. Total Solids 145*5 Water 854*5 Fig. 509. Appearance of a drop of blood in this case. Fig. 510. The same after the addition of acetic acid. 2^0 diam. LEUCOCYTHEMIA. 875 10 ) i- <^J ^ .-—X . - .^( m - 15 ^. 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 authorities. The sp. grav. of the blood and serum was very accurately taken, and the errors of manipu- lation cannot exceed 5 per 1000 in each constituent. The blood allowed to remain in a vessel for twenty-four hours presented a large and firm clot. Examined microscopi- cally, it exhibited the same appearance as in Fig. 509, the rolls of colored 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 color, having apparently imbibed coloring mat- ter dissolved in the serum. Some of the crescentic nuclei had become nearly straight. (Fig. 511.) February 2d. — Urine is observed to be loaded with lithates, and diarrhoea has returned. Sumat pil. plumhi opiat. unam ter in die., et Syrupi lodidi Ferri guttas quindecim ter in die ex aqud. lllinatur Tinct. lodinei parti dolenti. Intermitantur alia. March 2Mh. — During the last few weeks the hemorrhage from the nose and gums has continued to recur, and the ascites has not abated. He was ,. ordered an astringent lotion for his gums. Since the 11th, ^ Spongio-piline, with Tr. of Digitalis, has been applied to the " abdomen, which apparently, in consequence, is less tense, while the pain has undoubtedly diminished. April 8ih . — Diarrhoea again violent. Stools very fluid. He suffers also from cough, and there is harshness of respiratory murmurs, Uig. 511 . and prolonged expiration to be heard at the apices of both lungs. No dulness on per- cussion. Sumat pil. plumhi opiat. unam ter in die. April 12>th. — Pain in abdomen, and diarrhoea nearly gone. Sweats profusely at night. H Quince Sulph. gr. xij ; Acidi Sulph. dil. 3j; Syrup. Aur ant. 3 j; Aquce font. § v. M. Ft. Mistura; sumat 3 ss ter in die. Repetantur pil. plumhi opiat. April 2S5. — The diarrhoea has ceased for the last eight days, but to-day has returned with considerable pain. Tntcrmittatur mist. Quince Sulph. ; Applicehtr emplastrum Opii (4 x 4) ahdomini ; Sumat pil. plumb, opiat. ij ter in die ; Utatur enem. amyli cum Sol. Morph, statim, et suppositorio opii quotidie hard somni. May 5th . — Has complained a good deal lately of nausea and vomiting, for which he has been ordered a draught every evening, with naphtha. He has also taken the squill and digitalis pill three times a-day, and the tumor has been fomented with infusion of digitalis. Girth of abdomen at this period was thirty- seven inches. 1^ Sp. Mdf.h. Nitrici \ iss; Aquce Potassce ; Sol. Mur. Morph, aa 3 ii; M. Sig. sumat 1 uqua ter in die. May *lth. — Distention of abdomen from accu- mulation stil increases, and pain continues. The urine presents an acid reaction, and is loaded with a copious sediment of lithate of ammonia, with a few colorless rhom- boidal crystals of lithic acid. Pulv. Scillce Dj ; Pulv. Digitedis gr. x ; Extr. Hyoscy. 3 ss ; Cons. Rosarum q. s., ut fiant pilulce xx; Sig. sum, at unam ter in die. May \8th . — Since last report diarrhoea has been very profuse, the bowels having been acted upon sometimes twenty times in the course of a night. Stools very loose but fseculent. Spongio-piline with digitalis to be discontinued, on account of its pressure causing uneasiness. He has taken the lead and opium pills four times a day, as well as the starch injection, with Sol. Mur. Morph, at night. Omittantur pil. plumhi opiat. ^ Tannini gr. xv ; Pulv. Opii gr. vj ; Co7is. Rosarum q. s. ut fiant pil. vj ; sumed unam sexto, qunque hord. 5 Acidi Nitrici dil. ; Syrupi aa 3ss; Aquce |j. M. et Sig. sumat 3 j ter in die ex aqud. June — Since last report the diarrhoea has con- tinued, but it is now much abated. Fluctuation in abdomen evidently diminished. There has been occasional slight epistaxis. Still sweats at night. Girth of abdomen at broadest part diminished to thirty-five and a half inches. Intermitt. mist. Quince. June Vlth. — Has progressed favorably to this date ; the tumor and ascites continue to diminish ; and the diarrhoea and other symptoms having abated, the abdomen is now flaccid, and the skin is cracked, similar to what is observed in a woman after preg- nancy. To-day the diarrhoea has returned with some violence, with abdominal pain. Haheat Pil. Tannini ut antea. June 2<6ih . — Diarrhoea still more diminished. There is a good deal of cough, with some expectoration, and harsh respiration is heard under clavicle, with increased vocal resonance. Has been taking 3 ij of cod-liver oil three times a day. His general strength is now greatly improved. He sits up the greater part of the day, and even walks about on the green. His amendment is so Fifi-. 511. The same after the blood has stood for twenty-four hours. 250 diam. 876 DISEASES OF THE BLOOD. great that he is very anxious to return to his parents, who reside in Hull. August ^th . — Since last report the diarrhoea has returned at intervals, and still continues to be troublesome. On the whole, however, his health has improved ; his appetite and strength have increased, and all ascites nearly disappeared. The cough and expec- toration have ceased. The tumor measures transversely thirteen and a half inches, and longitudinally fifteen inches. From the lower border of ribs to inferior margin of tumor, ten inches. The circumference of the abdomen at the widest part (a little above the umbilicus), is thirty-four inches. He was now dismissed, having for some time expressed great impatience to return to his friends in Hull, and the further pro- gress of the case has been kindly communicated to me by Dr. Sand with of that town. For some time he was in the Infirmary there, when the same symptoms were observed, more or less severe, that had been previously noticed. Then he lived at his parents’ hovel, and finally he went into the Union Work-House, where he died at midnight, July 22, 1851. During all this time the abdominal swelling from the tumor continued, but he had no ascites ; the diarrhoea was more or less urgent ; the emaciation extreme, and the weakness gradually progressive up to the moment of dissolution. Sectio Cadaveris. — Twelve hours after death. This was performed by Mr. West, surgeon to the Union Work-House. The follow- ing report of the appearances observed was communicated to me by Dr. Sandwith : — Extreme attenuation of the entire body. Thorax. — The heart was small, very small, with a few patchy points on its sur- face. Its cavities contained a whitish imperfectly-formed lymph. The lungs had so per- fectly healthy an appearance that we did not think it necessary to cut into them. There was no more effusion into either the pleural or peritoneal cavities than is quite natural. There was, however, an effusion, a little in excess, into the bag of the pericardium. Abdomen. — Nothing unusual in the appearance of structure of the liver, save that the larger hepatic vessels were filled with small patches of coagulated black blood, side by side with immense flakes of dirty white matter, like imperfectly formed lympli. The gall-bladder was filled with a glairy amber-colored fluid, not much like bile. The liver weighed three pounds twelve ounces. On cutting into the organ there oozed out from the smaller vessels a very thin watery blood. The spleen weighed three pounds four- teen ounces. Its surface was of a sky-blue color, and dappled with numerous specks like cicatrices, most of them very small, but there 'were two much larger ones near the summit. It adhered here and there by bands of lymph to the peritoneal lining of the abdomen, and also to the peritoneal covering of the intestines. On the under surface of the organ there was a very small globular lobule, enveloped in ( rganised lymph. A cord, run lengthwise along both surfaces of the spleen, measured twenty-four and a half inches. A cord similarly applied across the org.in, measured eighteen inches. The structure of the spleen was very firm — indeed very much like that of liver. The omentum was entirely wasted. The mesenteric glands were most of them somewhat enlarged, pale, and with hard gritty matter in some of them. There were several en- larged glands at the caput caecum in a state of congestion. Pale enlarged glands were also seen all along the sigmoid flexure of the colon. The kidneys were unusually shrunken and small, and weighed together six ounces. There was but little difference in the relative weight of each. Their structure Avas firm. Microscopic Examination. — Next day I received from Dr. Sandwith a portion of the spleen, about four inches long, three inches deep, and one inch thick ; v ith a no- dule, the size of a large bullet, at the hilus of the organ. In structure, it ivas found to be simply hypertrophied, the fusiform cells of the trabeculae presenting their noiinal charac- ter and arrangement, and the cells of the pulp unusually abundant. I also received por tions of the clot taken from the heart, vena cava ascendens, and vena portae. They presented exactly the same appearance as the clot in case CXCIX., divided into a dead- white purulent-looking layer, and a tolerably strong healthy-looking red one. The former, on microscopic examination, was almost wholly composed of colorless corpuscles, aggregated together by molecular fibres of fibrin ; and the latter, though principally composed of colored corpuscles, also contained many colorless ones. Two of the en- larged mesenteric glands which were sent, on section yielded a copious juice, that con- tained the same cells as are represented Fig. 50. Commentary. — This boy was in tlie Infirmary upwards of six months, and the symptoms and entire progress of the case were watched with the greatest care. Unlike the former case the spleen was the only organ LEUCOCYTHEMIA. 877 enlarged, the liver presenting its normal dulness on percussion. The abdomen, however, was also the seat of ascitic distention. The smallest drop of blood taken from the boy's finger exhibited, during the wdiole of his residence in the Infirmary, the excess of colorless corpuscles, and the number of these underwent no perceptible increase or diminution, notwithstanding the varieties of treatment to which he was subjected. Owing to the theories which have been from time to time advanced re- garding the functions of the two kinds of corpuscles found in the blood, and of the nature of its coloring matter, iron was the drug wnich seemed indicated. This boy had also lived in the fenny districts of Lincolnshire ; and, although he denied ever having been affected with intermittent fever, it seemed very probable that the enlargement of the spleen was owing to this cause. I commenced the treatment, therefore, with the exhibition of iron and quinine. Other symptoms, however, became so urgent as to demand special attention, and the suspension of these remedies. I allude to the diarrhoea and dyspnoea, the former of which constituted the leading symptom of the disorder during the entire period he remained in the house. All kinds of astringents were given, with occasional temporary, but never with permanent advantage. At one period he was so exhausted that for some weeks I daily expected his death. He, however, again gained strength ; and his bodily powers, .except towards the termination of his residence in the house, were sub- ject to considerable variations, evidently dependent on the amount of diarrhoea. In April, pulmonary symptoms were added to his other complaints ; and from the character these presented, as well as from the physical signs, a strong suspicion was formed that he labored under phthisis pulmonalis. Under a tonic treatment, with cod-liver oil, assisted by the advance of summer, these symptoms diminished, and his general strength was so improved that, as is stated in the report, he insisted on going home. At the time of his discharge he was remarkably ill, greatly emaciated, cachectic-looking, with an enormous abdomen, — so that it was only by comparison with what he had been that he could be said to enjoy tolerable strength. It seems, however, that he reached Hull, by the steam-vessel, in safety, and lived nearly a twelvemonth longer, so that altogether he was under medical observation nearly eighteen months, the morbid condition of the blood existing during the whole of that time. After death the appearance and structure of the coagulated blood exactly resembled that presented in the former case, and there was the same hypertrophy of the spleen and similar enlargement of the lymphatic glands, but not to so great an extent. The liver, however, was normal, and the lungs externally healthy, but not cut into. Dr. Eobertson was kind enough to analyse the blood for me in this case, and from the results he obtained, it appears that the fibrin was in- creased to about double its amount in healthy blood. The albumen and salts existed in their normal proportion. The globules were diminished to about one-half their proper amount, which deficiency was counter- balanced by an increase in the amount of water. This combination of increase in the anmunt of fibrin and diminution in the amount of cor- puscles, indicates a condition of the blood which, so far as I am aware, is not peculiar to any other morbid condition of the economy. 878 DISEASES OF THE BLOOD. Case CCI .^ — Commencing Leucocythemia determined during Life — Enlarged Spleen and Liver — Ascites. History. — Thomas Welsh, a sailor, aet. 20 — admitted into the clinical ward of the Royal Infirmary, September 22d, 1851. In June 184Y, he first experienced a gnawing pain in the left side, and a hard swelling was distinctly felt in the splenic region. Shortly afterwards he was attacked with jaundice, and he became sensible of a swell- ing also on the right side of the abdomen. He says that, owing to medical treatment, this latter swelling disappeared, and he regained his health. Since then he has occa- sionally had attacks of jaundice, and the abdomen has slowly enlarged, notwithstand- ing the internal use of large quantities of mercury and iodine. Symptoms on Admission. — On admission, his body generally is emaciated ; the abdomen is considerably enlarged, measuring thirty-two inches round the most promi- nent part, which is two inches above the umbilicus ; no fluid can be detected. The hepatic duhiess measures vertically at its deepest part six inches, and its lower margin can be distinctly felt below the ribs, the left lobe sweeping backwards and upwards, and apparently coming in contact with the spleen. The splenic dulness measures verti- cally eight and a quarter inches ; the anterior margin can be distinctly felt, with a notch in its centre, terminating on a level with the upper edge of the iliac bone. Bowels are generally loose ; respiration is embarrassed and thoracic ; no dulness on percussion over the chest ; no cough, but occasional sibilation heard on auscultation ; impulse of heart feeble, otherwise normal ; pulse 78, small and weak. He has not in- creased in stature since he was sixteen, and has the external aspect of a boy of that age ; generative organs not developed ; urine healthy ; skin of a dingy yellowish color. On microscopic examination of the blood, it was ascertained that the colorless and colored corpuscles presented their normal relative number. It is unnecessary to follow the pr ogress of this case minutely. It will suffice to say that the bowels every now and then became very loose ; he occasionally had epistaxis, and frequently more or less tenderness over various parts of the swollen ab- domen. In October he experienced a severe attack of acute laryngitis, from which he recovered in fifteen days. During the latter part of December ascites came on, the excretion of urine diminished in amount, and it was intensely loaded with lithates. The blood had been examined from time to time, and on the third of January a de- cided increase of the colorless corpuscles was observed. A diuretic treatment, by in- creasing the amount of urine, caused the ascites to diminish. But the number of colorless corpuscles gradually increased, so that, during the whole of February, con- siderable groups of these bodies could be seen betw'een the rolls of colored discs in a demonstration under the microscope. Latterly, his general strength became much diminished ; but his mother insisted on taking him home to Berwick, and he left the Infirmary, February 27, 1852. I learnt from Dr. Johnson that he died two days after reaching Berwick. There was no post-mortem examination. As soon as it was determined that the colorless corpuscles of the blood had de- cidedly increased, I requested Dr. W. Robertson to analyse the blood, which he did on the 7th of January, with the following results : — The blood coagulated firmly, but little serum exuded from the coagulum, although it stood undisturbed for forty-eight hours. Surface of coagulum flat, and thinly coated with fibrin. Density of blood 1043 * 6 “ of serum 1027* Composition of 1000 Fibrin 3*2 Serous soUds, | [ 80-7 Globules 82*3 Total solids. 166*2 Water.. 833*8 1000 Commentary . — Up to the occurrence of the present case, no example of leucocythemia had been met with in which the disease was seen to Reported by Mr. Wm. M. Calder, Clinical Clerk. LEUCOCYTHEMIA. 879 commence and progress. It will be observed that the spleen and liver had attained a very large size before the blood became affected. Nothing, indeed, can be more various than the mere bulk of one or more of the blood glands, and the leucocythemic condition of the blood. In several cases the spleen has been greatly hypertrophied, without any change in the blood whatever. The true explanation of these apparent discrepancies has yet to be discovered. The increase of colorless cells must commence at some particular time, but the exact period of com- mencement has been observed subsequently only in one other case by Virchow. Case COII .* — Eczema of the Trunk and Limbs — Enlarged Lymphatic Glands — Leucocythemna^ which sensibly diminished. History. — Peter Smellie, aet. 62, workman at an iron foundry near Glasgow — admitted October 4th, 1860. Sixteen years ago his legs and ankles first became covered with an eczematous eruption, which disappeared in three or four weeks, but generally returned every spring. Four years ago the shoulders were affected, and from that time it has gradually extended in patches over the trunk and extremities. For the last three years the glands in the groin and the axillm have become enlarged, and three abscesses have been opened in the right groin, the formation of which were preceded by febrile symptoms. Symptoms on Admission. — The entire trunk is covered with chronic eczema, of a dusky red, and, in some places, brown color. The skin, here and there, is indurated, and from the entire surface copious laminated scales are peeling off, accompanied by great irritation and itching. All four extremities are similarly affected ; but on the legs the integument is dense and hard, and the scales so thick as somewhat to resemble ichthyosis. The axillary and inguinal glands are greatly enlarged, consisting of bunches of tumors, soft to the feel, and varying in size from a hazel nut to that of a small hen’s egg. Other enlarged glands may be felt behind the sterno-mastoid muscles, and at the flexure of the elbows. Another gland, size of a pigeon’s egg, exists on the left side of the thorax, inside the nipple. A soft systolic murmur is audible at the base of the heart. Pulse 69, somewhat weak. Dulness over liver and spleen normal. The blood contains a great increase of colorless corpuscles, with numerous naked nuclei, exactly similar in size and appearance to those represented Fig. 622. The diseased skin over thighs and trunk was ordered to he kept moist with a light alkaline lotion (see Skin Diseases, p. 887), and the legs to be anointed with Ung. ZincL Steak diet. Progress of the Case. — December 2%th. — Since admission the eczematous surface has been treated by the alkaline lotion and Ung. Zinci, and is now everywhere much better, in some places well, and entirely free from itching and irritation. The glands in the axilla and groin are diminished in size. January \bih. — Dr. Murray Thomson was kind enough to analyse the blood for me, with the following results : — Composition of 1000 parts of blood. Fibrin Serous solids, Globules j Organic, ] Inorganic, 80-54 i 7*32 f 87-87 vo-ss Total Solids Water 828-97 1000-00 January ^Qth. — The skin eruption is now gone from the trunk, but the legs remain indurated and of a mahogany color. The glands are much reduced in size, and the colorless corpuscles in the blood are not so numerous. Dismissed. Commentary. — This man, in his occupation at an iron foundry, was * Reported by Messrs. D. Murray and J. Saidler, Clinical Works. 880 DISEASES OF THE BLOOD. constantly exposed to the heat of large fires, which at length excited eczematous inflammation of the skin. This in its turn caused irritation and enlargement of the lymphatic glands, and, as a consequence, leuco- cythemia. The colorless corpuscles in the blood presented exactly the same size and appearance as I previously noticed in a case of cancerous enlargement of the thyroid and lymphatic glands (Case CLXIII.), and could leave us in no doubt as to the source of their origin. (Figs. 522 and 523.) It was interesting to observe that, as the skin eruption and irritation diminished, the glandular enlargements and the leucocythemia diminished also. The four previous cases, together with eight others previously re- corded in this work (Cases LXXIII., LXXVIII., LXXXV., XCIY., CXXV., CLXIIL, CLXXXIX., and CXC.), are sufficient for the study of this important lesion of the blood. In my work on Leucocythemia, published in 1852, I have given thirty-seven cases more' or less illustra- tive of the symptoms and pathology of the disease. Since then I have myself met with a considerable number of others, and, many more have been published in the British, American, French, and German periodi- cals. Several other analyses of the blood also have been made. But very little advance seems to have occurred in our knowledge of the pathology and treatment of leucocythemia since I wrote in 1852, whilst all the facts which have been published confirm the conclusions which I then arrived at. A systematic account of the symptoms and progress of the disease, divided, as is usual among French writers, into three stages, has been compiled by M. Vidal,* chiefly from the facts contained in my work. It has been carefully done, although the basis as regards num- ber of cases (only 32) is not sufficiently large. Pathology and Treatment of Leucocyhtemia. If the blood of living persons affected with this disease be examined microscopically (which is most readily accomplished by extracting a drop from the finger by pricking it with a needle and placing it between glasses, under a power of 250 diameters linear), the colored and color- less corpuscles will be at first seen rolling confusedly together, and the excess in number of the latter at once perceived. This, however, be- comes more evident after a short time, when the colored bodies are ag- gregated together in rolls, leaving clear spaces between them, which are more or less crowded with the colorless ones. Means are altogether wanting to enable us to determine with exactitude the relative propor- tion of the two kinds of corpuscles in different cases. In some the colorless corpuscles are only slightly increased beyond their usual num- ber. In one case they are described as five times as numerous as those in health. They are also said in particular instances to be “ greatly in- creased,” “ one- third as numerous,” and “ as numerous,” as the colored corpuscles. In all these statements there is nothing exact. Perhaps the best method of judging is to regard the spaces or meshes left be- tween the rolls or aggregations of yellow blood corpuscles. When these are completely filled up, the colorless bodies do not, in fact, amount to one-third of the colored ones, on account of the large number of the lat- * Gazette Hebdomadaire, 4 Avril 1856. LEUCOCYTHEMIA. 881 ter whicli may exist in a small space, in the form of rouleaux. This will appear upon counting them in Fig. f)09, p. 874. The size of the colorless corpuscles in the various cases given, differs considerably. Even when at first sight they appear to be of tolerably uniform size in any one case, it may be observed, when they are magni- fied highly and carefully measured, that some are twice the size of others, with all the intervening sizes between them. In some cases, though comparatively few in number, they are described as being three or four times larger than the colored corpuscles, and in three cases they were in one about the same size, or somewhat smaller, Fior. 514, © Fig. 512. Fig. 518. and in two others of two sizes, one larger and the other decidedly small- er, Figs. 522, 523. In the cases in which the blood was carefully examined after death, the same variations with regard to number and size of the colorless cor- puscles were found to exist, as have just been referred to in blood drawn fresh from the finger. It was always observable, however, that they were most numerous in the clot ; and when they existed in any number, as in case CXCIX., they communicated to the* colorless coagulum a peculiar dull, whitish look, and rendered it more friable under pressure. When less numerous, portions of the colorless coagulum from the heart and large vessels might be seen to present a dull cream color, easily dis- tinguishable from the gelatinous and fibrous appearance of a healthy clot, and such altered portions always contained a large number of the color- less bodies. The blood has been carefully examined chemically in several cases, from which it would appear that there is generally an excess of the fibrin and diminution of the corpuscles. The former ranges from 3 to 7 parts, and the latter from 100 to 49 parts in a thousand. In a well-recorded case by Dr. Wallace of Greenock, the blood was analysed by Dr. W. Kobertson, and ascertained to contain in 1000 parts only 1'5 of fibrin, and 79’ of corpuscles.^ The organs which have been found most uniformly diseased are the spleen, the liver, and lymphatic glands. The spleen^ in the great ma- jority of cases, has been enlarged, varying in weight from one to above nine pounds. The texture of the organ varied in different cases — in some being of unusual density, in others it was natural, and in a third class was more or less pulpy. In a few cases it contained yellowish masses, apparently a form of deposit, but in reality degenerated tissue. In most cases the cell and nuclear elements of the pulp were increased in amount, while the fibrous portion of the organ was apparently normal. Merc enlargement of the spleen, however, is not necessarily connected with leucocythemia, as I have met with many cases where it has been greatly hypertrophied without appreciable alteration of the blood. It has * Glasgow Journal, April 1855. Fig. 512. Colorless corpuscles slightly increased in number. Fig. 513. The same after the addition of acetic acid. 56 250 diam. 882 DISEASES OF THE BLOOD. appeared to me that in such instances the enlargement is- more owing to congestion and fibrous hypertrophy, than to increase in cell elements. !Next to the spleen, t\\eliver is most commonly found diseased in leucocy- themia. In the majority of cases it is simply hypertrophied, and in a few, cirrhosed in various stages, or G'\ Fisr. 515. cancerous. The lymphatic glands • (C)®* frequently enlarged. In most cases they are soft, presenting on section a granular whitish ap- pearance, and yielding a copious turbid juice on pressure. In a few cases they were indurated, loaded with calcareous deposits, or infiltrated with cancerous or tuber- cular exudation. The solitary and aggregated glands of Payer have also been found hypertrophied in a few cases. The thyroid body was cancerous in one case, and evidently gave rise to the leucocythemia (Case CXCIII.) ; and in certain cases of bronchocele, in which the blood was examined by Drs. Holland and Neale, a similar condition was observed. Hr. Addison has also shown, in tv/o of his cases of disease of the supra-renal capsules, that the blood w’as leucocythemic. Other lesions which have been occasionally found in cases of leucocythemia are evidently accidental, and in no way con- nected with that morbid state of the blood which we are now con- sidering. Relation existing between the Colorless and Colored Corpuscles of the Blood . — Many physiologists have maintained that the colored corpuscles are formed from the colorless ones; and among those who hold this opinion, some have supposed that the latter bodies are directly trans- formed into the former (Paget*). Others, again, contend that, whilst such may be the case in fishes, reptiles, and birds, in mammals the colored disc is merely the liberated nucleus of the colorless cell (Whar- ton Jonesf). From the observations I have made on the blood cor- puscles in cases of leucocythemia, the latter appears to me to be the more correct opinion. The mode of transformation of the nucleus of the colorless cell into Fig. 516. the flattened, biconcave, colored disc, has not yet been described ; but, from the appearances I have observed, it would seem to take place in the * Kirke’s Physiology, pp. 68, 69. •}■ bond. Phil. Trans., 1846. Fig. 5M. Colorless corpuscles increased in number, and of small size. Fig. 516. The same after the addition of acetic acid. 250 diam. Fig. 516. Colorless blood-cells observed in leucocythemia, showing the different appearances of the nuclei, placed in the presumed order of their development. 600 di. LEUCOCYTHEMIA. 883 following maimer : — The colorless cell may frequently be seen, on the addition of acetic acid, to have a single round nucleus. But more com- monly the nucleus is divided into two, each half having a distinct depres- sion, presenting a shadowed spot in its centre. Occasionally, before the division takes place, the nucleus becomes oval, and sometimes is elon- gated, more or less bent, and even of a horse-shoe form. Not unfre- quently the nucleus is divided into three or four granules, each having the central shadowed spot. All the appearances given. Fig. 516, have been frequently observed, and I have placed them in the presumed order of development. On two occasions the colorless bodies in the blood were of two dis- tinct sizes. The smaller were evidently free nuclei, such as could be observed within the larger. (See Figs. 522 and 523.) On examining these latter, after the addition of acetic acid, all the appearances repre- sented in the accompanying figure were observable, and these I have © a h Fig. 517. again placed in the presumed order of development. On examining the lymphatic glands in the first of these cases, they were observed to con- tain the first body figured («) in great numbers, associated with a few of the second one (h). On several occasions the blood, when crowded with colorless cor- puscles, was removed from the arm by venesection ; and it was observed, that after standing twenty-four hours those variously-shaped nuclei had become of a straw color, and exactly resembled the colored discs in tint. It was immediately apparent that they had imbibed the coloring matter of the blood, leaving the cell which surrounded them perfectly trans- parent. (See Fig. 511, p. 875.) With a view of still further determining the transitional changes in the colorless cells, I performed the following experiment : — A rabbit was killed three hours after having eaten a meal. The thorax was rapidly opened, and a ligature placed round the pulmonary artery, to prevent the corpuscles coming from the thoracic duct passing into the lungs. The abdomen was then pressed gently for a few moments to favor the flow of chyle, and then a ligature placed round the large ves- sels, and the heart removed by cutting above it. On examining the blood in the right ventricle, it presented an unusually large number of color- less cells, the nuclei of which, on the addition of acetic acid, exhibited all the transition stages figured Fig. 516. On examining the blood in the left ventricle, the colorless cells were found normal in amount. This experiment was repeated with the same results. I am therefore of opinion, with Valentin and Wharton Jones, that the colored blood corpuscles in mammals are free nuclei. But I do not consider, with the latter observer, that these nuclei in mammals should necessarily proceed so far in development as to be surrounded with a Fig. 517. Presumed development of the nucleus in colorless blood-cells, in another case of leucocythemia. 500 diam. 884 DISEASES OF THE BLOOD. © © © Fish (Haddock). Reptile (Frog). Bird (Turkey). cell-wall, — in other words, the colored disc is not always a further phase in the evolution of the colorless cell. On the contrary, I believe that the vast majority of the colored blood discs simply reach the nuclear stage of growth before they join the circulation. Many of them, how- ever, do proceed beyond this point in development, and may be seen to have cell-walls around them. Under such circumstances, the nuclei in- crease endogenously by a process of fissiparous division, in the manner formerly described, circulate in the blood within colorless cells, and, on the solution of the cell-wall, also become colored blood discs. 1 have further examined the blood of birds, reptiles, and fishes, and have been enabled to observe transitional forms between the colorless and colored cell, with even greater facility than I could in man. Indeed, the attention once directed to this point,scarcely a demonstration of blood can be made in these animals without seeing abun- dant evidence that the latter is a transformation from the former. In them, however, the colorless cell, at first round, enlarges gradually, becoming oval, and color is added to it. The nuclei, also, ^ Q Q g o after the addition of acetic acid, may be ob- ^ O served in these animals to be undergoing ® © © V § O Turkey, fissiparous multiplication within the cells. Haddock. Thus all the appearances. Fig. 519, may readily be seen. Hence the same mode of endogenous development may take place in the blood-cells of all the vertebrated tribes of animals, the ditference being, that whilst in birds, reptiles, and fishes, the corpuscles retain the form of nucleated cells, in mammals we find the majority of them to be free nuclei. Origin of ilie Blood Corpuscles . — Hewson was the first who distinctly stated that the blood corpuscles were derived from the lymphatic glands, yet few have adopted his opinions. Even Cruickshank, who wrote on the lymphatic system immediately after him, and was one of his con- temporaries, says of the lymphatic fluid in which these corpuscles swim, “ that we do not know the use of this fluid.”^ The correctness of Hew- son’s views is not even clearly admitted by his recent commentator, Mr. Grulliver,t and has been denied by most physiologists in this country ; Fig. 518. © © § Fig. 519. * The Anatomy of the absorbing Vessels of the Human Body. London, 4to, 1786. P. 73. f The W orks of William Hewson, F. R. S., edited by George Gulliver, F. R. S. L. Printed for the Sydenham Society. Note, p. 281. Fig. 518. Cells of various sizes, colorless and colored, observed in the blood of a haddock, frog, and turkey, placed in the order of their supposed development. The three first bodies figured in each line are colorless. Fig. 519. The nuclei of the blood-cells of the haddock, frog, and turkey, as seen after the addition of acetic acid. 450 diam. LEUCOCYTHEMIA. 885 » •' .o O' and although Nasse, Wagner, Muller, and a few others, have contended that the lymph corpuscles in the blood are the same as those found in the lymphatic vessels, the mode of their origin and their functional im- portance 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. 462, p. 743). 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 frequently be observed in mammals to present the same size and bi-concave discoid form of the colored blood corpuscles (Fig. 462, a). Moreover, on the addition of water, they in like manner become globular, and, after the fluid has been allowed to evaporate a little, assume a puckered or crenated appearance. They only differ in their want of color, and in not being partially soluble on the addition of acetic acid (Figs. 462, a; -'0'^ \ •.rr.-j..- 520, and 521). On cutting '! into a well-formed lymphatic gland, and examining the juice ' which may be squeezed from * ‘ . it, it will be found to contain '■j/ numerous free nuclei and nude- ‘ * ated cells. These are evidently Fig- 520 , Fig. 521. the same bodies as are found in the lymph and chyle, and those found in the latter closely resemble the colorless cells of the blood. The nucleus of these corpuscles also may frequently be observed to have undergone the fissiparous division formerly described, and to exhibit various stages of this process in chyle taken from the thoracic duct. The opinion, therefore, held by many physiologists, that the colorless cells of the blood and those of chyle or lymph are the same, and consequently that in the highest class of animals they are not formed in the blood itself, but before they are mixed with that fluid, seems to be well founded. According to Henle, the molecules of the chyle unite together in order to form the nuclei, which are afterwards surrounded by an enve- lope.* These, he thinks, are delayed, and become more fully developed in the lymphatic glands.f Nasse| also states that he has seen aggrega- tions of the chyle molecules and granular bodies formed before they reach the lymphatic glands. On 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 colorless 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 O' * Anatomie Gencrale, par Jourdain. Tom. i. p. 455. f Anatomie Generale, par Jourdain. Tom. ii. p. 103. Wagner’s Handworterbuch. Arts. Chylus and Lymphe. Fig. 620. Fluid chyle, mingled with water, taken from the thoracic duct of a cat three hours after it had been fed on milk. Fig. 521. The same after the addition of acetic acid. . 250 diam. 886 DISEASES OF THE BLOOD. organs. It is to these, therefore, we must attribute the principal influ- ence in the formation of the colorless cells, and to them evidently we must look for the origin of the blood corpuscles. Hewson considered the lymphatic glandular system to consist of the spleen, thymus, and l^unphatic glands. He believed that particles were produced in these organs, which ultimately became the blood-corpuscles, and that the spleen especially served to secrete the coloring matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudiated by all British physiologists up to 1852. Mr. Simon* * * § declares it to be im- possible that the globules of the thymus can enter the lymphatic or blood-vessels, on account of the limitary membrane within which they are enclosed. But that they do find their way into those vessels was shown by Hewson and Sir Astley Cooper,! who found them there; and that the colorless 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 the&e 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 en- tering 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 colorless molecules, 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 colored blood-discs of mammals, and the cells corresponding to the colorless corpuscles of the blood. The very slight differences which do exist are at once explained by variations in the degree of development. 3. They have no excretory ducts, so that if the corpuscles formed in them are to leave the organs in which they originate, it can only be by the lymphatics or veins. Now, it is certain that the blood of the splenic and portal veins, even in health, is always richer in colorless corpuscles than that of the sys- temic circulation.^ It is also well known that in young animals the blood contaius a larger number of the bodies than it does in their adult condition — that is, when all these glands, including the thymus, thyroid, and supra-renal capsules, are fully developed and in a state of activity. In leucocythemia, we observe that when these glands are hypertrophied and their corpuscular elements are multiplied, the colorless corpuscles of the blood are increased in number. Two very carefully made obser- vations, however, appear to me sufficient in themselves to determine the * On the Thymus Gland, p. 91. - f Anatomy of the Thymus Gland, pp. 15 and 43. X Beitrage zur Physiologie des gesunden und kranken Organismus. Jena, 1843. § This well-known fact has been confirmed by the careful observations of Funke. — Henle's Zeitschrift, 1851, p. 172. LEUCOCTTHEMIA. 887 0 Q> o * * . ® © 'r. © . 0 o © . " o w ""'o O © o Fig. 522. Fig. 523. connection of these lymphatic glands with the cells of the blood. Thus in Case CXCIIL, where the thyroid body was enlarged, its cells and their included nuclei were considerably smaller than usual, and it was ascer- tained that the colorless bodies in the blood and their nuclei were smaller also (Figs. 463 and 464, p. 755, and Fig. 514, p. 882). In two cases it was seen that the colorless cor- puscles in the blood were of two distinct sizes, the smaller corre- sponding with the nuclei of the larger ones, and in one of them the lymphatic glands were found to be crowded with corpuscles, also of two distinct sizes, exactly corresponding to those in the blood (Figs. 522 and 523). From these facts, we can have little doubt that the colorless corpuscles are formed in the lymphatic glands, and from thence find their way into the blood. By what channel they effect this, whether by the lymphatics, the veins, or by both, it is very difficult to determine. The limitary mem- brane which surrounds the saccular glands is exceedingly delicate ; in- deed, so much so, that its existence has been denied by some observers. When distended, therefore, it may easily break, and the contents be poured into the pulp, surrounding stroma, or blood-vessels. Dr. Sanders* has shown that the Malpighian sacs of the spleen are traversed by very large vessels, and Mr. Gray has attempted to demonstrate an intimate relation between the former and the splenic veins.f But it Taust be ac- knowledged, that notwithstanding the certainty which exists as to the connection between the closed lymphatic glands and the blood-vessels, and the passage of corpuscles from one to the other, the method by which this is accomplished has not yet been satisfactorily shown. I can- not help thinking, however, that there must be a direct venous commu- nication. Of late years physiologists have been in the habit of calling these glands the blood glands, although nothing more definite has been deter- mined with regard to them than that they are in some way subservient to nutrition, especially during an early period of life. But if I have been successful in establishing that the corpuscular elements found in these organs are transformed into those of the blood, it will follow that the lymphatic glands secrete the blood corpuscles in the same manner as the testes secrete the spermatozoa, the mammae the globules of the milk, or the salivary and gastric glands the cells of the saliva and gastric juice. With regard to the exact mode in which the corpuscles are formed in the glands, two theories exist, both of which are dependent upon nu- * Report of Physiological Society of Edinburgh for January 31st, 1862. Monthly Journal for February 1852. jf On the Spleen, pp. 233-34. 1854. Fig. 522. Numerous naked nuclei with the colorless corpuscles of the blood. Fig. 523. The same after the addition of acetic acid. 250 diam. 888 DISEASES OF THE BLOOD. merous facts and observations closely connected with the origin of all vital structures, and indeed of organization itself. One is, that tliev are thrown off, in the form of epithelium, from the membrane which" sur- rounds them ; the other, that they originate in an organic fluid, by the production of molecules, the successive development and aggregation of which constitute the higher formations.* I have long been of opinion that the latter theory is the more consistent with known facts, and cer- tainly all that I have seen during repeated investigations into the struc- ture of the various lymphatic glands is in harmony with it. Nowhere have I seen the nuclei and cells of these glands attached to, or apparently 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, color is added to them, and they become blood corpuscles. Multitudes of free nuclei in this way join the blood, and are at once con- verted into colored blood discs.f The cells, which in health are com- paratively few in number, circulate for a time as colorless corpuscles, but after a certain period their walls dissolve, when their included nuclei also become colored discs. In leucocythemia the colorless 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 colored on reaching the lungs, the formation of red blood is more or less checked. In the three inferior vertebrate tribes, the entire cell becomes oval, and assumes color. 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 occurs in the interior of cells in the vascular layer of the germinal membrane, which cells are afterwards transformed into vessels. At this period the colorless cells are very abundant, and their nuc’ei maybe seen to undergo the fissiparous mode of multiplication formerly described ; the cells themselves also in this foetal condition multiply by division, j In the invertebrate tribes, there are no lymphatic vessels or glands. In fact there is only one circulation, which has been shown by IMilne Ed- wards to consist of a series of tubes, analogous to arteries or veins, which communicate by means of lacunae that surround viscera. But the cir- culating 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 colorless and colored corpuscles of fishes, reptiles, and birds. In fishes a lymphatic system exists separately, and in them * Report of Physiological Society of Edinburgh for January 31st, 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 instruments. But having confirmed the observations made originally with Oberhaeuser’s microscope, by means of an excellent lens by Ross, of one-eighth of an inch focus, with the most careful attention to the management of the light, it is my conviction that the great majority of these bodies possess no cell-walls. These changes are well figured by Fahrner . — De Olobuloruni Sanguinis^ etc., Turici, 1845. LEUCOCTTHEMTA. 889 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 lym- phatics are numerous and direct. In birds we first observe, in addition, glands on the lymphatics of the neck, but not on the lacteals, and there are two thoracic ducts. In the mammalia the highest development of the lymphatic glandular system exists, including mesenteric and lympha- tic glands, a spleen, thymus, thyroid, pineal and pituitary bodies, and supra-renal capsules. Thus, we observe a correspondefice between the amount of corpuscular elements in the blood, and the extent and com- plexity of the lymphatic glandular system. The corpuscles are compar- atively few and colorless 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 colored, with the appear- ance of a spleen and supra-renal capsules, in fishes. Both in fishes and reptiles, however, the colorless cells are numerous. In birds the color- ed cells are smaller, but still nucleated ; and in mammals the colored bodies are free nuclei, and are even much more abundant. Again, it has been supposed that the colored cannot be formed from the colorless 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 third, Because, on the addition of acetic acid, while the colored 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 colored 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 correspond perfectly with the colored corpuscles of the blood. Besides, in different cases of leucocythemia, although the colorless cells have been seen to be smaller, of the same size, somewhat larger, and even twice as large as the colored bodies, their nuclei may always be ob- served to correspond exactly with the different phases of the latter. With regard to the second argument, advanced by those who have not succeeded in detecting transition-forms in embryonal blood, I am per- suaded that this arises from the circumstance that attention is directed to the colorless cells, instead of to their nuclei. For my own part, I have never failed to observe all the changes previously described, not only in foetal, but even in adult blood. As to the third objection, in reference to dissimilarity of chemical composition, it must be remem- bered that when the chyle corpuscles enter the circulation by the left jugular or sub-clavian vein, they pass immediately through the pulmon- ary artery into the lungs, come in contact with oxygen, and undergo chemical changes with which we are as yet unacquainted. Some phy- siologists have supposed that color is added to them before they join the pulmonary circulation, because yellow corpuscles have been seen in the upper extremity of the thoracic duct. In all such observations, how- ever, they have been necessarily exposed to the atmosphere ; and I have frequently confirmed the observation of Emmert, viz., that the coagulum of chyle, at first colorless, becomes pinkish-red in contact with air. On 890 DISEASES OF THE BLOOD. this point I offer no opinion, believing that neither chemistry nor physiology has as yet communicated to us any exact information with regard to the when or how ha3inatin is produced. But whatever the changes may be which occur in the lymph corpuscles on their passage into the lungs, to those organs we must attribute the alteration in their chemical constitution, as they are colorless and insoluble in the lympha- tic glands and in chyle, but colored and partially soluble in the torrent of the circulation. Moleschott,* having found the colorless cells increase in the blood of the frog after excision of the liver, supposes that it is in the latter organ color 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 nat- ural 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. & Fig. 524. 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 differently interpreted. Gerlach is of opinion that they are new blood corpuscles forming within a mother cell ; f whilst Kdlliker^ 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, containing sev- eral colored nuclei, I believe to be cells of the lympha- tic glands which, under especial circumstances, assume power of increased development, with endogenous multiplication of nuclei. They are common not only in the spleen, but in the mesenteric and other lymphatic glands, especially when hypertrophied from neigh- boring irritation, the result of inflammatory or cancerous exudations, and especially in typhoid fever. A similar increased power of devel- opment may occasionally be observed in the epithelial cells of the pul- monary 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. 1| It is true they closely resemble the lymph cells, with multiplying nuclei, but may, I think, be separated from them by possessing more color. I have seen them not only in * Muller’s Archives. Hept, 1, 1853. f Handbuch der Allgemeine und SpecieHen Gewebelehre, etc., s. 63. \ Mikroskopisohe Anatomie, etc. 2 Band, s. 282. § Wagner’s Handworterbuch. Art. Blukgefassdriisen. I See Dr. Sanderson on the Metamorphosis of Colored Blood Corpuscles, etc. Monthly Journal for September and December 1851. Fig. 524. Cells with single and multiple nuclei ; many of the latter in color and form exactly resemble blood globules. From the human spleen. 250 diam. LETJCOCYTHEMIA. 891 the spleen, but in other glands, and especially in the brain, following spontaneous and artificial sanguineous extravasations (See Figs. ol6, 817, p. 248), But surely it will not be maintained that the normal function of the organs in which these accidental formations occur is to dissolve the blood corpuscles. Besides, from the numerous facts which have been referred to, I trust it has been made apparent that the spleen is much more probably a blood-forming than a blood-destroying gland. The view which seems to me most consistent with facts is, that the blood corpuscles are dissolved in the liquor sanguinis, and, with the effete matter absorbed from the tissues by the lymphatics, constitute blood fib rin. From the various facts which have been stated, I think we may con- clude : 1. That the blood corpuscles of vertebrate animals are originally formed in the lymphatic glandular system, and that the great majority of them, on joining the circulation, become colored 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 color by ex- posure 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 lym- phatic glands. 3. That in fishes, reptiles, and birds, the colored blood corpuscles are nucleated cells, originating in these glands ; but that in mammals they are free nuclei, sometimes derived as such from the glands, at others, developed within colorless 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 colorless cells. A corresponding diminution in the formation of free nuclei, and consequently of colored corpuscles, must also occur. This is leucocythemia. Since the above views were published by me in 1851 they have been confirmed by observations of various kinds. Thus Holland* and Nealef 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 colorless cells were increased in number. In a case of dysentery, with thickening of the mucous membrane of the small intestine, I found leucocythemia. (Case Lxxxy.) Attempts have been made to divide leucocythemia into varieties. Thus Virchow speaks of a splenic and a lymphatic variety. But in this manner we might make further distinctions of a thyroid, a supra-renal, an intestinal, and a mesenteric variety, according as disease in these organs occasioned the blood lesion. Nay, more, we might speak of an hypertrophic, a tubercular, a cancerous, a dysenteric, and an anaemic form, according as we found the blood glands simply increased in size, loaded with tubercle or cancer, or associated with dysentery or anaemia. * Journal of Microscopical Science, vol. i., p. 176. f Medical Times and Gazette, vol. viii., p. 430. 892 DISEASES OF THE BLOOD. 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 of organs, and any hind of disease in them may structurally affect the blood. What appears to me, however, now a desideratum in research is, to determine why, in some cases, the blood should, and in others should not, be leucocy- themic, when these glands are diseased ; and why simple anaemia, as was first shown by Remak, should increase the number of colorless cells in the blood? In one case examined by me in the autumn of 1852, and the characteristic blood in which I had the pleasure of showing to Dr. Hanover 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 concerning whom a difference of opinion existed between two distinguished obstetricians, the one declar- ing a tumor in the left flank to be splenic, and the other that it was ovarian. I showed it to be splenic by demonstrating that the blood was crowded with colorless cells. With regard to treatment, nothing that I have yet tried has appeared to be of the slightest service directly in well-marked cases of leucocy- themia associated with distinct glandular enlargement. Iron, quinine, chloride of potassium, hydriodate of potash, and a variety of medicines given internally, with tincture of iodine applied externally, have been of no avail. But I have now seen several cases where, in the course of time and by judicious treatment, the enlarged glands have diminished, and the morbid condition of the blood become less and ultimately dis- appear. Of this, cases CXG. and CCII. are good examples. The chief indications for treatment in advanced cases, however, will be found to be furnished by accidental complications, the most common of which are diarrhoea and epistaxis, which require astringents, combined with tonics, nutrients, and stimulants, to support the vital powers. Discovery of Leucocythemia. Professor Kolliker of Wurtzburg (in Month. Journ. 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 Virchow. The following is my reply : — It is said by Professor Kolliker that the first observations on this subject occur in the year 1845, and take their origin from a case of disease observed by Dr. Craigie. Now, the fact is, that Dr. Craigie’s case occurred in 1841; audit is admitted by Dr. Craigie himself that it would not have been published even four years afterwards but for the occurrence of mine. He says, “ I kept it unpublished from the period at which it took place ; and it is published at this time, chiefly because the occuiTcnee 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. Journal, vol. Ixiv., p. 402. Professor Kolliker takes great pains to show that Dr. Craigie and myself 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 any where 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. Is^, 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 purnlc'iit matter and lymph thus formed had been conveyed into their interior with the blood, and thence into the vena cava. LETJCOCYTHEMIA. 893 heart, and vessels of the brain.” 2c?, 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 injiammation^ and taking into account the large vessels with which this organ is connected to other organs, it appeared to me that this inflammatory process^ which had been continuing so long without abat- ing, subsiding, or being subdued, was at length beginning to give rise to the formation of lymph and purulent matter, and that these substances, as they were formed, were immediately taken into the veins, and thus circulating with the blood, gave rise to the peculiar assemblage of symptoms which the patient presented during the few days preceding his death.” (P. 409.) From these extracts it must be clear that JJr. Craigie considered the blood disease as secondary, and dependent on the absorption of pus from an inflammatory lesion either in the mesenteric veins or spleen. The view taken up by myself was wholly different, viz., that the blood disease was primary, originating in that fluid itself, altogether independent of local inflam- mation, and especially unconnected with inflammation of the veins. This will appear from the following extracts from my paper : — “ In the present state of our knowledge, then, as regards this subject, the following case seems to me particularly valuable, as it will serve to demonstrate the existence of true pus formed universally within the vascular system, independent of any local purulent collection from which it 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 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 imagine such a lesion, the present must be an instance of it. But it would require no labored argument to show that such a view is entirely opposed to all we know of the phenomena of inflammation.'''' (P. 421.) From these passages it must be clear that I then sepa- rated the state of the blood from pre-existing inflammation in any of the tissues, which had not been done by any preceding author. I especially distinguished it from pyaemia as it was then generally understood. Thereby I established a new blood disease — one of a primary nature. I carefully described all the facts, which Virchow has only sub- sequently 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 color- less corpuscles in the blood, which I minutely described, were unconnected with inflam- mation. Notwithstanding all this. Professor Virchow has pertinaciously endeavored to persuade his countrymen that I regarded the case as one of ordinary pygemia or purulent absorption; and Professor Kblliker, in his communication, says of these laborious researches that “ nothing further was elucidated ” beyond what had previ- ously been determined by Craigie and Reid. Here it should be observed that Dr. Craigie was no histologist, and had never em- ployed the microscope in the investigation of disease. To argue, then, that the dis- covery of this condition of the blood — a discovery altogether dependent on histolo- gical research — was made by him, seems absurd in the extreme. But it may be maintained that this part of the inquiry was carried out by Dr. John Reid, because he stated in the register kept by him as pathologist of the Infirmary that the blood “ contained globules of purulent matter and lymph.” The few words now quoted constitute literally the whole of Dr. Reid’s observations on the matter. They would have been buried in oblivion if I myself had not found them in the register of dissec- tions, pointed them out to Dr. Craigie, and indicated their importance. I have fre- quently conversed with Dr. Reid himself on the subject, who had forgotten the cir- cumstance 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 then) selves the discovery of leucocythemia. Who then did make it ? Certainly not Virchow, who, with Kblliker, in order to depreciate the value of my observations, claims it for these gentlemen. And if none of the three made it, the inference undoubtedly is, that the discovery belongs to me. What then, it may be asked, does Professor Kblliker claim for his colleague? It 894 DISEASES OF THE BLOOD. cannot be the discovery of the facts, or of the existence in large numbers of colorless corpuscles in the blood, independent of indainraation. 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 paper of the 1st of October 1845, and their accuracy has been everywhere confirmed. (See Case CXCIX.) Surely this description oi facU never before published, and of their connection with a new blood-disease, constitutes the discovery. On the other hand, Virchow’s short and comparatively imperfect histo- logical description of a case of white blood (the white appearance of the blood being the chief point he dwelt upon) was printed in the second number for the following November, although, from the admission of Professor Kolliker, as to the practice which prevails in Germany, the actual period of its publication may have been much later. Hence all that can be claimed for Virchow amounts to this, that he put forth an opinion regarding these facts different from mine, but the possibility of which I clearly indi- cated. For, having described the peculiarities of the blood — the white coagulum, its structural characters, the colorless corpuscles, the relation to the red ones, and the absence of the inflammatory appearances in every tissue, not excepting the veins — the questions remained. What are these corpuscles ? How are they produced ? In reply, I remarked, that “ with regard to the colorless corpuscles of the blood, we know of no instance wliere they existed in the amount, or ever presented the appearance described.” From this passage Professor Kolliker draws the inference that I denied that these bodies were the colorless corpuscles of the blood. But I need scarcely point out that the passage does not fairly bear that construction. On the other hand, it clearly shows that the possibility of their being these colorless corpuscles was fully entertained. At that time the whole subject was histologically new ; and having shown that the cells observed closely resembled those of pus in their structural and chemical characters, I said so, and concluded they were pus corpuscles. But having also demonstrated that they could not have been derived from any inflamed tissue, it only remained to be con- cluded that these bodies were formed in the blood system itself, constituting a primary suppuration of the blood. Here, I contend, was the real discovery, which was at that time quite new, and remains up to this hour, in my belief, a correct generalization. Whilst Professor Kolliker seems to attach no importance whatever to my careful histological examination of the blood and of the tissues, and wholly disregards the fact I was at so much pains to establish, that the colorless corpuscles I described were not dependent on inflammation, he thinks it of the greatest importance that Virchow should have stated that these corpuscles were not those of pus. To me it has always seemed of little importance by what name these bodies were designated, so long as the facts regarding them were described with exactitude. It cannot be denied that I first dis- covered and described them, and pointed out their origin in the blood itself. What histological difference there can be between pus cells independent of inflammation, originating spontaneously in the blood, and the colorless corpuscles of that fluid, I am at a loss to imagine. Yet this is the only distinction which Virchow made. But what are pus corpuscles but cells presenting certain physical characters originating in an exuded blood-plasma? and what are the- colorless 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 difference between them ; I believe still that the only distinction is, that the same corpuscles originate in blood-plasma, sometimes outside, and sometimes within the blood system. If so, the controversy raised by Virchow, and maintained by Kolliker, is wholly one of words. Here I may mention, that, act- ing on the persuasion that the two kinds of corpuscles, hitherto separated, are really identical, I opposed the generalization of Mr. Henry Lee, which set forth that pus brought in contact with living blood caused its coagulation. In conjunction with the late Professor Barlow of the Veterinary College, I injected considerable quantities of pus into the veins of an ass, in order to determine this point. I thus increased the colorless cells in the blood of the animal without producing any coagulation or inflam- mation whatever. — (Monthly Journal, January and March 1853, pp. 80 and 2V2, 2'7o.) Moreover it may be questioned, and indeed it has been questioned in a communication which I received from Professor Gluge of Brussels, and in an article by Dr. Radcliffe (Half-Yearly Abstract of the Medical Sciences, vol. xvi., p. 295), whether this distinc- tion can have any real foundation. Rokitansky still maintains that the colorless cor- puscles of the blood in leucocythemia are truly those of pus, and Vidal, after a series of observations directed to this very point, has come to the conclusion that the color- LEUCOCYTHEMIA. 895 less corpuscles of the blood, those of pus and those of mucus, are the same (Gazette Hebdomadaire, Avril 11th, 1856), If so, the pretended discovery of Virchow 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- ment at the statement made by Professor Kdlliker, that in 1851, in the Monthly Journal, and that in 1852, in my separate work, I made no allusion to my former views, and did not take the slightest notice of the labors of Virchow. It is most untrue. My views regarding this disease have always been the same, but never such as Virchow and Kolliker have represented them ; and so far from denying the labors of the former pathologist, I have fully set .tliem 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 leucocythemia, or to the merit of giving it a place in pathology. Careful investigation into this subject will, I am satisfied, convince the candid mquirer that the discovery of leucocythemia, and the subsequent progress of ideas r< garding its nature, may be divided into three epochs or stages as follows : — 1. Professor Bennett. — Discovery of a new morbid condition of the blood, con- Octoher 1, 1845. sisting of multitudes of colorless corpuscles, resembling those of pus, associated with hypertrophy of the spleen and liver, and presenting after death peculiar v/hite coagula. Shown to be unconnected with inflammation in any of the tissues, and especially unconnected with phlebitis. Attributed to the development of the corpus- cles 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 colorless cells of the blood. 2(/ or Sd week of Novem- New cases, and especially one of great value, in which a her 1845 to 1847. similar condition of the blood was associated vvdth enlarge- ment of the lymphatic glands without hypertrophy of the spleen. Origin of the colorless cells attributed to the lymph glands ; proposed name of leukhemia, or white blood. 3. Professor Bennett. — Systematic view of the whole subject. Additional facts Series of Papers^ 1851, and cases, with chemical analyses of the blood. Doc- and separate work, trine that the lymphatic and other ductless glands secrete 1852. Bl. 8vo, Edinr. the blood ; proposed name of leucocythemia, or white- cell blood, and the relation of this disease to other patho- logical conditions and to practical medicine pointed out. From this view of the case, it will be seen that although I claim the discovery of leucocythemia, and have given it the correct scientific name it bears, I am far from 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 Germany, 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 least six weeks after mine, was, in fact, the first one. Thus, in his “ Gezammelte Abhandlungen,” 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 the:j goes on to detail them, observing, “Case 1, observed by 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 Jahrbiicher 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. ; 2dly, my papers in the Monthly Journal ; and 3dly, my separate work. Yet what are the dates of these publications? My papers appeared in 1851, with the first chemical analyses of the blood made by Dr. W. Robertson. My separate work is dated March 1852, and Virchow’s paper, with the chemical analyses by Pro- fessor Scherer, is dated August 1852 ! The French writers on this subject have declared the term leukhemia to be faulty, and adopted that of leucocythemia. Leudet,* Vidal,f and Schnepfij; have followed * Gazette Hebdomadaire, 27 Juillet 1855. \ Idem, 15 Fevrier 1856. X Gazette Medicale de Paris, 5 Avril 1856. 896 DISEASES OF THE BLOOD. the representations of Virchow, and, in a professed historical sketch, have stated that his and my cases appeared about the same time. As if six weeks were not more than a sufficient period for the Edin. Med. and Surg. Journal to reach Berlin, and to be placed on the library table of the Koyal Library there, where it might have been seen by such readei'S of English medical literature as Virchow undoubtedly is long before the latter published his note, in the 2d number for November 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 case as occurring in March, and mine in October, 1845. That is, he gives to Virchow’s case the date at which mine was investigated in Edinburgh, five months before the latter occurred ! The real dates are as follows : — Observed. Published. 1st Case. . . .Prof. Bennett. . . .March 19th, 1845. . . .October 1st, 1845. 2d Case. . . .Prof. Virchow. . . .August 1st, 1845. . . .November, 2d week, 1845. 3d Case. . . .Dr. Fuller Decern. 31st, 1845 July, 1846. Dr. Craigie’s case must obviously be placed amongst those that occurred long before the discovery of leucocythemia was made, although, on looking back upon it, one can have no doubt that it was an example of the disease similar to a very excellent one published by Duplay, in the Archives Gen. de Medicine, 2d series, vol. xxxvi., p. 223, 1834 ; or the one which occurred to M. Barth in 1836, but was only published in 1856 by Vidal, when the subject was fully known. Notwithstanding the above explanations and dates, which may be easily determined to be correct, the Medical Times and Gazette, when under the editorship of Mr. Spencer Wells, continued to represent Virchow’s first paper as having been published two months before mine (see No. for February 2, 1861). In a long leading article, also (see No. for October 5, 1861), other misrepresentations are published, which, as they may deceive others, require to be exposed. This is further requisite, in order to defend the reputation of Hewson, whose scientific labors, while now recognised to be of the highest merit, are completely ignored by Virchow. When I published Case CXCIX. on the 1st of October 1845, the subjects of inflammation and pyaemia were actively engaging the attention of pathologists and practical men. By some (Addison, Williams) it was maintained that an increase of the colorless cells in the blood was the cause of inflammation. Piorry talked of a haematitis or inflammation of the blood itself. Others spoke of pyaemia or purulent blood ; and among these, discussions arose as to whether pus entered the blood by metastasis, by absorption, or as the result of phlebitis. The subject of inflammation, in its various aspects, had strongly engaged my attention. It was natural, therefore, when meeting with this important case, that my inquiries regarding it should, in the first.instance, bear reference to its connection with that morbid process. And whereas, previously, most inquirers had associated such appearances in blood either with in- flammation or with the softened clots so accurately described by Gulliver in 1839, I conclusively demonstrated, for the first time, that in reference to this case neither of these views was applicable. True, the cells described were called pus-corpuscles, because they were identical with them, and I spoke of suppuration of the blood ; but pus and suppuration were not necessarily with me expressions that implied inflamma- tion. A pus cell was a structure having certain characters, and a suppurative fluid was one containing pus-cells. But in saying that these might occur without inflamma- tion, an entirely new opinion was advanced, and a morbid state indicated never pre- viously suspected. In the then state of science, the important point to prove, as it appeared to me, was that there was no inflammation whatever, either primary or se- condary, no abscess anywhere, no phlebitis, no haematitis, no metastasis, no absorption of pus. As the corpuscles, therefore, were not derived trom wdthout or from the vascular walls, it followed, and this was distinctly stated, that they originated in the blood itself. I therefore called the condition of the blood “ suppuration, independent of inflammation,” an idea which has proved very perplexing to all those who regard suppuration as necessarily dependent on inflammation. The truth is, the mere name given to these corpuscles appeared to me (then, as it does now) to be of secondary importance, so long as the meaning attached to them is understood. Call them pus-cells, colorless cells, or leucocyths, after Robin ; speak of the fluid in which they occur as a purulent fluid, as leukhaemic fluid, or as LEUCOCYTIIEMIA. 897 1 leucocytotical fluid (see Virchow’s Cell. Pat., p. 167), the cells and the fluid are the same. But to show that, whatever term be employed, the cells and fluid tf'unainmg them were in no way connected with inflammation, was an important even in pathology. Still, it occurred to me that the employment of the terms pus tnd suppuration was apt to mislead persons not acquainted with histology. This was why subsequently I proposed the expression leucocythemia, or white-cell blood, oecause it “expresses the simple fact, or a pathological state, and involves no taeory.” In Virchow’s first paper (Froriep’s Notizen, November 1846), which appeared six weeks after the appearance of mine, he says : — “ In the older authors observations occur here and there concerning blood which had so completely lost its color that it was likened to milk, chyle, mucus, or pus. The communication of the following case will confirm this apparently fabulous statement.” Then follows the case, concerning which I need only remark, that the fact pointed out by Virchow was the color of the bloody which, as he truly says, was well known to previous writers. Hence why he called it “'Leukhsemia,” or white blood, whiclj he supposed to occur during life in the last stage of the disease. His words are “ It must not be overlooked that cough, diarrhoea, and oedema occurred before the epistaxis, and that the remarkable transformation of the red blood into white ca.i only have occurred to that degree in the latest stages^ for the blood of the epistaxis was always redy Now the truth is, that in this disease the blood is never white at aJ during life. The coagula auer death are white or colorless, but so they are in variety of affections where coagulation takes place slowly. If, then, I committed an error in calling the state of the blood “ suppuration ” without inflammation, as some maintain, I must leave you to judge whether a greater error was not committed ia calling it white blood, when it certainly was not white. Moreover, if my term suppuration led to confusion by assimilating the altered blood to inflammatory pus, Professor Virchow’s term led also to confusion by causing it to be confounded with a state of the blood which has been recognised as white, fatty, or chylous blood from the earliest times. Thus, then, while I endeavored to prove that a new morbid condition was inde- pendent of inflammation. Professor Virchow sought to establish the doctrine of a “ white blood,” which he himself says was previously known to the older writers ; but it appears to me that he might, with equal correctness, have easily framed, after the notions of Hippocrates, another doctrine of black blood, the truth being, that neither the one nor the other has any foundation except on post mortem pheno- mena, The real white — that is, milky or chylous blood — had been long known, is altogether different in itself, and is owing to different causes. His views concerning epistaxis being the cause of white blood, and that the alteration must have been pro- duced shortly before death, because the bleeding from the nose was red, while they prove that the color of the blood was what principally engaged his attention, do not merit refutation. Attention, however, being now directed to the new morbid state, other cases soon occurred. The magnificent hospital of La Charite in Berlin furnished several before I could meet with one other in Edinburgh, all of which were immediately published by Professor Virchow. They tended to show that the blood disease occurred either from enlargement of the spleen or the lymphatic glands. In the Med. Zeitung, another Berlin medical journal, for August and September 1846, Nos, xxxiv.-xxxvi., he adds three cases to his own, which he finds recorded in the British medical journals. These he introduces to the German scientific world in the remarkable manner for- merly referred to : — “ About the same time that I published my case, other two cases were made known in Edinburgh.” He then enumerates them as follows : — Case 1. observed by me ; Case 2, by David Craigie ; Case 3, by John Hughes Bennett ; Case 4, by John Fuller. That some French and German writers, therefore, should have been mistaken as to the priority of observation, is not surprising. But it was reserved for the Medical Times and Gazette, so late as February 1861 — long after these errors had been clearly exposed — boldly to tell its readers that Professor Virchow’s original case was publislied two months before none, although, in fact, it appeared six weeks afterwards. The object of this second paper by Virchow was “ to vindicate for the colorless blood- corpuscles a place in pathology,” and to maintain that “ in man there was a white as well as a red blood.” I shall only say that the notion of the blood-corpuscles being % cause of disease had been previously entertained by many, especially by Addison and 57 898 DISEASES OF THE BLOOD. Williams in this country, so that they already had a place in pathology, and with regard to the white (that is chylous) blood of preceding writers being dependent on these corpuscles, the idea was then and it is now erroneous. It was in the same journal (Med. Zitung for January 184V) that the connection between this supposed white blood and the spleen was first referred to, and it is observed that the splenic bodies are shut sacs, and he compares them to the placenta ; so that, if they furnish nourish- ment to the blood-cells, the nutritive matter must transude through the membrane to nourish them. But this, he says, “ is naturally a pure speculation, and only consti- tutes a basis for further researches.” So that up to this time nothing positive had been made out by Virchow as to the cause of leucocythaemia. In his Archiv fiir Patholog. Anat. und Physiolog. for 1848, Professor Virchow in- serts a short abstract of the preceding papers, with another case. In the same periodi- cal for 1849 he gives one more case ; and the theoretical conclusion he now arrives at as to the changes in the blood is the following : — “ The blood being a constantly de- veloping, transitory tissue, with a fluid intercellular substance, always contains young elementary tissue-cells. In health, the majority of these transform themselves into specific blood-cells ; the red blood-corpuscles carrying hmmatine. Under abnormal circumstances an interniption of development occurs, which prevents the formation of specific tissue elements, and favors the development of young cells as non-specific simple cells. These last are the so-called colorless blood-corpuscles or lymph-cor- puscles. Now, if we take a general survey of the circumstances under which a dis- tinct increase of the colorless blood-corpuscles occurs, we can distinguish three ditfer- ent states of the blood — 1. The simple interruption of specific cells (leukeemia), with chronic enlargement of the spleen and lymphatic glands ; 2. The simultaneous change in the development of the specific tissue elemente of the blood, the hsematin e-cells and fibrine, in inflammations, pregnancy, and after repeated bleedings ; 3. The in- terruption of the specific blood development connected with atrophy of the blood in typhus, in cholera, and in putrid infection (the so-called pyaemia).” I do not see that any definite infoi'mation is to be obtained from these passages as to the origin of the blood-corpuscles from the blood-glands, nor any explanation of the causes of leucocytheraia. It was in January 1851 I again wrote on the subject (Monthly Journal, January to October 1851), Tiaving in the interval also been making investigations and studying the disease. In this paper I object to the term “ white blood,” saying it properly belongs to the milky or ch)dous blood formerly known ; I no longer call the cells in the blood pus-cells, though still maintaining their identity with those of pus ; and propose the name leucocythemia^ or white cell-blood, because, as previously stated, it “ expresses the simple fact, and involves no theory ; ” that is, it avoids equally the errors likely to arise from the use of the term pus, suppuration, and white blood. I then reproduced all the facts known on the subject, carefully translating all Virchow’s cases. The subject is illustrated by numerous woodcuts ; and several analyses of the blood are given, made by Dr. Wm. Robertson at my request. It is pointed out that mere en- largement of the spleen is not necessarily the cause of leucocythemia, as shown by hypertrophy of that organ from intermittent fever, which does not produce it. A systematic account of the symptoms, the structural and chemical composition of the blood, and the morbid anatomy of leucocythemia are detailed. Further, in a paper on the Function of the Spleen and other Lymphatic Glands as Secretors of the Blood, read to the Roya. Society of Edinburgh, Feb. 2, 1852, I fully develope these points, carefully giving to each observer his due credit in the matter. Perhaps I do not suffi- ciently dwell on the great merits of Hewson, although it is said “ Hewson was the first who distinctly stated that the blood-corpuscles were derived from the lymphatic glands ; yet few have adopted his opinions.” And again, “ Hewson considered the Ijnnphatic glandular system to consist of the spleen, thymus, and lymphatic glands. He believed that particles were produced in these organs which ultimately became the blood-corpuscles, and that the spleen especially served to gecrete the coloring matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudiated 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.” (This, we have seen, was the view of Virchow.) “ But that they do find their way into tliese vessels was shown by Hewson and Sir Astley Cooper, who found them there ; and that the colorless corpuscles of the spleen and lymphatic glands enter the blood in large numbers is proved by what occurs in LETJCOCYTHEMIA. 899 leucocythsemia, and by the great preponderance of these bodies at all times in splenic and portal blood.” Here I vindicate for Hewson the merit of having first pointed out the true origin of the blood-corpuscles in the spleen and lymphatic glands ; and the idea that such would ever be claimed for Virchow must appear to any reader of Hewson’s works, and of Gulliver’s notes on this point, to be simply preposterous. My paper concludes as follows ; — “ From the various facts which have been stated, I think we may conclude — 1. That the blood-corpuscles of vertebrate animals are originally formed in the lymphatic glandular system ; and that the great majority of them, on joining the circulation, become colored in a manner that chemists have not yet explained. Hence the blood 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 color by exposure to oxygen in the lungs, 2, That in mammalia the lymphatic glandular system is composed of the spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lymphatic glands, 3, That in fishes, reptiles, and birds, the colored blood-corpuscles are nucleated cells, originating in these glands ; but that in mammalia they are free nuclei, sometimes derived as such from the glands, at others developed within colorless cells. 4. That, in certain hypertrophies of the lymphatic glands 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 colorless cells ; this is leucocythemia. 6. That the solution of the blood-corpuscles, conjoined with the etfete matter derived from the secondary digestion of the tissues, which is not converted into albumen, constitutes blood-fibrine.” Here, then, it seems to me, is a distinct theory of leucocythemia brought forward. Further, in a separate work on Leucocythemia (Edinburgh, March 1852), besides a re- print of all the previous facts, additional chapters are given on the disease viewed in relation to inflammation, to purulent infection, to phlebitis, and to other morbid condi- tions of the lymphatic glandular system, in which the subject was almost exhausted. It was in the fifth volume of his Archiv for 1863, and bearing the special date of Wurzburg, August 23, 1852 (six months after the publication of my separate work, a copy of which had been sent to him), that another long paper appeared by Virchow, claiming for himself the discovery of the whole matter ; and that he still considers himself to be the discoverer is proved by the following paragraph from his Cellular Pathology, published in English in 1861, in which he thus speaks to the countrymen of Hewson : — “A good many years elapsed (after 1845), during which I found myself pretty nearly alone in my views. It has only been by degrees, and indeed, as I am sorry to be obliged to confess, in consequence rather of physiological than pathological considerations, that people have come round to those ideas of mine^ and only gradually have their minds proved accessible to the notion that, in the ordinary course of things, the lymphatic glands and the spleen are really immediately concerned in the production of the formed elements of the bloody — (Cellular Pathology, by Chance, p. 1'72, 1860.) The fifth chapter of Hewson’s work, containing an account of the manner in which the red particles of the blood are formed (p. 2V4, Sydenham Society’s edition), may be referred to for a complete refutation of this claim of Professor Virchow. Hewson says, concerning the production of the formed elements of the blood (sect. 108, op. cit.., p. 285) : “ But if we allow the spleen to make the red part of the blood, we can readily account for the reason why the spleen may be cut out of an animal, and yet the animal survive and suffer but little inconvenience ; for though the office of the spleen is to form the red particles of the blood., yet it is not the only organ in the body capable of doing that office; for we have already proved (sections 85 and 88) that the lymphatic vessels do also form the vesicular portion ; the spleen, therefore, is not the only organ capable of doing it,” etc. I submit, therefore, that to Hewson (whose name is not mentioned in the Cellular Pathology), and not to Virchow, are we indebted for our knowledge of this matter. It is further to be observed that, though fully acquainted with my paper published in March 1852, in which Hewson’s views are referred to, and the whole subject fully elaborated, he continues, in the Cellular Pathology, to represent me as continuing to hold no other opinion than that leucocyihaemia was pyaemia, although from the com- mencement my object was to prove there never could have been pyaemia, by which was understood absorption of pus into, and poisoning of, the blood. He says : “ This conclusion of his, indeed, was not original, but was based upon the haematitis of Piorry.” But in my first paper (1846) it was said of this very theory of Piorry’s, that such a view is opposed to all we know of the phenomena of inflammation^ and was thus emphatically repudiated. 900 DISEASES OF THE BLOOD. The whole arguments of the Medical Times and Gazette in 1861 consist in main» taining that, as I called the corpuscles in the blood pus, while Virchow called them colorless corpuscles, therefore the entire originality belongs to him. But Virchow now tells us (Cellular Pathology, page 155): “A pus-corpuscle can be distinguished from a colorless blood-cell by nothing else than its mode of origin. If you do not know whence it has come, you cannot say what it is ; you may conceive the greatest doubt as to whether you are to regard a body of the kind as a pus or a colorless blood corpuscle. In every case of the sort the points to be considered are, where the body belongs to and where its home is. If this prove to be external to the blood, you may safely conclude that it is pus ; but if this is not the case, you have to do with blood-cells.” According to this definition, a cell closely resembling a pus-cell in the saliva, inasmuch as it originates externally to the blood, is a pus and not a salivary cell. On the other hand, if a blood-vessel be full of a thick, creamy, yellow fluid, containing a multitude of cells undistinguishable from pus-cells, inasmuch as these are formed in the blood, it is not pus. According to Professor Virchow, there- fore, practical men in future, in a case of puerperal phlebitis, when they see the uterine sinuses and neighboring veins distended with pus, or surgeons, when they see the veins of the arm full of purulent matter from the bend of the elbow to the axilla, are to conclude that it is not pus ! I maintain, on the contrary, that it is pus, because it results from inflammation ; that is the real question to be considered. It is only when it occurs independently of inflammation that the lesion can be said to be one of a novel character, as I first stated. But perhaps some one will say it is not pus but leucocytosis. This new word of Professor Virchow’s means white cell forma- tion ; so that most embryonic transformations, the secretion of saliva, a gonorrhoea, or an abscess, is a leucocytosis, inasmuch as there is a formation of colorless cells in all of them. Such confusion of ideas and of terms can never take a place in pathology. White blood has no real existence, unless chylous blood be so called, the term being copied by Professor Virchow from the older writers. Hence, the expression leucocy- themia, or white cell-blood, is the only one which properly distinguishes the lesion in question. It follows from what has been said, therefore — 1. That Professor Virchow cannot claim the discovery of leueocythemia as a matter of fact and observation, because the first case of it was carefully described and published by me, before he wrote on the subject, and separated from all known lesions, under the name of “ suppuration of the blood independent of inflammation ” — an idea previously unknown. 2. That he cannot claim it in consequence of calling it “ white blood,” as this was spoken of by the ancients, and is everywhere known as the milky or chylous blood of authors. The confusion resulting from applying this term to leueocythemia may be Judged of by reference to a discussion in the Academie de Medecine, January 29, 1856, when the most distinguished chemists declared they had been familiar with it long before Professors Bennett or Virchow wrote. 3. That he cannot claim it on the ground that he has demonstrated any difference between the colorless corpuscles of the blood and pus cells, as he himself admits they are identical ; and 4. That he cannot claim it on the ground that he first pointed out the blood-corpuscles, colored or colorless, to be derived from the spleen and blood-glands, as this was unquestionably made out by Hewson nearly a century ago, and was claimed for him by myself, to the exclusion of Virchow, in March 1852. At the same time, great merit is due to Professor Virchow for diligence in observa- tion and the publication of many valuable cases, which his superior advantages as pathologist to the great hospital of La Charite in Berlin enabled him to do. It is only to be regretted that, while assisting in the development of this subject, he should have claimed for himself priority in its discovery, and have concealed and misrepre- sented the labors of those who had preceded him in the inquiry. CHLOROSIS AND ANAEMIA. Case C CIII.^ — Chlorosis and Ancemia — Cured. History. — Lilias Ross, aet. 19, servant in a hotel — admitted October 13th, 1856. She states that menstruation commenced in her sixteenth year, and continued to recur regularly till about a year ago. It then ceased, and she experienced debility, palpita- tion with pain under the left breast, defective appetite, and discomfort after meals. * Reported by Mr. John Glen, Clinical Clerk. CHLOEOSIS AND ANEMIA. 901 On leaving off work for six weeks, her health was restored, and the catamenia returned. She again went into service, and in four months the symptoms came back. She dates the present indisposition from the last menstrual period, four weeks ago. Symptoms on Admission. — She seems in every respect well formed, not emaciated, but the skin is blanched, and of a slight greenish waxy tint. Over the chest and mammae 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 blowing murmur with the first sound, loud at the base of the organ, and audible in the course of the aorta and large arteries. Over the carotids ab^ove the clavicle, a loud double blowing is audible, which, on pressure with the stethoscope, becomes a continuous humming-top sound. Pulse 100, soft. Tongue pale and fiabby, appetite defective, food causes a painful sense of weight with distention 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 difficulty 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. R Pil. Rhei Comp. xij. Two to be taken every third night. R Ferri Citratis^ 3 j ; Syrupi Aurantii et Tr. Aurantii aa I j ; Inf us. Calumh. § iv. M. One table-spoonful to he taken three times a day. Progrkss op the Case. — October 2Mh. — Is improved in strength, and can walk about the ward. The heart’s palpitations are easily excited. Sometimes the murmur over the carotids in the neck is of a hoarse double character, at others continuous and very loud. To encourage a return of the catamenia, four leeches ordered to be applied to the vulva., followed by a warm hip-bath. November \0th. — Is gaining strength slowly on the whole, but experiences alternations in this respect — palpitations and pain under left mamma being sometimes severe, at others absent. The soft blowing murmur at base of heart has disappeared, but the humming-top sound over cervical vessels con- tinues. November 2Uh. — Blowing murmur at base of heart occasionally returns only after exertion. Sounds in neck less intense. No catamenia, although pediluvia, mus- tard poultices to the feet, and other means have been employed at the supposed menstrual period. December \Qth. — Has continued to take the chalybeate mixture all this time, and is now strong and vigorous. A faint sound only is audible over the vessels in the neck, after exertion. Appearance healthy, appetite good, 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 little. Dismissed. Commentary . — This was a well-marked case of anaemia and chlo- rosis, cured by iron, tonics, and rest. Such cases, in young women, are exceedingly common in the female wards of the Infirmary, espe- cially among 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 arguments of Dr. Ogier Ward, who first maintained the seat of the anaemic murmur to be in the jugular vein, are generally considered to be well founded. They are — 1st, The continuous murmur is often co- existent with distinct carotid impulse, which alternates with repose ; 2d, It may be interrupted by pressing the vein above the stethoscope ; 3d, The two murmurs may be occasionally heard by employing a small- ended stethoscope, and shifting it slightly to the right or left ; 4th, It is increased by any cause which accelerates the flow of blood through the jugular vein, as during the act of inspiration, and when in the upright posture — it is diminished when there is an impediment to the venous circulation, as during expiration, the recumbent posture, and when the veins are swollen or turgid. Andral endeavored 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 902 DISEASES OF THE BLOOD. below 80 parts in 1000. But Dr. Davies has pointed out that the murmur is not peculiar to anaemic persons, but often exists in indivi- duals of robust health. He attributes it to friction on the inner surface of the veins, which is more or less audible according to the readiness with which their parietes take up vibrations, and the facility with 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 separation of anaemic arterial and venous murmurs 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 colored corpuscles of the blood may be increased or dimi- nished in quantity, constituting and Oligocythcemia (Vogel). These changes may be absolute or relative. In the former case, the cor- puscles are uniformly increased or diminished throughout the body gene- rally ; in the latter, this depends upon the amount of water, which, by being less or more, alters the proportion of the corpuscles to the other constituents of the blood. Becquerel drew a distinction between anaemia and chlorosis, which, on the whole, is well founded. Thus, anaemia is caused by a variety of circumstances which impoverish the blood, such as long continued hemorrhage, exhaustive discharges, star- vation, chronic diseases, certain poisons, etc. ; chlorosis is induced by obscure causes connected with the nervous system, generally originating in disturbed uterine functions. In anaemia, the alteration of the blood is constant and pathognomonic; in chlorosis, it is only one of the pheno- mena, and not always present. In both diseases the physical signs may be alike, but in anaemia the functional sound is more often in the arteries, in chlorosis in the veins. In anaemia there is constant relation between intensity of symptoms and poverty of the blood. This is not the case in chlorosis. The duration and progress of anaemia is dependent on the causes which produce it, but chlorosis is very variable, and no such evident connection is visible. The treatment of anaemia has two indi- cations — 1st, To suppress the exhausting causes which occasion it; and, 2dly, By means of wine, proper nutrients, and regulated exercise, to im- prove the quality of the blood. In chlorosis, iron is the chief remedy, which should be conjoined with efforts to regulate the menstrual function. ICHORHiEMIA or (so-called) PYEMIA. Case CCIV .'^ — Acuie Articular Bheumatism — Mulii'ple Abscesses in the Joints^ in the Muscles, within the Cranium, etc. History. — James Lockie, set. 17, a rope-spinner — admitted December 1, 1854. Ten days ago, when spinning ropes m the open air, he was exposed to more than usual cold and wet. Next day rigors and other febrile symptoms appeared, followed by pain, redness and swelling of the right elbow-joint. During the four following * Reported by Mr. A. W. Moore, Clinical Clerk. ICHORH^MIA OR PYEMIA. 9C3 days the right wrist and ankle joints were also affected, together with both knee- ioints. Four days before admission the heart’s action became very violent, and leeches were applied to the precordial region. The pain and swelling of the joints have continued since. Symptoms on Admission. — On admission he complained of great pain in the right wrist, ankle, and left shoulder joints, which were swollen, immovable, doughy to the feel, tender to the touch, with the integuments over them erythematous. From the left shoulder-joint the swelling extended into the axilla and down the inside of the arm. Pulse 130, full and strong ; heart’s impulse violent, but no blowing murmur. The tongue coated with brown in the centre and white at the edges ; no appetite ; great thirst ; skin hot and dry ; urine turbid from excess of lithales ; bowels open ; no headache, and the other functions normal. Fiat venesectio ad | xiv. Fotassce NUratis 5 ss, Aqum § vj. Solve. § ss to he taken in half a tumblerful of water every four hours — warm saturnine lotions to the inflamed joints. Progress op the Case. — December 2d. — Little change, pulse 120, more soft, blood not buffed, but it was drawn from a small orifice. Dec. Adh. — Pain in all the joints greatly diminished ; the swelling, however, continues. A blister has formed over the external malleolus of right ankle — complains of soreness in the heels. Pulse 100, of good strength. No blowing murmur with the heart’s sounds. Took ^ j 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 profuse dia- phoresis. On the ^th 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 %th, complained of pain in the back of the neck, and a bed sore was seen to be forming over the sacrum. To he placed on the water bed. From this time the pulse, which ranged from 110 to 140, lost its fulness, and became much more weak; the skin assumed a dirty yellowish or tawny hue, the typhoid febrile symptoms continued, with dry tongue 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 18^A, and another over the manu- brium of the sternum, extending up the left side of the neck, which was opened on the 24^/i. The skin over the heels, trochanter of the right hip, and the sacrum, sloughed, notwithstanding every care taken to prevent it. On the 26• 03 O O !z; c g 12 5v rO .'2 o 00 1^5 1 «c 73* i 73 <1 ^ d 52 s e 2 S Cl, 03 'd o -S J Ph CO ^ C ^ 9 « Ph a> o> 00 g Jl Ph no o Sd' £ M ■5 ^ cc O s ^ o> b£).9 .S « w. 2! S o ^ e o _o O ^ ^ cu ge o o 'TO O O S Pi 00 CO CO -H i ^ 1 51 .s ^ o o ^9 00 .IT) ■ ■ o 3i ®'d h13 ii ■9 8 6^ -Id O I ^ ?- s ’ Si. i > ; 5..' ^ g Ph gq a. Ph ^ p' .15.11 & § o o S l>H CO ^>5 Is r-H ~ o ^ o " g Oo o < .g o ' ^ lO g| _ is 53 O 52» o o o - ;S'=I ' - ^ CO >:§ o ft ^ o ^ 0^ cq i o (M CO CO 05 O o o *r-« N oi o 9 c3cq oi I P2 I PP ^ I '. CO >n. .. <5 sJ' « J I I'l CASE CCXIII. — John Macdonald, weaver, 3>t. 46 — admitted May lltli, 1864. He has been getting weaker for the last three or four years. First noticed that he made more water than usual last summer, and found that thirst became urgent at the end of the harvest season. The patient is much emaciated m appearance. Pulse 80, feeble. Skin dry, but occasional sweats at night. Tongue moist ; bowels regular. Has a slight cough with trifling expectoration. Long-sighted : arcu& senilis. Average daily estimate from \Zth to 25 th May^ while on ordinary diet. 917 O c3 QJ to Q, Ol p:^ s Oi w .P £ . p 00 P . P S • - cn Q O Pk .§ o fcU .p 'p .p p o o C O bD C/2 ; (M p| 1- 'p Q I Ps . OH H ^ og H Pi N •Sf o 00 O •H 6 k> lb lO i-H t-H .ti .■P 02 *m m m O P, ® 1 ^ .1 p. -2 P 'TS O S QJ ^ O -.i ^ 1 o .2 S' o O g T3 ® ^ 1 :s i ;.4 L ba o P 02 P O I- C? j a h’-B II g-3 h o CO ri |.§ . g ^ 5 I o I s I; Gq s> o ►th. — Puffing of the cheeks more marked ; unable to move the right arm ; great prostration. Wine § vj. Blister to the head. Nov. l^th. — Died comatose. There has been no eruption. Commentary. — No examination of this woman’s body could be ob- tained, and we are therefore in doubt as to whether an exudation had or had not taken place between the membranes of the brain. The cerebral complication, however, was in this case well marked. At first, indeed, there was nothing more than usual; but the vomiting was obstinate, and latterly the convulsion and partial paralysis indicated distinctly the organ afi’ected. Having previously resolved to try the quinine treatment, it was given energetically in this case, but without any effect on the pro- gress of the fever. It may even be contended that it did harm, seeing we had a cerebral complication to deal with. Of this, however, at an early period, we could not judge, although it appears to me that the quinine practice is contra-indicated in such cases. Case CCXXITI.* — George Johnson, boot-maker, set. 21 — admitted 8th December 1851. Had severe rigors on 29th November, which were followed by the usual fever- ish symptoms. No exposure to contagion. On admission, tongue densely furred, coated, and cracked ; no appetite ; intense thirst ; skin hot and dry ; confused in his ideas, without great pain in the head; pulse 108, full. Dec. ^th . — Slept very ill, and continues the same as yesterday. Pulse 120, full. ^ 01. Ridni 3 vj. Vespere . — Sulph. Quince 3 j ; Div. in pulv. vj. One every two hours. Bowels freely moved in the afternoon; great heat of skin ; much mental excitement; pulse 120, full and strong ; no eruption. Dec. \Qth. — Slept well ; no restlessness ; skin cool and moist ; no headache ; slight singing in the ears ; pulse 87, of good strength. Pulse rose to 88 during the day, and in the evening was full and strong. Quinine repeated ; 10 grains given at first., then 13 grains every two hours. Dec. Wth. — Pulse 84, of good strength; thirst great ; skin moist; no eruption. Dec. 12^A (14th day) — thirst less; some appetite ; no eruption ; slight deposit in urine. Improved from this* time, and was dismissed January 5 th. Commentary. — This was a slight case of fever from the begirmiug, with no alarming symptoms, recovering on the fourteenth day. Whether this result was in any way owing to the quinine is doubtful, for, as we shall see, there were other cases very similar, in which the fever was of no longer duration. When first given, it certainly brought down the pulse, and all the symptoms abated. On their return, therefore, the treatment was again had recourse to, and the dose increased to thirteen grains. On this occasion, however, no further benefit was obtained; and it appeared to me that the disease terminated with critical sediment in the urine, on the fourteenth day, in the usual manner. There was no erup- tion in this case. Case CCXXIV.f — John Craik, blacksmith, aet. 23 — admitted January 6th, 1852. On December 28th, had severe rigors, followed by feverish symptoms, and during * Reported by Mr. A. Dewar, Clinical Clerk. f Reported by Mr. W. H. Broadbent, Clinical Clerk. CONTINUED FEVER. 929 the night, severe cough and much expectoration. On admission, tongue red and moist ; slight sore throat ; no appetite ; constipation ; pulse 80, of good strength ; severe cough, and considerable expectoration, tinged with blood ; mucous rales are heard over chest, chiefly at base of lungs ; skin soft and dry ; no eruption or exposure to contagion. January 1th. — Bowels freely opened ; cough very severe. Ordered saline mixture ; blister to front of chest. Jan. %th (11th day). — Very restless ; delirious ; drowsy and stupid; cough abated; pulse 108, weak. Vespere. — Pulse 121, quick; skin hot and dry. Quinine treatment ordered. Jan. ^th. — Skin cool and moist ; pulse 90, weak ; tongue moist and red; extreme deafness. Jan. 10th . — Slight diaphoresis. Jan. llth (14th day of fever). — Skin hot and dry; flushed and delirious; marked rose- colored eruption over chest and abdomen ; great thirst ; sordes on lips and teeth ; tongue red and moist, dark in centre. Jan. I'ith . — Delirious; eruption remains; sord^es disappearing ; skin hot and dry ; cough severe ; crepitation distinct at base of right lung ; no dulness, but marked resonance. Ordered antimonial mixture. Jan. 13^/i. — Countenance flushed ; pulse rapid and weak ; great prostration. Blister to right side; wine § iv. Jan. 14^4. — Symptoms urgent. Jan. Ihth. — Great thirst; tongue foul ; crepitation gone, and the respiration is heard very indistinctly ; vocal re- sonance well marked. Jan. llth. — Improving; no dulness, nor increased vocal reso- nance ; some sibilant rales ; slight deposit in urine. Steady improvement until February 20, when there was oedema of lower limbs ; urine normal. Is now quite convalescent. Dismissed. Commentary. — In this case it will be observed that, although the quinine at first produced an apparent improvement, the fever, with de- lirium and the usual symptoms, shortly returned, and ran a rather pro- tracted course, owing to the pulmonary complication. Case CCXXY.* — Anne Dowie, aet. 18, servant — admitted December 10th, 1851. Seized with pain in the head, heat of skin, and general debility, Dec. 3d. Next day general pain over the body, which has continued since. On admission, pulse 120, feeble ; tongue dry, red, and fissured ; no appetite ; great thirst ; bowels constipated ; skin hot, and covered with a clammy sweat, and presenting on the chest and arms an eruption of numerous minute petechial spots, which have existed for some days ; slight cough and expectoration: scattered bronchitic rales over chest. Dec. llth. The quinine treatment was ordered. After the fifth dose of 10 grs., slight deafness, ringing in the ears ; one more dose taken, after which the medicine was stopped. Dec. llth. — Pulse 80, “ excessively small and weak;” surface cooler. In the after- noon, the pulse was 86, strength much increased ; skin warm and moist ; tongue dry, rough and fissured ; much thirst ; respirations 43 in the minute ; slight subsultus. 13^/i. — Pulse 84, of good strength ; skin moist ; eruption unchanged ; lips covered with sordes ;* tongue dry and cracked. On the 14^A, she had smart diarrhoea, which was checked by an astringent mixture, l^th (12th day). — Appearance of patient much better; pulse 88, of good strength; eruption faded; tongue cleaner. llth (14th day). — Cough troublesome ; a good deal of opaque dirty-looking muco-purulent mat- ter expectorated ; moist rales heard on auscultation ; thirst and anorexia continue ; urine turbid, but without sediment. 10th (16th day). — Urine loaded with lithates; pa- tient improving. After this date, she recovered rapidly, and was discharged on the 15th January, quite well. Commentary. — This was a well-marked case of petechial typhus, in which the quinine treatment was tried without apj^arently in any way arresting its course. Although the physiological action of the drug upon the pulse was remarkably characterised. Case CCXXYI.* — Isabella Adamson, set. 20, servant — admitted December 19th, 1851, with eczema of the scalp and face. Eigors appeared January 4^A, followed by febrile symptoms. Rose-colored exanthematous spots appeared on the chest and arms on the 0th. On the 10th, the treatment by quinine commenced. On the 11^7i, the im- mediate effects of the quinine have disappeared, and the report is — Pulse 100, full * Reported by Mr. W. H. Broadbent, Clinical Clerk. 59 930 DISEASES OF THE BLOOD. and compressible ; had no sleep ; pain in head very intense ; no sweating ; tono-ue furred and cracked ; eruption darkex\ \Uh . — Confusion of intellect ; vertfgo ; pulse 110, weak and intermitting; sordes on lips and tongue; subsultus tendinum.’ \^ah. Head symptoms have been relieved by a blister ; and she now began slowly to im- prove. On the 24^A, pulse 80 ; returning appetite ; sordes disappeared. On the 28^/i convalescent. ’ Commentary. — This also was a remarkably well-characterized case of fever of considerable severity, evidently caught in the ward, runnino- its usual course, notwithstanding the quinine treatment was commenced so early as the sixth day. The eruption here presented rose-colored spots at the commencement, becoming darker afterwards. Seven cases of con- tinued fever treated by quinine have thus been recorded, which we may now contrast with six cases treated in the ordinary way. TYPHUS FEVER TREATED WITHOUT QUININE. Case CCXXYII.* — Anthony Kerracher, laborer, ast. 20 — admitted November 12, 1851. On the 7th, had rigors, followed by confusion of head and general feverish symptoms. No exposure to contagion. On admission, tongue furred and white ; in- tense thirst ; no appetite ; expression anxious, only slight headache ; no eruption. November ik — Cough severe ; dulness at lower part of left lung; cough mixture. November 20 . — Feverishness gone ; sleeps well; expression good. Dismissed on De- cember 8, 1851. Case CCXXYIII.* — Laurence Cochrane, laborer, aet. 43 — admitted December 1st, 1851. Had first severe rigors, November 28th, followed by febrile symptoms. No exposure to contagion. Had fever six years ago. On admission, tongue furred and moist ; appetite gone ; constipation ; pain in back and loins, and great weakness. Complains of cough ; no expectoration ; chest resonant, but crepitation is heard at base of left lung ; pulse 100, full and regular. December 2d. — Bowels well moved ; pain unrelieved ; appetite returned ; no eruption. December Vltli. — Fever disappeared, but very weak. Dismissed January \2th. Commentary. — Both these cases, although complicated with pulmonary disorder, ran their usual course, and in this respect resembled Case GCXXV., in which quinine was given. In neither was there any eruption. Case CCXXIX.f — Isabella Stevenson, set. 44, washerwoman — admitted November 10th, 1851. On the 3d, first experienced pain in the head, followed* by sweating, but says she had no rigors. She was in bed, complaining principally of cephalalgia, during the whole of last week. On admission, the skin is dry and hot, but at night always bathed in perspiration. No eruption ; tongue furred ; no appetite ; thirst moderate; intense headache, with occasional stupor; pulse 120, small, threadlike. Cold to the head and stimulants. On the 12^/<, crepitation was heard in the left lung posteriorly. 13^A. — Great dyspnoea; moist and dry rales over anterior of chest. These symptoms increased, and she died November loth. Sectio Cadaveris. — Forty-eight hours after Death. Both lungs anteriorly were emphysematous in the highest degree, presenting nu- merous bullae, with deep fissures between them, with patches of collapsed lung here and there. If anything, the left lung was most affected. Posteriorly, both lungs more or less collapsed, and, on section, the lining membrane of the bronchi was deeply congested, and the tubes, on pressure, yielded an abundant muco-purulent dis- charge. Spleen small, weighing one ounce and a half; brain and other organs healthy. * Reported by Mr. A. Dewar, Clinical Clerk, f Reported by Mr. J. L. Brown, Clinical Clerk. CONTINUED FEVER. 931 Commentary. — This woman came into the ward on tlie same day as Case CCXXil., the fever was equally severe, and, if anything, the headache was more violent. It was resolved to give quinine in one case and treat the other in the usual way. It so happened that both died. Case CCXXX.* — Margaret Menzies, ast. 16, servant — admitted December 28, 1851. Seized with lassitude and febrile symptoms on the 22d, but without distinct rigors. On admission, pulse 100, full ; tongue coated ; headache and vertigo ; skin dry and hot, with rose-colored elliptical spois scattered over the abdomen and chest, which ap- peared this morning ; they are of mulberry color on the arms. Janucui'y 1st. — Urine loaded with lithates ; eruption disappeared ; skin cool ; pulse natural. January 3d. — Convalescent. Case CCXXXI.* — Christina Swan, servant, ast. 25 — admitted December 16, 1851. Had rigors on the 14th, followed by febrile symptoms, but had headache and other premonitory sytnptoms on the 11th, The day before admission (l5th) an eruption ap- peared on the body. On admission, pulse 120, small; tongue florid at edges, furred at the sides ; no appetite ; great thirst ; cough. The entire surface is covered with a mulberry-colored eruption, in small crescentic patches, and though not raised, strongly resembling that of rubeola. Eyes red and suffused, not sensitive to light. December \Mh. — Was delirious last night. Mouth and teeth covered with sordes; tongue dry and cracked ; is now insensible; pulse 120, small. Subsultus tendinum, bronchitis on both sides, with pneumonia on lower half of right lung. December — Since last report, constant low delirium, which to-d-.iy is somewhat diminished. Cough and ex- pectoration very troublesome. Absence of respiration from right back, with pealing vocal resonance. Pulse rapid and weak ; eruption faded. Blister to head. Wine ^ vj. and brandy '^\y. December 29//n — No delirium, but lies in a comatose state, A lateritious sediment in the urine has appeared, and a swelling in the right parotid gland. Pulse 98, more full. January Isif. — Consciousness returning ; cough much diminished, and respiration audible in right back ; skin cool. An abscess forming in the neck, below right side of jaw. From this period convalescence was slowly estab- lished ; the abscess was resolved, and she was dismissed February 2d. Commentary. — This was a very severe case of typhus, with pul- monary complication, which, however, by means of stimulants liberally given, struggled through on the twenty-first day. The eruption in her case was very peculiar, closely resembling that of rubeola, which it was maintained to be by several persons who saw it. It appeared on the second day after the rigor. But there was none of the intolerance to light, or coryza of measles ; and moreover, she and her friends stated that she had previously had the disease. Under these circumstances, it is probable that it constituted the “ mulberry rash ” of Jenner, appearing early. Case CCXXXII.f — Bridget M‘Fadyen, mt. 20, laboring woman — admitted Decem- ber 17, 1851, with psoriasis of the arms and legs. Rigors appeared January 4, fol- lowed by slight febrile symptoms, which became fully established on the 10^/i. Wth. — Delirious ; face flushed ; pulse 120, rather strong and jerking ; no eruption. With . — Quite unconscious. Head shaved and blister applied. \%ih. — Head relieved; pulse rapid and weak. Ordered 4 oz. of wine. On the 24fA, sediment of lithates in urine. She gradually improved after this date, and on the 26th was convalescent. No eruption. % Diagnosis of Continued Fevers. On reviewing the nineteen cases of continued fever previously given, with a view of determining how far we are enabled to distinguish its ^ Reported by Mr. J. L. Brown, Clinical Clerk, f Reported by Mr. W. H. Broadbent, Clinical Clerk. 932 DISEASES OF THE BLOOD. varieties at an early period, it will, I think, appear that this is impossi- ble. If there be any fact connected with the disease better established than another, it is that at the onset we are unable to say whether any given case will turn out to be a febricula or a typhus, a relapsing or a typhoid fever. If you study carefully the symptoms presented by Cases CCXVI., CCXVIII., CCXIX., and CCXXIV., you will be satisfied of this. We may, indeed, when acquainted with the prevailing type of an epidemic, often be led to guess, with more or less correctness, as to its probable course, but exactitude is impossible. Should the fever cease on the seventh day, then it may be febricula or relapsing fever. The latter is determined by the return of the disease , but I know of no cir- cumstance, beyond the type of the epidemic, which can lead us to pre- dict that event. On the other hand, should the fever continue beyond the seventh day, then we may have to do with typhus or the typhoid form. Notwithstanding all that has been said as to the means of dis- tinguishing these varieties, by means of the eruption or of the abdomi- nal symptoms, I believe that in practice it will be found to be impos- sible in several cases before the twenty-first day. In many other cases, however, the general features of the disease will enable us to speak posi- tively before that time. We have seen, in the three cases of typhoid fe- ver which have fallen under our observation, that no eruption existed in any of them. With regard to the ten cases of typhus fever also, in five there was no eruption (Cases CCXXIL, CCXXIII., CCNXVIL, CCXXVIIL, CCXXXII.) ; in three there were rose spots (Cases CCXXIV., CCXXVI., CCXXX.); in one a mulberry or measly eruption (Case CCXXXI.) ; and in one petechias (Case CCXXY."^) Then with regard to diarrhoea, it is only diagnostic of typhoid fever after the fourteenth day. Thus, in case CCXIX. it first appeared on the twenty-eighth day, and in Case CCXX. on the fifteenth. In Case CCXXI. on the other hand, it is said to have been present from the first ; but such an occurrence, however it may excite our suspicions, is far too common in all fevers to be much regarded as more particularly indicative of typhoid than of typhus fever. From all these considera- tions, the distinctions which have been made out between the various forms of continued fever are often retrospective, and only determined in the advanced stages. You cannot, therefore, be too careful in com- ing to a conclusion on this matter. * This paragraph has been criticised by a writer in the “ British and Foreign Medical Review ” for October 1853, who is a strong supporter of Dr. Jenner’s opinion. It may be worth while, in turn, to analyse his arguments. He admits that if the eruption is not distinctive, the objection to Dr. Jenner’s views would be well founded. He says, however, that in cases CCXXIII., CCXXVIL, and CCXXXII., the eruption may have been absent simply on account of the youth of the patients. But typhus fever frequently attacks young people, and if the diagnostic eruption can only be depended on in persons after the age of 25, its value cannot be very great. CCXXII. is declared to be a cerebral disease, and Case CCXXVIII. a pulmonary one. Cerebral and pulmonary complications were undoubtedly there, but I can assure the critic that they were cases of typhus fever notwithstanding. Thus, however, he disposes of the five cases which are hostile to his views. Then, as to the three cases of typhus (Cases CCXXIV.. CCXXVI,, and CCXXX.), with rose spots, he denies that such spots are ex.anthematous. But if not exanthematous, w^hat are they? Certainly, they were not macular or petechial. Then, because it is said in Case CCXXVI. that they became CONTINUED FEVEE. 933 The investigations of Wunderlich on the continent, and of Drs. Parkes and Ringer in this country, indicate the importance of thermo- metric observations in febrile states of the body. Continuous daily determination of the temperature, according to them, exhibits fixed variations for ditferent fevers, and forms a valuable addition to our means of diagnosis. Thus in typhus, the temperature steadily rises from 98“^, the standard of health, to be above 103° in three or four days, and it declines rapidly when the fever subsides. In typhoid fever, a high temperature persists for a longer period, but peculiar remissions in the range of temperature occur, which are specially marked towards the latter end of the fever. In intermittent fever the temperature begins to be elevated during the sensation of chilliness, and having risen several degrees above 100, in a short period declines rapidly during the sweat- ing stage. In scarlatina. Dr. Ringer concludes that the ranges of tem- perature indicate cycles of about five days in that disease, and that a similar periodicity prevails through the complications and sequelae. This requires confirmation. As a general rule, it may be stated that in scar- latina the temperature attains its maximum from the second to the fourth day ; it then declines rapidly with the pulse until convalescence. The introduction of thermometric investigation as an element of clin- ical research being of comparatively recent date, there are many points of interest still undetermined. From some observations made by Mr. T. Evans, one of my clinical clerks in 1864, it would appear that in typhus fever the temperature attains its maximum about the latter end of the first week ; that is, when the eruption, if present, is most marked. It begins to decline a few days before the pulse does, and falls rapidly during the last week — a sudden diminution of two or more degrees occurring on certain days. After the subsidence of the fever, the temperature is a degree or two below that of health ; and subsequently it rises to be a degree or two higher than the normal tem- perature. Generally it reaches its minimum earlier than the pulse, in the same way as it begins to rise and reaches its maximum earlier. The earlier the pulse and temperature begin to fall, the earlier the fever may be expected to subside. Dr. Parkes has shown that the amount of urea excreted has a certain correspondence to the temperature ; that a sudden diminution of the temperature is coincident with the occurrence of a “ critical discharge ; ” and that a diminished excretion with a per- sistent high temperature is fraught with danger, indicating the proba- bility of the approach of inflammatory complications. It is further to be observed that in typhus the general height of the range of tempera- ture does not appear to be proportionate to the duration or severity of the attack. darker afterwards, and in Case CCXXX. it is noted they are of mulberry color on the arms, therefore they must have presented the ordinary character of a typhus rash. All I can say is, that to me they were in no way distinctive. The absence of eruption in the three typhoid cases (CCXIX., CCXX., and CCXXI,), is thus explained by the reviewer : — “ As the rose spots only appear in 85 per cent, it is not impossible that t'liey might have been absent in these three consecutively, and may have been present in the next fifteen.” But if so, how is our diagnosis to be assisted by a supposed pe- culiar form of eruption which need not occur in all the cases of the disease admitted into the clinical wards for perhaps six months. 934 DISEASES OF THE BLOOD. Morhid Anatomy of the Edinhurgh Epidemic Fever during the JFinter Session 1847-48, when Typhoid Disease was prevalent. During this epidemic, I opened the bodies of sixty-three indi- viduals who had died of typhus and typhoid fever, with the following results : — Spleen. — The organ most frequently affected was the spleen. In the majority of cases it was more or less enlarged and softened, presenting a mahogany-brown color 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-colored discolorations with abrupt margins, sometimes diffused in masses varying in size from a walnut to that of a hen’s egg, at others, disseminated in miliary spots through the organ. In two cases, these altered masses of the spleen’s substance had softened and burst into the peritoneum, causing fatal peritonitis. In another case, a distinct line of separation was observed to be forming round a mass about the size of a walnut. On examining this altered texture in the spleen with a power of 350 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 fusi- form corpuscles of the organ. The granular cells were frequently ruptured, more or less broken down, and appeared to me at that time to constitute the structural character of a new ’ formation which had been described by Roki- (!)■■ tanski and other German pathologists, as ty phus deposit. This deposition, according to them, bears the same relation to the constitu- i'i4. 'oZo. Fir tion of the blood in cases of typhus fever, as tubercle and cancer do to the tubercular and cancerous cachexiae. Al- though the facts described by Rokitanski and others are quite correct, as well as his description of the structure of this altered tissue which I confirmed in 1847-48, further observation has convinced 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 de- generation 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 color, more or less infiltrated with serum or exudation. The fine bronchial tubes were frequently 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 Fig. 525. Structure of a decolorized mass in the spleen. Fig. 526. The same after the addition of acetic acid. 250 diam. CONTINUED FEVEK. ' 935 Remak, as discovered by him in the sputum. The apices of the lungs were very commonly oedematous, yielding on section a copious grayish frothy fluid. In fifteen cases, the lungs were more or less consolidated by exudation, which seldom presented the characters of normal hepatiza- tion. It was sometimes of a dirty yellow tint, at others of a brownish chocolate color, existing in masses of irregular outline, and of variable size, resembling the discolored portions of the splenic pulp, formerly alluded to. In three cases there was pulmonary apoplexy. The dirty yellow or chocolate- colored exudation into the lungs was ascertained, on microscopic examination, to consist of — 1st, nume- rous molecules and granules, filling up the air vesicles, and infiltrated into the areolar tissue; 2d, naked nuclei; 3d, enlarged and isolated epithelial cells, with multiplying nuclei ; and 4th, several compound granular corpuscles. This material was also supposed to belong to the Fig. 527. Fig. 528. Fig. 529. so-called typhous deposits, but is more probably in part an altered exuda- tion, dependent on the constitution of the blood, and partly a desquama- tion of the epithelium, with tendency to multiplication of inclosed nuclei. Intestines . — The intestines presented the lesion so well described by Bretonneau, Louis, Cruveilhier, and others (dothinenteritis, typhoid ulcer, etc.), in nineteen cases. It consisted of a peculiar alteration of the round and oval glandular patches of the small intestine, exhibiting in its first stage a flesh-colored mass, raised above the mucous membrane, presenting 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 the gland affected, but varying in depth, occasionally passing through the muscular and resting on the peritoneal coat of the intestine. In this latter case, the peritoneum externally often presented a red or violet 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 eleva- tions, about the size and shape of a split pea, extended over all the Fig. 527. Appearance of exudation and epithelial cells in the lung in a case of typhoid pneumonia. Fig. 528. Another portion of the same lung, after the addition of acetic acid. Fig. 529. Portions of normal epithelium separated from the air vesicles. 250 diam. 936 DISEASES OF THE BLOOD. ascending and transverse colon. In a few cases the isolated follicles in the large intestine were observed swollen and empty, presenting in their centre a dark blue or black spot. In others, the round and oval patches of the small intestine exhibited a grayish or slate-blue appearance. Per- foration of the intestine from ulceration, causing fatal peritonitis, oc- curred in three cases. Dysentery, with flakes of lymph attached to the mucous surface over the ascending and transverse colon, was associated with intense dothinenteritis in one case. Oval and round cicatrices, exhibiting different stages of the healing process of the intestinal typhous ulcer, were observed in two cases. On examining the matter found in the intestinal glands in the above cases, it was shown to consist of numerous molecules and granules associated with free nuclei and cells of the glandular sacs, which were unusually distended, and filled with cell elements in various stages of development and disintegration. In this respect it closely resembled the altered substance of the spleen formerly described, and indeed appeared to consist of the same glandular lesion. Mesenteric Glands . — In all the cases where the intestinal ulcerations were recent, the mesenteric glands were enlarged, soft and friable, and of a grayish or reddish-purple color. Some of these glands reached the size of a hen's egg. On section, they presented a finely granular surface, of a dirty yellow-grayish or dark fawn color, and their substance was generally soft and friable, but sometimes, in one or more parts of the swollen gland, broken down into a fluid of creamy consistence. On examining this creamy matter, or the fluid squeezed from the gland, with a power of 250 diameters linear, it was found to contain numerous cells, generally spherical, varying in diameter from the l-150th to the l-35th of a millimetre. In some cases numerous nuclei were contained in the cell, occupying three-fourths of its interior, generally about the l-200th of a millimetre in diameter. At other times from one to four of these nuclei were seen scattered within the cell. On the addition of acetic acid the cell-wall was rendered very transparent, whilst the nuclei were unaffected. Many of them were free, and at first looked like altered blood-corpuscles, from which they were at once distinguished by the action of acetic acid. (See Figs. 223 to 225, p. 209.) Blood . — The blood in the great majority of cases, was fluid, and of a dirty brownish color. In those instances, however, where the disease had been protracted, and especially in such as presented well- marked glandular disease, firm coagula were found in the heart and large vessels. Other Lesions . — "With regard to the other lesions observed in the sixty- three bodies, it may be said that in two there were glossitis, and laryn- gitis with tonsillitis ; in one, abscess of the kidney ; and in one, abscess of the posterior mediastinum. The brain did not appear to participate much in the disease. It presented only occasional congestion, with slight effusion into the subarachnoid cavity, or into the lateral ventricles. In seven bodies no lesion whatever could be discovered. Such is a summary of the appearances observed in sixty- three bodies of patients who died of fever during the prevalence of the typhoid form CONTINUED FEVEE. 937 of the disease during 1847-48. The proportion of typhoid to typhus cases has considerably increased of late years. Pathology and Etiology of Continued Fever. With regard to the nature of typhoid, as of all other forms of fever, we know little ; but, from what has been said, it is impossible to avoid seeing that the spleen, mesenteric and intestinal glands, are especially liable to be affected. Now these glands constitute part of an apparatus which, I believe, secretes the blood (see Leucocythemia) ; and if so, we begin to catch a glimpse, at all events, of the connection between altera- tions of these structures and of the blood in fever. Further researches, however, are required to determine the nature of such connection, as well as how far in this disease the glands operate upon the blood, and the blood upon the glands. The same arguments which apply to the uncertainty of diagnosis may be raised against the general doctrine, that the different forms of fever are dependent upon separate poisons, run a separate course, and are governed by laws as distinct as those which regulate the various kinds of eruptive fever. Without denying the existence of various kinds of continued fever, I am of opinion that this doctrine has not been estab- lished. On the contrary, I believe that internal complications, and the accidental circumstances of season, diet, constitution, and other causes of a like nature, modify fever in particular individuals at different times, and that to these the variations observed are in many cases attributable. Moreover I am satisfied that typhoid and typhus fever may occur to- gether epidemically, run into one another, and be mutually communi- cable. This was very well shown in the Edinburgh epidemic of 1847-48, in which both diseases occurred together at the same time and in the same localities, some individuals coming from the same house affected with typhus, and others with typhoid, the latter having intestinal lesion after death, as proved by dissection. At the same time, there can be no doubt that these different forms of fever may succeed each other just in the same manner that there may be relapses or returns of the same form of fever. Of this the following is a good example : — Case CCXXXIII.* — Typhoid succeeded hy Typhus Fever. History. — Sarah Hewson, let. 23, unmarried, kitchen-maid — admitted October 23d, 1864. She has always enjoyed good health up to the lYth instant, when after exposure to cold .she was seized with febrile symptoms. Being unable to work, she took a dose of salts three days afterwards, but weakness and prostration increasing, came to the Infirmary. Symptoms on Admission. — On admission, skin hot and dry ; no eruption ; pulse 96, of fair strength ; tongue covered with a brown fur. No appetite ; thirst ; no diarrhoea nor abdominal pain ; no headache. A saline mixture., and heef-tea and milk for nourishment. Progress op the Case. — October 26^A. — Pulse 94, weak. To have ^ iv of wine daily. Oct. 21th. — A few rose-colored spots visible on the abdomen. Bowels loose, the stools of a pea-soup character. From this time the case assumed the usual char- acters of typhoid, a marked improvement occurring on the 6th of November, being the Reported by Messrs. Wm. Johnston and R. Mackelvie, Clinical Clerks. 938 DISEASES OF THE BLOOD. 21st of the disease. The prostration from purging was extreme, and her convalesence greatly prolonged, notwithstanding the liberal employment of wine and food. Dis- missed December 14th. Re-admitted December l%th, with all the symptoms of typhus fever, except an erup- tion. Face flushed and anxious. Skin hot ; temperature 104°, covered with perspira- tion. Pulse 128, weak. Tongue white and furred in centre. No appetite; great thirst ; bowels constipated. Headache ; great muscular depression ; sleep disturbed ; no delirium. Respiration, 35 per minute, slight cough, and thick mucous expectora- tion ; urine normal. From this time her case went through the usual course of typhus fever, from which she was convalescent on December 26th (14 days from the rigor), and was dismissed quite well January 23d. It appears that on December 12th, two days before she left the house, she had a severe feeling of cold or rigor, but was much better when she left on the 14th. She remained in her brother-in-law’s house, feeling weak and unwell, which symptoms in- creasing she returned to the Infirmary. She says that for fifteen days bel'ore leaving the house she was in the habit of waiting upon another woman (Boyd) in the ward, laboring under typhus fever, and frequently sat down by her bedside, and as there was no fever in the brother-in-law’s house either before or after her visit, she supposes that the disease was caught in this way. Dr. Murchison endeavors to prove that typhus and relapsing fevers are caused by over-crowding, with deficient ventilation and destitution. Typhoid fever, on the other hand, he considers to be caused by emana- tions from decaying organic matter, or by organic impurities in water, or by both of these causes combined. The arguments he has brought forward in support of this theory merit careful consideration, and were steadily kept in view in the inquiry of 1862-63 and since. The facts, however, which came under my notice in the remarkable epidemic of this city (1847-48), already referred to, cannot, I think, be explained, by any such supposition. Further, in none of the many cases which have entered the Infirmary under my care since the views of Dr. Murchison became known, could I trace any relation between the occurrence of the typhoid fever and exposure to putrid organic matter, although in every instance this point was carefully investigated. In one case only has there been a difference of opinion in the class on the subject ; and as it exhibits how easily one may be misled and guided by preconceived views, the facts may be specially referred to. Case CCXXXIY.^ — Typhoid Fever — Convalescent on the ‘list day. History. — Kenneth Sinclair, mt. 21, unmarried, sailor, native of Caithness — ad- mitted 6th May 1864. The patient’s health w'as good previous to the present attack of fever. About the middle of March (1864) he sailed from Wick to Dantzic, in a schooner laden with pickled herrings in barrels, from the lower of which the brine leaked into the hold, producing an intolerable stench. The sailors were allowed plenty of food, with a fair supply of fresh vegetables ; but the forecastle in which they slept, was small and ill-ventilated. The boat made the voyage to Dantzic in twelve days, and remained there three weeks, during which time the patient was kept hard at work on board, but was supplied daily with abundance of fresh meat. The refuse of the town being poured into the harbor of Dantzic produces abominable smells in it. About a week before the vessel left, the patient drank by accident some bad water from a pump, and two days afterwards was seized with diarrhoea, which continued up to his admission — his bowels being opened three times a day on an average. The ship sailed from Dantzic to London, laden with wheat, and arrived in the Thames about the 26th of April. The patient worked during the whole voyage, and besides assisted in cleaning the vessel for two days after her arrival. Feeling exhausted, he then applied to an apothecary for some medicine to check his diarrhoea, but it failing, he lay up for some days; after which, feeling himself getting gradually worse, and having been seized with a * Reported by Mr. J. M. Moore, Clinical Clerk. CONTINUED FEYEE. 93G rigor, he left London on the 4th May, in the London and Edinburgh steamer, and arrived in Edinburgh on the 6th. Symptoms on Admission. — Patient is exceedingly weak, and unable to answer questions. Tongue covered with a white creamy fur, red at the tip. Bowels loose ; stools of a pea-soup character. Tenderness over the whole of the abdomen. Face flushed ; skin hot ; decubitus dorsal. Pulse 96, incompressible, and of good volume. This appears to be the 11th day of the fever. Progress of the Case. — From this date to 16th (21st day of fever) the patient’s bowels were opened on an average twice a day, and his pulse i-anged from 88 to 96. On the 16th, pulse 84, good strength, regular, and bowels open twice. The patient con- tinued to progress slowly but steadily, and was dismissed perfectly well on 27th June. Commentary . — The history of this case is given exactly as it is recorded by the Clinical Clerk, which, though generally correct, conveys the impression that the cause of this man’s fever was the bad smells and putrid emanations to which he was exposed. After his convalescence he was repeatedly examined and cross-examined by the class, with a view of determining exactly what were the circumstances which pre- ceded his illness. The following were the facts elicited. He was in good health up to the time he left Wick. A horrible smell did pervade the vessel in consequence of some casks containing pickled herrings leaking into the hold. He was ten days on the voyage out ; was two days unloading at Hantzic; was another week in the harbor, during which the vessel lay empty ; was three days loading her with wheat, and remained other two days. During these twenty-four days he was in perfect health, and performed all his duties on board the vessel. During the last two days of his stay in Dantzic harbor, on one occasion when ashore, he applied his mouth to a pump in order to drink ; but after taking one mouthful he desisted as the water had a bad “ roUen ” taste. During this period the crew were well supplied with fresh meat and vegetables. The vessel then went to Fairwater, six miles below Dantzic, where she remained a week. Two days after arriving there, diarrhoea came on. He continued his work, however, and continued to do so during the ten days occupied in the voyage to Loudon, although during fifteen days — that is, ever since the diarrhoea commenced — he had about three loose stools every day. On arriving at London, he went ashore and obtained some medicine from a druggist to check his bowel complaint, but he was now seized with shivering and considerable pros- tration. He therefore determined to come to Edinburgh, and arrived there two days afterwards by one of the General Steam Navigation Company’s steamers. This circumstantial account, it seems to me, in no way supports the theory that putrid emanations were the cause of this man’s typhoid fever. They were removed with the cargo of herrings, twelve days before the occurrence of diarrhoea, which seemed rather to be occasioned by the bad water he drank. Again, if that diarrhoea had been properly treated and checked at the commencement, would he have had typhoid fever at all, the febrile attack commencing fifteen days after the diarrhoea, with rigor, etc., on his arriving in the Thames ? These questions are important, and the whole history of this man shows how necessary it is to analyse facts carefully before arriving at conclusions as to the cause of disease. Considering the effluvia which pervade cities, harbors, and ships, it TABLE OE TYPHOID AND TYPHUS FEVERS, 1862-63. UO cc^ . o ■i& -3$ ® '§ “■ ® .a 05 fee fee .■ lljlllfi ftS ® P.2 a ^ « P te g P prp w g g-g^ § o P^c2 -- o np 0 1 _“i e-i ^ p .s all pi . 1:1 ! .£ o ; -I. llil .2 S '-s p 'p 1“ » OJ 'p.2 P a „- 2 "5 ft a >5 I I o ® ® p fcc'^ p ;p .a Sap ■|8^ f^® I 00 ,o ^ s .s| if Is o TO p"'* fe« ® - ^2 ’co -2 .« -p & •P ol § P* a ^ 0-3 ” '2 w “ a S.S a, O £hO s^4q O ^ lijll .2^ ^ a p ;>i Cf-. * bo °Mi $rd ft«+- OJ Ills- ja o .p.a g K rt’S ® ® ^ “:gi3 |llil lfl|i 1 <1^ 03 ^ >> >> p d fp 'p 5 Tf< rri d P ^ tp § r. p o ^-"P I-2.P ^ Q 'd d tp th day * between 17th and day L3th day 5 days r admis- P to d ,2 _ 'P rP 4th day 4 days r admi’s- i ^ C5 fd 1 H > ^ Pc o o o p p P w g<^» o P « « d R ^ . ® » . ® ®!2c O PP P Died afte: P tip .2 to O U r Pi >43 •ig^ O o fl 'O c K a g CQ o> efore admis- sion bsent 1 s g .2 ,P .d rt o to o p's Sg g r® 2 2 C3 CQ rO P to P! t3 44 P .“3 •T3 a> "p p CO (5 M << t> o o 0 .2 0 o ■2 O 'o a. (1) Ph 00 9 Pii ^ ft T; CQ 73 to p.a p,a .2 *5< ■? Pr2 p a a d o 'q P g w o t5 .1 9 d St:! a g-p g-r.gh.r4g « o ^ d i2 a.slai o'^.i'P 0 44 o^ 9 w p.'d d d o.P d 2 ^.2 o a & Pr2' ^ ^ ® -P w d ;3 o TJ ® o p rC P ® C3 *0 d P o3^ d c3^ d d c3 fe o a gg^^^S-Sg "3 3 g o 02 a> o-^"® o ,a 1^ 0 p M S P p p rt Pi g § p O 05 C3 o o p g KO il (H ll h g d C3 g to .'2 "o o g II .a» li 8 r2 O Hill Place Blackfriars Wynd Fountainb] o-« o *3 tppj c« .'9 (2 OQ rS C/3 H Norton P Portobell Portobell Grassmai Portobell tp « tp o In the wards seized In the in No fixed s 1 S3 1 ^ P 1 i u G3 o o s 1 Q? rg u o o C5 o Baker Glass-blo Policema Clerk Message- Charwon O |p a is .§ ®.=f o Wp p "Wife of s maker 0 1 § Servant Seaman Servant 1 ■ 1 02 <» ao iTi O UO CO iO C5 ^ 00 o s tc -* CO CM C4 O ® ® rP li -i o S®. a p 'o M .2 -g § 1 p C3 2 05 Sg 1 cc _d “p 1 1 w &• ca § W MI-5 CO M of •4 ccxxxv. CCXXXVI. CCXXXVII. I CCXXXVIII. CCXXXIX. eeXL. CCXLI. CCXLIT. CCXLIII. CCXLIV. eeXLY. CCXLVI. CCXLVII. OCXLVIII. CCXLIX. CCL. CONTINUED FEVER. 941 must always be easy to attribute disease to some such cause. But when we see how frequently these supposed causes are innocuous, and the extreme uncertainty with which they are even coincident with their presumed consequences, we may well ask, are they in truth causes at all ? In the winter session of 1862-63, I reviewed and carefully re-examined the whole subject of fever, in consequence of the appearance of Drs. Tweedie and Murchison’s important works on this disease.* Thirteen cases were the subject of comment, and they were all taken with great care. As too much space would be occupied by recording them at length, I give the chief facts in a tabular form, together with two other I cases admitted under my care in the summer of 1863. In all the cases j the fever was well marked, and the points more especially investigated were the residence, exposure to contagion or to putrid emanations, as causes, and the diagnosis, more especially as determined by the integu- mentary, intestinal, and arterial symptoms (see opposite Table). Commentary on the Cases Tabulated . — Of these sixteen cases of fever, ten were typhoid, including Case CCXLIX., the nature of which was long doubtful, but from its prolongation beyond the twenty-first day was at length declared to be typhoid. Five cases were typhus, and one febricula. The residences of these cases were widely diffused, the typhoid cases coming from no place especially distinguished for effluvia or bad drainage. The typhus cases originated in the Grassmarket, Fountainbridge, and the Infirmary itself. Great pains were taken to determine the immediate cause of the disease — whether contagion or ex- posure to noxious effluvia — ^yet, except in the two cases which occurred in the Infirmary, and which therefore are presumed to be owing to contagion, in none could the fever be traced to either cause. Of the ten typhoid cases, a rose-colored eruption was observed in seven. Of the five typhus cases, a mulberry- colored rubeolar eruption was observed in four, so marked that the cases were considered at first by the clerks to be those of measles. Profuse and continued diarrhoea was present in five of the ten typhoid cases, was moderate in one, and slight in four. The pea-soup stools were well marked in four, while they resembled coffee-grounds or chocolate in one — a fatal case. Among the five typhus cases there was constipation in two, slight diarrhoea in two, and coffee- ground stools in one. Of the ten typhoid cases, head-symptoms, amount- ing to excessive pain or delirium, were present in five and absent in five. One of the former had meningitis. Of the five typhus cases, they were present in three and absent in two. Among the ten typhoid cases were three deaths, in all of whom the bodies were carefully examined, and typhoid ulcerations of the intestines found. Of the remaining seven, four were convalescent about the fourteenth day, and three only on or after the twenty-first day — which is said to be the usual period. Of the five typhus cases, four were convalescent on the fourteenth day, while one was later, although the exact day could not be fixed. All who watched these cases were, I think, satisfied, as must be evident from the above analysis, that the systematic descriptions of those writers who ^ Lectures on Continued Fevers, by A. Tweedie, M.D., etc. ; and Treatise on the Continued Fevers of Great Britain, by "C. Murchison, M.D., etc. 1862. 942 DISEASES OF THE BLOOD. seek to draw marked distinctions between the various leading pheno- mena of these fevers, especially as regards modes of origin, eruption, intestinal and cerebral symptoms, and day of termination, so far from being uniform, admit of frequent and striking exceptions. It follows that we should be very cautious in hazarding an early diagnosis, and attaching too much importance to any one of these symptoms in par- ticular. In recent times it has been maintained that the gases originating from decomposing animal and vegetable matters, bad drains, etc., are not only the especial causes of certain specific fevers, but that bad smells are the evidence of the existence of these specific morbid causes. Sanitarians and municipal authorities have succeeded in exciting at the present time a public f urore on this subject, and are producing effects which for extravagance and uselessness can only be compared with those resulting from the railway mania which existed some years ago. Gigantic works are being constructed, having for their object, not the utilization of human excreta, but channels by which they may be effec- tually wasted. Millions of pounds are to be thrown away in conveying that matter so necessary for the land and for agricultural purposes into our rivers and seas, under the idea that the smells and emanations arising from it are the source of pestilence, and that it should be removed at any cost. The following considerations may perhaps serve to correct erroneous views on this subject : — 1. Atmospheric air^ strongly impregnated with odor of various hinds^ is not necessarily injurious to health. — This is shown — 1st, In various parts of the world where odorous flowers are largely cultivated for the manu- facture of perfumes. Strangers, indeed, often complain of headaches in such districts, but anything like epidemic diseases are unknown. 2. At Paris there is an establishment at Moiitfaucon for converting ordure into a dry mass by simple evaporation. It is then called poudrette, and sold for agricultural purposes. The smell of this place to visitors is at first almost intolerable ; but the inhabitants of the neighborhood are uncon- scious of it, and it occasions no disease. 3. The state of the Thames in 1858 was loudly complained of in consequence of its putrid odor, but no disease was caused by it. 4. The Craigentinny meadows, near Edin- burgh, have for 200 years been rendered fertile by causing the drainage of the city to flow over them. The odor is often very bad, but they occasion no unhealthiness. 5. The drains in Naples run down to the sea, having large slits in them opening into the streets, and the beautiful bay is rendered foul, close to the shore, with the drainage of the city. This, combined with the sulphuretted hydrogen given olf from the volcanic soil, renders the atmosphere so unpleasant, that the rents of the dwellings, unlike what exists in other cities, augment as the apartments ascend in the stair. The latrines in the public hospitals also exhale the most foetid ammoniacal gases. Notwithstanding, neither in the city nor in the hos- pitals is fever, and especially typhoid fever, so common as in other cities of the same size. 6. Drs. Livingstone and Kirk informed me, that in Africa the smell of the mangrove swamps was often intolerable, but was never productive of disease. CONTINUED FEVER. 943 2 . Atmospheric air, productive of the most dangerous epidemics, may he quite inodorous. — This has been proved in various parts of the world, as in the marshes of Essex and Lincolnshire, the low grounds of Hol- land, the Carnpagna of Rome, the Delta of the Ganges, the swamps of Louisiana, the Guinea coast, Jamaica, and many other places. It has never been known, that those who catch intermittent, remittent, or con- tinued fevers, on visiting such localities, have connected the morbific causes with peculiar smells. It follows that — 3. There is no necessary connection between smells and deleterious gases. — Some of these have smells, such as sulphuretted hydrogen, whilst others are inodorous, such as carbonic acid gas. Now, it is to be observed, that what makes these and other gases injurious is their being so concentrated as to exclude atmospheric air, or their being pent up in con- fined places, from which they escape in injurious quantity. Hence why workmen going down into pits expire, for the same reason that dogs do in the Grotto del Cano. It has been asserted, however, that smells, though not injurious in themselves, give indications of danger. At a discussion on this subject which took place in the Physiological Section of the Rrit- ish Association in September 1864, one chemist maintained that during putrefaction the smell was given off first, and the noxious vapor after- wards ; whilst another declared that the smell was given off last, and was the proof that all danger had ceased. The first likened smell to the tail of the lion, which, when seen, gave evidence that the claws and teeth were not far off ; while the second, continuing the simile, declared that a sight of the tail was the best evidence that danger was departing. I do not believe that smells, as smells, are injurious to health, nor are they a nuisance to those who live among them ; yet, one of the great difficulties in making the sewerage of towns useful in agriculture has arisen from exaggerated notions as to the danger of smells, and the necessity of deodorisation. 4. Fresh sewerage entering into running streams is not dangerous to health. — This is shown — 1st, By the state of the Thames in 1858; 2d, By the condition of the Water of Leith, which has been proved by the statistics of Dr. Littlejohn, officer of health for the city of Edinburgh, to be a more healthy district than others in proportion to its population, and by Dr. Millar to be equal, in point of health and as regards death- rates, to the best parts of the town. He shows from the tables of the Registrar-General for Scotland that the death-rate from fever in the Water of Leith district is 17’G2; in the whole city 24-5 ; and in the Canongate and St. Giles’ districts, 29‘1. Excluding the streets in the Water of Leith district inhabited by the higher classes, the death-rate is 18'80.* 3d, It is not destructive to the fish, for according to Dr. Elliot cf Carlisle,! the salmon have increased in size and weight since the drainage of that city was conducted into the Eden ; while it is shrewdly suspected that the fkmed whitebait of Greenwich and Blackwall actually owe their existence to the peculiar condition of the neighboring Thames. 5. Typhoid or other Fevers cannot he proved to originate from f cecal fermentation or emanations. — It is true that Dr. Murchison has col- * Speech to the Town Council of Edinburgh, March 29th, 1864. f Statement made to Brit. Association of Social Science, 1863, 944 DISEASES OF THE BLOOD. lected many examples where typhoid epidemics have occurred coinci- dently with the opening of some drain, or with imperfect drainage of a place. But an equal number of facts might easily be produced to show that where drainage has been very bad, no fever has originated, or where fever has occurred and drainage has been perfect. The great epidemic of typhus and typhoid fever in Edinburgh in 1847-48 followed failure in the potato crop. Formerly, when there was little or no drainage in the old town, typhus was the only fever met with, and typhoid was unknown. Now, drainage has been largely introduced, and typhoid has become common. Dr. Murchison endeavors to explain this by sup- posing that water-closets, now largely introduced into the houses, diffuse emanations there in consequence of a bad water supply. If such were the case, fever should increase largely in autumn, when the supply of water is scarce ; whereas it is always most prevalent in winter, when the water is abundant. Formerly also typhoid fever was as unknown among those who had water-closets as those who had not. Further, it should be remembered that the men who are employed almost constantly in the great London drains, though so much exposed to their emanations, are not particularly liable to fever. 6. Ejpidemic fever j and especially typhoid fever, therefore, must oriyi- nate in other causes, amongst which, besides contagion and infection, may be cited starvation, improper quality of food, bad water — especially from springs arising in the neighborhood of cess-pools or churchyards — overcrowding, bad ventilation, and the. numerous ills arising from poverty and dissipation. Dr. W. Budd of Bristol has with great ability supported the doctrine, that the cause is a specific virus, always emanat- ing from the body, which may be conveyed by, but never originates in drains."^ For my own part, I believe we have yet to discover the cause producing essential fevers. But while there are so many sources of fallacy, we cannot be too cautious in accepting plausible explanations, or in acting upon them, either in our efforts to cure disease or to im- prove the health of towns. Another question which will be found discussed in systematic works relating to the pathology and mode of propagation of continued fever is * Papers in the Lancet, from 1856 to 1868. Fig. 630. A clinical ward of the Royal Infirmary in 1817, 60 feet by 24, showing the arrangement of fever beds, and the screen which isolated them. CONTINUED FEVEE. 945 important, namely, Whether it be or be not advisable and right to admit fever cases into the general ward of an hospital. My reply is decidedly in the affirmative, being satisfied it is far better in every point of view to dilute the contagious element as much as possible, rather than to concentrate it by providing special wards for typhus cases. Previous to 1825 a few fever cases were treated in each clinical ward of this In- firmary without injury to the other patients, the disposition of the fever beds being represented in shadow in Fig. 530. The space around them was partially isolated by a screen partition seven feet high, with a door at each end. At present the arrangement of fever beds in the clinical wards is represented in Fig. 531. Each bed has 1100 cubic feet of space, and 8^ feet of head room. There is a window on each side of every fever bed, and a space of six feet between it and the adjoining ones. The result of this system has been most satisfactory, as during the last fifteen years there has been no spread of fever in the wards, except on one occasion, which was traced by Dr. Christison to the rules of the house having been neglected.* Treatment of Continued Fever. The general treatment of continued fever which I have found most useful, and which you have seen practised in this Infirmary, consists, during the stage of excitement, of giving saline antimonials, administer- ing slight laxatives if occasion require them, and ordering the head to be shaved and cold applied. Fluid nutrients, such as milk and beef-tea, are given from the first, and wine and stimulants as soon as the pulse becomes weak. In prolonged cases, the effect of pressure on the skin from decubitus must be carefully guarded against, whilst the different complications which arise will require careful management. Salines and Laxatives . — At an early period of the disease, when the skin is hot, and the pulse rapid and strong, the saline mixture generally ordered is the following: — Sol. Tart. Antim. 3 ij ; Lia. Ammon. Acet. * Monthly Journal of Medical Science, March 1850.' Fig. 631. Clinical ward, No. XL, 1858, 81 feet by 24, showing the present ar- rangement. — ( Chrisiiso7i.) 60 946 DISEASES OF THE BLOOD. 3 j; Aqum^ 3 vss. M. Fiat mist.^a talk- spoonful to he taken every four hours. Should a laxative or purgative be required, not otherwise, castor- oil is the one usually employed. Water or thin lemonade may be taken ad libitum. Cold to the Head . — The oppressive headache of fever is greatly alle- viated by cold applications to the head. Indeed, none but those who have experienced it can understand the feeling of relief and grateful seasation of l;ase wdiich is in this way produced. The best method of applying cold I have found to be as follows : — A wash hand basin should be placed under the ear on one side, and the head allowed to fall over the vessel by bending the neck over its edge. Then from a ewer a stream of cold water should be poured gently over the forehead, and so directed that it may be collected in the basin, care being taken not to wet the dress or bed-clothes. It should be continued as long as it is agreeable to the patient, and repeated frequently. In hospitals, and more especially in fever wards, this method requires too much attend- ance. You will have observed, indeed, that I seldom order cold to the head, experience having taught me that it is more frequently converted into warmth to the head. For, notwithstanding every injunction to the contrary, all that is done in these cases is to moisten a piece of double rag or lint in cold water, and lay it upon the warm head of the patient. In a few seconds it is converted into a warm and steaming fcmentation, and too frequently allowed to remain in this condition for hours. Hence, unless cold can be applied properly (and in large hospitals that can scarcely be expected without procuring a nurse for every two or three patients), it is better not to order it at all. It has occurred to me, how- ever, that a water-pipe might be conveyed round the walls of fever- wards, with a vulcanised india-rubber tube and stop-cock attached, so that with a little contrivance the patients might procure a flow of cold water and regulate it for themselves. I am satisfied that much relief . would be in this way obtained. To secure the application of cold efficiently, it is necessary that the head be shaved. In all severe cases this is indispensable. Such prac- tice, however, is often stoutly opposed by the friends of young wmmen, who are unwilling that they should lose a handsome growth of hair. I have occasionally 'compromised the matter by allowing the long hair to float in cold water,, and act by capillary attraction on the scalp, so as to keep up a refreshing feeling of coolness. Regulation of Diet . — During the early period of fever the patient generally loathes all kinds of food. Care must be taken, however, that nourishment should be introduced in the form of drink, and diluted milk, beef-tea, toast and water, thin panada or similar fluids given with a little toast or biscuit. Should collapse come on, together with stimu- lants, chicken broth, good strong beef-tea, or milk should be administered. The danger from fever is not the result of over, but of under nourish- ment, which, by reducing the strength, leaves the patient less capable of struggling with the subsequent weakness. I have especially noticed, with regard to relapsing fever, that those who have fed well in the in- terval have been less attected by the re-accession. The body is also drained of its saline constituents, whilst such as enter with the food are. CONTINUED FEVER. 947 witli it. cut off ; hence I have found it useful to add a large amount of common salt to the beef-tea, which also renders it more sapid and agree- able to the patient, and serves to clear away the accumulation of fur and Sardes that gather about the mouth. On the other hand, when conva- lescence comes on, we should take care not to indulge the appetite too much. We can never be sufficiently grateful to Dr. Graves, of Dublin, for his able advocacy of the principle to “ feed fevers.” It is only to be regretted he did not apply it more extensively, and cause inflammations to be fed also. JFine and Stimulants. — When, after being rapid and strong, the pulse falters, becomes soft and weak, very often without losing its fre- quency, it will become necessary to administer wine or other stimulants. The quantity of wine usually given is from three to six ounces a day ; but in some cases marked by unusual depression, or when the individual has been previously accustomed to alcoholic drinks, a larger quantity, or instead, from one to four ounces of spirits, may bo required. Nothing is more difficult than to lay down rules as to the extent to which stimu- lants ought to be given in certain cases, or as to the period when they should be administered. The pulse, strength of constitution, previous habits of the patients, but above all the type of the prevailing epidemic, must be your chief guides. Nothing, perhaps, is more indicative of ex- perience and practical tact in the treatment of fever than the judicious use of stimulants in this disease, and certainly there is no other method of acquiring the necessary knowledge than that of carefully watching their elfects in a large number of patients. iVmorig all the agents at your command, there are none which will enable you to conduct a case of fever to a favorable termination more successfully than stimulants, when properly managed. Indeed, it is easy to conceive that, in a dis- ease where loss of appetite and abstinence from food constitute essential phenomena, a period must arrive sooner or later when artificial support is absolutely required. You should be careful, however, not to prolong their use more than is necessary. Very singular anecdotes still linger about the clerks’ rooms of this Infirmary of instances where whole bottles of whisky were consumed daily by fever patients, and where, notwithstanding their recovery, owing to some mistake in the order- book, the whisky was still supplied, and disappeared with surjDrising regularity. With regard to the complications of fever, I have nothing further to say, than that they must be treated according to circumstances ; always keeping in remembrance that active depleting means are never useful, and seldom fail, by diminishing the vital powers, to augment the collapse and increase the danger. Can we cut short a Continued Fever ? — There cnn be little doubt that it is of immense importance to cut short the disease, if possible. With- out speaking too positively, I have been induced to believe in this possi- bility, under certain circumstances, by means of emetics. A fortnight after being appointed Physician to the Fever Hospital of this city, in 1844, I experienced lassitude, headache, and that peculiar cold feeling in the back, which generally usher in fever. I took an emetic of anti- mony and ipecacuanha, and on the following day was well. Three weeks 948 DISEASES OF THE BLOOD. afterwards, I experienced the same symptoms ; hut thinking it possible that, after all, the emetic had not really been the cause of their removal, I allowed the disorder to proceed, which terminated in a prolonged relapsing fever, with three distinct relapses. I think I have observed the same thing in other cases ; and now, as a rule, whenever called in at the early period of fever, I always order an emetic. This practice, so far as I have observed, never does harm, often good ; and, although the point is of course impossible to demonstrate, it has, I think, been successful in checking at the onset many cases of fever. With regard to cutting short continued fever by quinine, as contend- ed for by Dr. Dundas, I regret to say that the trial you have seen made of it has entirely failed. In none of the seven cases (Cases CCXIX., CCXX., CCXXII., CCXXIII, CCXXIV., CCXXV., and CCXXVI.) in which it was given, notwithstanding the physiological action of the drug was well marked, did it in any way shorten the disease, or produce on its progress, so far as I could ascertain, any amelioration whatever. On the other hand, it may be argued that in one case (Case CCXXII ) it was injurious, by increasing the cerebral complication. Dr. Christi- son also tried it in one case, and Dr. W. Kobertson in eight cases, both with a want of success. Thus, in sixteen cases it has been carefully and energetically tried, with uniform failure in all. Therapeutic Action of Quinine in Fever . — The effects produced by large doses of quinine are worthy of observation. With these I became first familiar in the wards of M. Piorry, in La Pitie Hospital, Paris, during the year 1838. At that time quinine was given in enorm.ous doses, with a view of cutting short interm ittents, and diminishing the size of the spleen. In this way I frequently saw 50 grains of quinine or 100 grains of salicine given in one dose, the administration of which was followed by the same effects you have observed to follow repeated doses of 10 grains in the Royal Infirmary. In both cases the principal phenomena induced are vertigo, dizziness of vision, ringing in the ears, often complete deafness, with confusion of ideas, occasionally coma with contraction of the pupil. At the same time the force and frequency of the heart’s contractions are diminished, and the pulse, from being 120, strong and full, was frequently reduced in a few hours to 80 beats, which were soft and even weak. The skin at the same time becomes cool and often moist from slight diaphoresis. This sedative action on the heart is apparently the result of the comatose condition produced by the primary action on the brain, as is proved by the fact that the disappearance of the cerebral induces cessation of the circulatory phenomena. In large doses, therefore, quinine is a narcotic. Its principal action, however, seems to be on the ganglionic system of the nerves (See p. 338), through which it operates on the blood-vessels and blood. Of late years it has been called an anti-periodic, from the specific effects it exercises, not only on intermittents, but on all diseases which exhibit a tendency to return at periodic intervals, as certain cases of epilepsy, neuralgia, and even re- lapsing fever. This property is altogether peculiar, and is distinct from what ought to be understood by febrifuge, unless, indeed, the statements and views of Dr. Dundas should be subsequently confirmed. Quinine is also spoken of as being a tonic when given in small doses. INFANTILE REMITTENT FEVER. 949 Tins property seems to have been attributed to it on account of its bitter- ness, as well as its remarkable effects in the cure of ague. But whether it increases the appetite, stimulates the digestive organs, or in any other way operates by increasing the tone of the system and improving the nutritive powers, is a circumstance which, though generally adopted as true, admits of strong doubt. If quinine be a narcotic in large doses, it is the only one of that class of remedies which is tonic in small doses. No doubt it is very frequently given to convalescents and weakly persons, who get better under its use, but whether this is owing to the quinine, or would not have occurred equally well without it, is a matter very diflB.- cult to determine. Of one thing I am satisfied, namely, that it is far in- ferior in tonic properties to many metallic and other vegetable drugs, and consequently a medicine with such known valuable anti-periodic proper- ties, the supply of which also is yearly diminishing, should not be wasted in endeavoring to produce effects so very doubtful as the tonic virtues which have been ascribed to it. For many years, therefore, I have not given quinine as a tonic, and have yet to meet with a case where it is necessary to administer it in order to increase the strength of the system. INFANTILE KEMITTENT FEVER— CAN IT BE SEPA- RATED FROM ACUTE HYDROCEPHALUS? Case CCLL* — Blanche Seott, set. 3 years, of scrofulous habit — admitted into the clinical ward November 10th, 1851. Her mother states that she enjoyed good health until a fortnight ago, when she was attacked with severe diarrhoea — the stools being thin, of a dirty green color, offensive odor, and mingled with slimy matter. She became dull and peevish during the day, but restless and uneasy at night, when the skin became hot, and the countenance flushed. The diarrhoea and fever continued eight or ten days, accompanied with los3 of appetite and great thirst. During the last four days there has been delirium; loss of consciousness ; oceasional moaning ; uneasy gestures in demand for drink ; hands frequently raised to the head, with a slight scream ; constant picking of the nose and angles of the mouth with her fingers ; latterly, retching and vomiting, and passage of the urine and faeces in bed. Symptoms on Admission. — On admission she presents the following symptoms : — Unconsciousness of surrounding objects, not recognising even her mother ; pupils not contractile to light ; slight strabismus of right eye ; frequently puts her hands to the head, which is rolled about uneasily ; continual grinding of the teeth, low moan- ing, and occasional muttering. Tip of tongue, which is all that can be seen, very dry, and of scarlet color ; loss of appetite ; constant thirst ; vomiting ; involuntary disebarges of fasces and urine ; on pressing the abdomen uneasiness evidently experi- enced, and moaning increased. Skin hot and dry ; no eruption ; a small abscess at the back of the neck, with a sanious discharge. Action of heart feeble and flutter- ing. Pulse 140, small, and occasionally intermittent. Breathing short and hurried ; no rales. The head to he shaved, and a blister to be applied over the scalp. To have § ij of sherry wine. Progress op the Case. — November l^th. — The fever increased towards night, and she was very restless. This morning it has abated. Skin now cool; pulse 120, stronger and regular ; no strabismus ; still unconscious. Pus has formed below the blistered cuticle. Nov. \^th. — Accession of fever last night; the pulse rising to 160, and becoming sharp. This morning consciousness has returned ; fever abated ; tongue dry, brown, and cracked ; swallows without difficulty ; pulse 120. Nov. l^th. — There are still accessions of fever at night, and remissions in the morning. The scalp is swollen and boggy to the touch, and pus oozes from it on making pressure. All movement of the head causes the child to cry. No tenderness of abdomen. Bowels are opened three times daily. Faeces are more consistent, of dull green color, and offensive smell. Pulse 110, more full. Three parallel incisions were made * Reported by Mr. W. M. Calder, Clinical Clerk. 950 DISEASES OF THE BLOOD. through the infiltrated scalp, by which a considerable quantity of pus was evacuated. To take 3j o/ cod-liver oil three times a-day. Chicken diet. Continue the wine. From this period she rapidly improved. The remittent fever ceased on the 18th. Extensive sinuses formed in the scalp, covering the occiput and neck, which, however, gradually healed on the application of a sulphate of copper lotion. Slight bronchitis appeared on the 26th. The appetite soon after became very good ; her strength im- proved. The incisions in the scalp had perfectly cicatrised on the 1st of December ; on the 11th she was discharged, the abscess in the neck, however, not havins: quite healed. Commentary . — In this case the fever was of a distinctly remittent type — the accessions being very marked at night, and the remissions very considerable in the morning. It commenced with intestinal, which were followed by cerebral symptoms. Was it a case of gastro-enteritis, or of cerebral meningitis, or, as these disorders are called by some, remittent fever, or acute hydrocephalus? No doubt these two separate diseases exist ; but if you ask me by what symptoms you may distinguish one from the other in children at an early period, I should be at a loss to reply. In the whole range of practical medicine, this must be allowed to constitute a question of the greatest difficulty to decide. Indeed, I am inclined to consider that it cannot be done until the disease is so far advanced as to render the cerebral symptoms unequivocally predominant. In systematic works on the practice of physic you will find the diagnos- tic characters of the two diseases set forth with wonderful order and propriety ; but if you depend on these at the bedside, you will, in the majority of cases, be greatly disappointed. Now, if the symptoms observed in the case before us be taken into consideration, it will be seen that they partake of the characters of both diseases. Such I believe to be really the case — the old distinctions between remittent fever and hydrocephalus having no basis on morbid anatomy. The former, however, is connected with irritation in the digestive organs, the latter with cerebral congestion or inflammation. It is clear that these two lesions may be conjoined in different cases in various degrees, and hence the different aspects presented in practice. The so-called remittent fever and acute hydrocephalus of authors, then, cannot be separated, and in most instances are mingled together. The case of Scott was one of this description, commencing with symptoms of intestinal derangement, accompanied by fever of a remittent type, com- plicated at a later period by cerebral congestion of an asthenic charac- ter; in short, the hydrocephaloid disease of Marshall Hall. The treatment was in accordance with this view of the case, consist- ing of small quantities of wine, good nourishment, blisters to the scalp, and subsequently cod-liver oil. Several of you expressed the opinion that this was a case of hydrocephalus, and a few were inclined to give mercury. As to hydrocephalus, much depends on what is meant by that terra. If by it is understood cerebral meningitis, then it was not hydro- cephalus; but if it means certain cerebral symptoms, independent of any particular lesion, then it was. Such symptoms, however, may arise from exhaustion, as well as from over-excitement, and the one we had to do with was certainly a case of this kind, coming on, as it did, after pro- tracted diarrhoea and fever. As to mercury, I have no hesitation in saying, had we depended on it, as some recommend should be done in similar cases, the patient would INTERMITTENT FEVER. 951 never have recovered. It has been said that mercury is the sheet anchor of the practitioner in hydrocephalus. I have never seen it beneficial in undoubted cases of cerebral meningitis, and the diagnosis in the vast majority of instances is so uncertain as to warrant the suspicion that the recoveries which have taken place were not those of true inflammation. In this little girl, notwithstanding the delirium, the coma, the screams, the tossing the hands towards the head, the strabismus, and the insensible contracted pupil — all of which have been placed among the principal evidences of hydrocephalus, the treatment was brought to a successful conclusion by stimulants and nourishment. I do not tell you that this will always succeed; but whenever such symptoms follow protracted diarrhoea, and are accompanied by remittent fever, I am satisfied you may place more reliance upon such treatment, aided by the powers of nature, than upon the vaunted, but in my opinion hypothetical, powers of mercury. INTERMITTENT EEYER. Case CCLII .'^ — Tertian Intermittent cured hy Quinine. History. — John Kelly, a laborer — admitted into the clinical ward October 20th, 1851. Had always enjoyed good health until three months ago, when he was attacked with intermittent fever in Lincolnshire, while working at the harvest. At first it assumed the quotidian type, but after three weeks it became tertian, and continued three weeks longer. Then being at Morpeth, there was an interval of a fortnight. Un leaving Morpeth he was much exposed to cold and wet ; the disease returned, and has continued up to the present time. Progress op the Case. — The day after admission he had a well-marked attack of fever. The cold stage continued fifteen minutes, and the hot and sweating stages three quarters of an hour, followed by languor and depression. He was ordered to take five grains of sulphate of quinine three times a day, and a scruple of the drug two hours before the next expected paroxysm. He had two other attacks on the 24th and 26th, the latter being very slight. On the 28th there was no attack, and the scruple dose was suspended. Discharged cured November 6th. Commentary . — The cause of intermittent fever is tolerably well ascer- tained. It is found in all countries which are low, swampy, and humid, and in localities where the ground is marshy, and presents a moist alluvial soil, especially in the neighborhood of extensive woods. We must not suppose, however, that marshes and a moist alluvial soil are the only causes of intermittent, for in India it sometimes prevails in hilly dis- .tricts, at a considerable elevation, and is known by the name of hill-fever. We may therefore conclude with Dr. Fergusson, that the cause of inter- mittent is a condition of the atmosphere occasioned by evaporation from the earth’s surface, by solar rays rather than by currents of air. The frequency of the disease during the autumn months is in favor of this theory. The occurrence or absence of intermittent fever in particular dis- tricts, according as the circumstances just alluded to be present or absent — be induced or prevented — is another proof of its correctness. Thus it is not a common affection in Paris, but in 1838 I saw it very frequent in the wards of M. Piorry, at La Pitie Hospital. It arose among the workmen of the St. Germains and Paris Railway, who, at a particular * Reported by Mr. W. M. Calder, Clinical Clerk. 952 DISEASES OF THE BLOOD. part of the line, which was low and marshy, caught the disease in great numbers. They nearly all came to La Pitie, as M. Piorry cured the disease rapidly by large doses of quinine, and was in consequence cele- brated among them; and thus, whilst numerous cases were always present in that hospital, it was very rare in Paris generally. On the other hand, there are many places in which ague was once common where it is now rare, from the draining of marshes, or local improvements in cities. Thus it was formerly common in London, in the district which surrounds the Tower, but disappeared when the ditch was allowed to become dry. I have also been told that, in Edinburgh, when the valley which now separates the old from the new town was a marsh, ague was frequent. At present it is very rare, and never met with except in individuals who have caught the disease elsewhere and travelled to this city. With regard to the nature of intermittent fever we know nothing, although we infer that the peculiar condition of the atmosphere alluded to causes a peculiar change of the blood, on which the disease essentially depends — but the nature of that change — why it should occasion an in- termittent instead of a continued effect — why it should produce in different people a quotidian, a tertian, or a quartan, etc. etc., — of all this we are ignorant. I cannot see that its pathology has in any way been advanced by endeavoring to connect it with diseased spleen. No doubt this organ is frequently enlarged in ague, and in chronic cases becomes hypertrophied and indurated. But it is also especially liable to undergo changes of texture in continued fever, as we have already seen, p. 934. Piorry contends that congestive enlargement of the spleen is the primary change, and that the general fever is a result. He has brought forward numerous cases, showing that, in ague, this organ may be demonstrated by percussion to be enlarged, and that recovery is commensurate with its diminution in bulk. He cites one case where an individual was knocked down in the street by the shaft of a carriage, which struck him on the left side over the spleen, and in whom the resulting fever was distinctly intermittent. This may have been a coincidence. Careful observation, however, has satisfied me that there is no uniform relation between the enlargement of the spleen and the intensity of intermittent fever, as M. Piorry supposes. We have seen that in leucocythemia the spleen has been much hypertrophied, and no ague occasioned. On the other hand, without denying that lesions of the spleen are very common in connection with ague, we are unable in the present state of pathology, to determine whether this be a cause or an effect, or to indicate why lesion of this organ should sometimes be connected with an intermittent, at others with a continued fever. The treatment which experience has proved to be most certain and rapid is that by quinine ; and I am satisfied that tolerably large doses are more efiicacious than small ones frequently repeated. I usually give five grains three times a day, and a scruple two hours before the occur- rence of the attack, and have never seen a case which resisted this treat- ment. Much larger doses have been given. Thus I have seen Piorry give fifty grains for a dose, with the effect in recent cases of at once cutting it short, and rapidly reducing the engorgement of the spleen ; ERUPTIVE FEVERS. 953 but a permanent and quick cure I believe to be equally well effected by the medium dose formerly recommended. Quinine in large doses pro- duces very inconvenient effects, such as cephalalgia, vertigo, tinnitus aurium, deafness, and other symptoms, which, should any cerebral com- plication exist, may render it fatal. During the prevalence of intermit- tent at La Pitie in 1838, a man was treated with large doses of the drug, and the head symptoms attributed to its stimulant action. He died, and on examination acute meningitis was found, with exudation of lymph on the membranes. Some years ago Dr. Douglas Maclagan introduced the sulphate of bebeerine as a substitute for quinine, and at the time I tried it with great success. Of late years, however — whether from change in the mode of preparation or otherwise, I do not know — its good effects have not been so uniform. Salicine is a useful drug in intermittent, and from numerous experiments I saw made with it in the wards of La Pitie in 1838, it may be depended on when given in double the quantity of quinine. In some chronic cases which have resisted quinine, arsenic has been found useful. I have frequently seen in the south-west of England a case cured at once by a scruple of Cayenne pepper suspended in water. Indeed, a vast number of remedies have been found occasionally beneficial in inter- mittent fever, but there are none so uniformly successful as quinine. - EKUPTIVE FEVERS. There are certain diseases which, in an arbitrary classification, may be considered as febrile eruptions, or as eruptive fevers. They compre- hend especially scarlatina, erysipelas, variola, and rubeola. Occasionally roseola, herpes, or other cutaneous eruptions maybe attended with fever, but they are separated from the others by their non-contagious or non- infectious nature. Plague and glanders, on the other hand, are true eruptive fevers ; and with the others mentioned, obey certain laws, which may be shortly noticed. 1. They may be infectious and contagious. By infection is under- stood the power of being propagated through the inhalation of air tainted by the breath or perspiration of the affected person. By contagion is understood communication of disease by actual contact. 2. The present theory with regard to the cause of these diseases is, that it depends upon a morbid poison, a small quantity of which entering the blood produces in that fluid a peculiar change which is analogous to that of fermentation. To distinguish this change in animal from what occurs in vegetable fluids, the term zymosis has been introduced by Mr. Farr (from fv/xoo), to ferment). 3. Some of these animal poisons, if excluded from the air or care- fully dried, will retain their communicating property for a longer or shorter time. This enables us to preserve matter for artificial inocu- lation. Hence also they have been supposed capable of attaching themselves to fomites — that is, substances of a rough surface or downy texture, such as wool, cotton, wearing apparel, dust, etc. It is on this theory that quarantine regulations are founded, the whole of which. 954 DISEASES OF THE BLOOD. together with the facts, real or supposed, that support them, require a thorougli revision. 4. All the animal poisons are distinguished by peculiarities in their mode of incubation and development. Thus a period of latency exists between exposure to the poison and accession of the fever, or first rigor. Again, the eruption appears at different periods after the fever is declared. Tims — • Period of Latency Appears after first Eigor from from Scarlatina, 4 to 8 days 18 to 24 hours. Erysipelas, 4 to 1 days 24 to 60 hours. Variola, 8 to 14 days 48 hours. Rubeola, 7 or 8 days 72 hours. 5. All the eruptive fevers, strictly so-called, invariably run a natural course, and cainot be cut short. It follows that — 6. The treatment of febrile eruptions has for its object conducting these cases to a favorable termination. To this end exactly the same general rules are to be followed as I previously gave when speaking of continued fever, and the same indications exist for the use of salines and laxatives, cold to the head, wine and stimulants, and regulation of the diet. The 56 I need not again repeat, and I shall confine my observations at present te the more special treatment of the diseases we have studied in the wards. Scarlatina. Ca.se CCLTII.* — Mary Clark, aet. 17, servant — admitted 20th December 1851. On the afternoon of the 17th her throat became sore, and in the evening she was attacked with rigors, followed by pain in the head and back, and other febrile symptoms. Last night she first observed a red rash upon her chest and arms; this is of a reddish-brown color, and resembles the ordinary eruption of scarlatina ; it disappears upon pressure. Pidse 12i5 and feeble; fauces, tonsils and back of pharynx red and congested; has great thirst and anorexia; tongue moist, with a white fur in middle, through which the red papilhe project ; bowels costive ; urine, sp. gr. 1030, contains no albumen — a deposit takes place, containing epithelial scales and crystals of triple phosphate. Tinct. Hjov'.tjvn. 3 ss; Z/jV/. A,n non. Acet. et Aquce puree ^ iij. M. 3 J tertid quaque horoL. Dic. 22 — Rash disappeared from arms, but is still visible on the chest; pulse 86, and soft, ; less pain in the throat, although fauces and palate are still congested. Ddc. 24. — Goiivalescent, and she was dismissed on the 27th of December cured. Case CCLIV.j- — Isabella Husketh, aet. 22, a woman of abandoned character, and addicted to intemperance, was admitted 19th December 1851, in a state of high delirium. It was ascertained that on the 14th she had been seized with rigors, followed by great debility, catarrh, and general febrile symptoms. On the following day an eruption appeared on her skin. On admission she was in a state of violent delirium, and required to be tied down in bed. Her eyes were suffused, and very sensitive to light; pulse 120; tongue dry and parched, florid-red at the edges, with the papillae projecting through a white fur in the centim; teeth covered with sordes; great pain in throat, increased on swallowing ; submaxillary glands tender on pres- sure, but not enlarged; eats nothing, but has great thirst ; bowels costive ; skin hot and pungent ; arms and chest covered with a bright scarlet exanthematous eruption. S X leechea applied to the throat — saline mixture. Dec. 20. — Delirium continues ; pulse 125 ; p lin in throat relieved. Vespere. — Delirium greatly increased. Nine leeches anplied to te>nples, and to have a drauc/ht of solution of morphia and some wine. Dec. 21. — Slept during night, and is nearly sensible to-day ; tongue dry and florid ; eruption fading ; considerable sore throat. Blister to he applied to the throat. On the * Reported by Mr. W. H. Broadbent, Clinical Clerk. \ Reported by Mr. J. -L. Brown, Clinical Clerk. SCARLATINA. 955 23d the eruption had quite disappeared. The throat symptoms, however, gradually increased. On the evening of the 26th, the breathing was observed to be very short and hurried, and on the morning of the 27th the patient died. Commentary . — The first case is an instance of mild scarlatina running its ordinary course, and terminating in recovery on the seventh day. The second case is an example of severe scarlatina, occurring in a woman ad- dicted to intemperance, and in whom all the symptoms of typhus fever, associated with sore throat, were present, proving fatal on the thirteenth day. Of all the eruptive fevers, scarlatina is the most rapid in its inva- sion and the most variable in its course. Great watchfulness is therefore demanded on the part of the practitioner, especially when the crisis is to be expected, so that if prostration comes on rapidly, or other untoward symptoms appear, he may be prepared to meet them. Perhaps, also, scarlatina is the most infectious of the eruptive fevers ; so that complete separation of the patient from the other members of a young family is at all times to be insisted on as soon as possible. A chief peculiarity of scarlatina is, that in addition to the general fever and characteristic eruption, the tonsils and mucous membrane of the mouth and pharynx are also apt to be inflamed. This occasions difficulty of deglutition, with soreness of the throat, symptoms which require for relief topical remedies, such as fomentations, astringent and slightly acid gargles, or a linctus, etc. If sloughing or ulceration occur, the application of the stronger acids, or the nitrate of silver, is often necessary. The difficulty of deglutition sometimes impedes the intro- duction of food into the stomach, and in this way assists in producing prostration, and prevents the administration of stimulants or medicine. It may also, in severe cases, impede respiration, and assist in producing asphyxia directly. A fatal result, however, when it does occur during the primary attack of scarlatina, is generally dependent on the same causes which induce it in typhus fever — namely, congestion of the brain, as indicated by delirium, passing into coma, and followed by prostration of the vital powers. In addition to the throat complication, there are various others, all of which may require a special treatment. In the vast majority of cases, a general treatment, directed in the first place to subduing the excess of fever, and afterwards to supporting the strength, is indicated. Many efforts have been made by different practitioners to check or modify the intensity of the disease by administering various drugs, or carrying out particular kinds of treatment. Hence, during certain epi- demics, or in its visitations to particular educational institutions, various practitioners have been sanguine enough to believe that their especial mode of practice has been more successful than any other. I do not consider it necessary to direct your attention to the numerous plans which have been thus proposed, because all of them have been only par- tial in their operation, and no one of them has been more successful than another. You must remember that the causes of scarlatina are as mysterious ard unknown as are those producing any kind of fever ; and that its fatality, like that of fever, is to be traced to constitutional cir- cumstances in individuals, to unhealthy localities, or to the so-called 956 DISEASES OF THE BLOOD. type of the particular epidemic. Nothing, therefore, is more difficult, under such circumstances, than to judge whether the non-fatality ob- served at one time, or in a certain establishment, is referable to this or that practice. At all events, I have been unable to satisfy myself that any general rule of empirical or rational practice is to be derived from the contradictory accounts which have from time to time been made public on this subject. Dr. Andrew Wood, who has had great experience as physician to Heriot’s Hospital and other educational establishments in this city, recommends the following treatment : — Several common beer bottles containing very hot water, are placed in long worsted stockings, or long narrow flannel bags, wrung out of water as hot as can be borne. These are to be laid alongside the patient, but not in contact with the skin. One on each side, and one between the legs, will generally be sufficient ; hut more may be used if deemed necessary. The patient is to lie be- tween blankets during the application of the bottles and for several hours aftei wards. In the course of from ten minutes to half an hour, the patient is thrown into a most profuse perspiration, when the stock- ings may be removed. In mild cases, the effect is easily kept up by means of draughts of cold water, and if necessary, by the use of two- drachm doses of Sp. Mindereri every two hours. In severe cases, where the pulse is very rapid — the beats running into each other — where the eruption is either absent or only partial, or of a dusky purplish hue — where the surface is cold — where there is sickness or tendency to diarrhoea — where the throat is aphthous or ulcerated, and the cervical glands swollen, then he follows up the use of the vapor-bath by four or five grain doses of carbonate of ammonia, repeated every three or four hours. Should this be vomited, then brandy may be given in doses proportioned to the age of the patients. Carbonate of ammonia he considers to act beneficially : 1st, by supporting the powers of life ; 2d, by assisting the development of the eruption ; and 3d, by acting on the skin and kidneys. Where the vapor-bath was used early in the disease, and its use con- tinued daily, or even twice or thrice a day, according to circumstances, he has found that the chance of severe sore throat was greatly obviated. In regard to supervening dropsy, he considers that, by the use of the vapor-bath, with the other necessary precautions as to exposure, diet, etc., its recurrence is rendered much more rare. In the treatment of the dropsical cases, it was also very useful, and in some instances might be trusted to entirely. Dr. Wood also condemns all depleting treat- ment, and even purgatives, during the first ten days, thinking them not only not required, but positively dangerous, as tending to interfere with the development of the eruption. In the later stages, as well as in the dropsy, however, he thinks purgatives are often beneficial. Shortly after this treatment was proposed at a meeting of the Medico-Chirurgical Society of this city, I tried it in the following case : — Case CCLY. — Margaret Walsh, set. 18 — admitted 2d July 1852. She is a servant girl, and had always enjoyed good health until June 29th, when she experienced dis- * Reported by Mr. J. R. Williams, Clinical Clerk. SCARLATINA. 957 tinct rigors, followed by sore throat and febrile symptoms. She admits having called previously on a family in which the disease existed. On the evening of the 30th a bright red rash appeared on the skin, and has continued ever since. On admission, the scarlatinal eruption is well characterised on the chest and arms. The skin is hot ; pulse full, hard, and 132 in the minute. Tongue furred, with elongated red papillae projecting through the white crust ; great difficulty in deglutition ; sore throat ; ton- sils and mucous membrane of pharynx swollen and red. There are also cephalalgia, slight deafness, and restlessness at night. Respiratory functions normal ; urine healthy ; catamenia regular. She was ordered by the resident clerk eight leeches to the head, a saline antimonial mixture, and eight grains of Dover’s powder. On first seeing her the following day, 3 i JuXy^ I found her in much the same condition as is described in the previous” report ; the skin still being hot and dry, and the eruption very vivid on the chest and arms. Hot bottles were ordered to be applied, encased in worsted stock- ings wrung out of hot water, as recommended by Dr. Andrew Wood. July Mh. — A slight perspiration followed the use of the vapor-bath last night To-day the rash has partly disappeared from the arms, but is now present on the legs as well as chest. Pulse 130, small; urine not coagulable. An astringent gargle for the throat — the vapor-bath to be again applied. July 5th. — Profuse perspiration resulted last night from the use of the vapor-bath. To-day the rash has entirely disappeared ; but there is great tenderness of the skin and in the joints on motion. July 9th. — Has continued much in the same condition, but to-day the appetite has somewhat returned, and she has eaten a good breakfast. Her joints are swollen, and there is considerable pain on moving them. Desquamation commencing ; throat ulcerated, and to be touched with a weak solution of nitric acid ; pulse 84, soft ; § iv. of wine daily. July 26^A. — Since last report has been slowly gaining strength, but is still far from well. The urine has been carefully examined daily, and has never presented coagulability on the addition of heat or nitric acid. To-day a distinct blowing murmur was discovered with the first sound of the heart, loudest at the base, and propagated along the vessels of the neck ; pulse 76, of good strength. August Mh. — Went out a little to-day, and in the evening the feet commenced to swell. August ^th. — Swelling of feet increased. To have a squill and digitalis pill three times a day. August 9th. — (Edema of feet continues ; urine healthy. Venesectio ad 3 viij. August llth. — (Edema of feet disappeared. This morning had a rigor. Was ordered an emetic. August \9.th. — To-day is feverish, with great thirst and heat of skin; pulse 128, strong. A saline mixture ordered. August Vlth. — Febrile symptoms continue, with tenderness over epigastrium; ^Vi^eight leeches were ordered to be applied there. The cardiac dulness is extended. No friction, but a blowing murmur, as formerly noticed, at the base of heart ; respiration somewhat embarrassed. August 9S)th. — Respiration normal ; no tenderness over epigastrium ; pulse 100, regular and soft. The urine all this time has been tested daily, but has never been coagulable. To-day, however, a deposit existed in the urine, and several casts of the tubuli uriniferi may be observed in it with a microscope. September ^fJi . — Since last report she has been convalescent, and all her symptoms have gradually dis- appeared. The blowing murmur over base of heart is still present, but not so loud, and the increased dulness has disappeared. Dismissed. Commentary. — Iq this case tlie disease, instead of being shortened or rendered milder, was unusually prolonged, and was followed by rheuma- tism, dropsy of the inferior extremities, and by pericardial effusion. The febrile symptoms terminated by critical deposition in the urine so late as the fifty-second day. Although admitted June 29, she was not strong enough to be dismissed from the Infirmary until September 7th. This was certainly an unfortunate case to commence the trial of a new treat- ment ; and yet the girl has been always healthy, and there was nothing to indicate at the commencement that the sequelae would be so severe or so prolonged. I persevered with this plan in four or five other cases, but in all of them it failed to bring about speedy resolution. At last I came to the conclusion that the heat, damp, and exposure, which it was difiicult to avoid, tended, especially in the class of servants and young women who entered the Infirmary, to rheumatism. I then adopted quite an opposite 958 DISEASES OF THE BLOOD. treatment, kept the skin dry and cool, and have had every reason to be satisfied with the result. Several very severe cases which entered the wards during the winter and summer mouths of 1856-57 were treated in this way with the best results, of which the following are examples : — Case CCLVI.*— Thomas Corrigan, set. 19, a laborer— admitted September 19th, 1856. He first felt sore throat on the evening of the 16th, followed on the 18th by rigors and febrile symptoms. To-day the rash first appeared, and on admission pre- sents a dusky-red color, covering the face, neck, arms, haunches, and thighs. The throat is much swollen externally on both sides. The mouth is with great difficulty opened, when the tonsils are seen greatly enlarged and ulcerated. The back of the tongue is swollen and covered with a thick crust ; anteriorly it is red and dry. Pulse 116, full and bounding. Respirations 21 in the minute. Deglutition difficult. Skin dry and pungently hot. Urine turbid, and of a reddish-brown color, not altered on the addition ot heat. Chlorides scanty. Other organs healthy. Warm fomerdationa to be applied to the throat, and to use the steam inhaler. Vin. Antim-. 3 ss ; Aqum Acet. Ammon. §j; Aquce ivss. M. Sumat quartd qudque hord. September 2Qth. — Has been occasionally delirious. Other symptoms the same. 2h omit fomen- tations, inhalations, and mixture. ^ Acid. Sulph. DU. 3 ij ; Syrupi ^ j ; Inf us. Rosar. § vij. M. Sumat 3 ss quartd quaque hord. September 21s#. — Delirium has been violent during the night. At present pulse 76, full and strong. Deglutition and respira- tion somewhat easier. Vin. Colchici 3 ij ; Spirit. .xRther. Nit. | iij ; Aquce ^vss. M. Sumat semiunciam quartd qudque hord. September 22d. — Urine to-day clear: chlor- ides more abundant ; no albumen. Pulse 60, not so full. Tongue still dry. Rash has disappeared. Sept. 2Zd. — Urine natural. Desquamation of the skin commencing. Swelling of tonsils and sore throat greatly diminished. Prom this time he rapidly re- covered, and was dismissed quite well October 9th. Case CCLYII.* — Eliza Campbell, set. 24, a married woman, ©f weak constitution, with two children, the eldest of whom is recovering from scarlatina, was admitted December 19th, 1856. On the 12th she experienced lassitude and general malaise. On the 15th she had rigors, followed by febrile symptoms, and pain in the back. On the morning of the 16th a rash appeared over the breast and other parts of the body. On the 18th her husband observed that her mind was wandering, and next day brought her to the Infirmary. On admission there is a uniform scarlatina eruption over the back, abdomen, and arms. On the legs there are numerous spots of purpura extend- ing up the thiglis. Skin hot and dry. Mouth dry. Tongue brown and cracked in the centre. The jaws are separated with difficulty, showing the uvula and fauces of a scarlet color, without swelling of the tonsils. Bowels costive. Pulse 108, small and weak. Is conscious, though rather confused, and very restless. Other organs healthy. Ordered § iij of Sherry wine and 3 iv of lemon juice, to be taken during the day with strong beef-tea. An injection of loarm water to unload the bowels. December 20th . — Violent delirium during the night. At the visit, pulse 160. Head to be shaved and cold applied. December 21s# — Had several hours’ sleep during the night, and awoke better. Pulse 110. Eruption fading. Urine dark and turbid, with a copious sedi- ment of urates. To have 3 ss of Sp. JEthcr. Nit. every two hours, and § ij 0/ brandy, in addition to the wine daily. December 22d. — The rash is fainter. Desquamation commencing. Purpuric spots also disappearing. Still dryness of mouth and cracked tongue. Deglutition easy. Continue nutrients and diuretics. Prom this time she be- came convalescent. On December 24th there were still traces of the eruption in some places, while desquamation was advancing in others. On the 29th the cuticle sepa- rated from the hands entire. She remained weak for some time, and was not strong enough to be dismissed until January 24th, 1857. Commentary. — In tlie first of these two cases there was violent angina in addition to the severe fever, with delirium, and yet the dis- ease pursued its natural course, crisis occurring on the seventh day, and he rapidly recovered without an untoward symptom. In the second case, occurring in a woman of a weak habit of body, who had been under-fed, tlie scarlatina was associated with purpura, violent head symp- * Reported by Mr. H. M. Maclaurin, Clinical Clerk. SCARLATINA. 959 toms, but DO angina. Strong stimulants and nutrients were administer- ed from the first, with diuretics to assist elimination, and ultimately she did well, without any sequelae, although from her previous weak con- dition, convalescence was prolonged. It has frequently been observed that the urine in scarlatina, espech ally when dropsy supervenes, becomes albuminous. Dr. James W. Begbie, who has with great pains tested the urine in a considerable num- ber of cases, considers its presence almost uniform. Aware of what he has written on this subject, I have tested the urine daily in certa,in cases without observing it. This non-persistent coagulability of the urine, as well as various deposits which appear in it on critical days, must, when they occur, be considered as an evidence of the excretion of morbid pro- ducts which have circulated in the blood. Hence they are common, not only in scarlatina, but in all inflammatory affections as well as fevers. This point you must have seen me very observant of in watching for the resolution of inflammations and fever at the bed-side (see p. 174). It sometimes happens, however, that the critical discharge is comparatively slight, and that the organic elements are not dissolved so as to constitute fluid albumen. This appears to have occurred in the following case, for whilst morphological evidence of the crisis existed in the urine, in the form of cells and casts, no albumen could be detected by heat and nitric acid. Case CCLVIII.* — Alexander Johnston, oBt. 14 — admitted June 23, 1851. Three days ago he experienced distinct rigors, followed next day by a general scarlatinal eruption. On admission there was restless delirium, and constant mo^ ing of the head from side to side on the pillow. He was apparently conscious when spoken to, but could not answer questions ; the tongue was protruded wii,h difficulty, dry, and of bright red color, studded with florid elevations ; deglutition was much impeded ; bowels open; pulse 130, weak; urine voided with difficulty, and diminished in quan- tity, sp. grav. 1025 — not acted on by heat and nitric acid ; skin hot and dry, covered with the bright-red Scarlatinal eruption. Ordered salines and slight diuretics. He con- tinued in the same condition, the angina increasing, and the coma alternating with delirium becoming more pronounced until the sixth day. During this period all the urine passed was carefully examined. The amount was diminished (17 oz. per day), but it was free from deposit, and unaffected by heat or nitric acid. Sp. .jEther, Nit. 3 iij ; Pot. Acet. 3 ij ; Tr. Colchici ^ ss ; Aquae f iij. Fiat mist. A tea-spoon- ful to he taken every four hours. On the folio v/ing day all coma and delirium had dis- appeared. He answers questions when put to him ; skin cool ; eruption faded ; pulse 96, weak; passed 30 oz. urine, which is turbid, with small flakes of a membranous character floating in it. On the eighth day the quantity of urine excreted was 50 oz., and it was still more loaded with sediments. On examining the urine with a microscope, it was seen to contain — 1st, membranous flakes, composed of aggregated rounded particles, apparently agglutinated together, and strongly resembling some forms of vegetable tissue ; 2d, rounded and irregular masses with spicula ; 3d, amorphous molecular masses. (See Fig. 104, p. 104, as observed in this case.) The whole of these elements, on being analysed chemically by Mr. Drummond, were found to consist of urate of ammonia. Next day the urine was only slightly turbid, and on the following one it was perfectly clear. From this time the boy gradually re- covered. Commentary. — This was a very severe case of scarlatina. The angina was intense, occasUnally rendering deglutition impossible. There was delirium on the third day, alternating at night with coma, which was often profound. The worst result was apprehended. It occurred to me that the head symptoms, in this as in several cases of * Reported by Mr. G. Scott, Clinical Clerk. 960 DISEASES OF THE BLOOD. typhus, might probably depend not so much upon inflammation of the brain as upon absorption of and poisoning by urea, an idea that ap- peared supported by the diminished quantity of the renal excretion, as well as its freedom from all deposit. Kemembering the alleged virtues of colchicum in increasing the elimination of this excretion, I ordered it, in combination with diuretics, and the result was remarkable ; for on the next day not only had the fever diminished, but the urine was increased in amount, and loaded with urates to an extent and in a form I had never previously seen. It may be argued that the fever had ter- minated by a natural crisis on the seventh day ; but I cannot help think- ing that in this case nature was assisted by the colchicum and diuretics. I have tried the wet sheet in several cases of scarlatina, but never could satisfy myself that it either shortened the progress of the disease, or mitigated in any way the symptoms of the patient. In the summer of 1864, Mr: Thomas Evans, one of the clinical clerks, was good enough to make a series of careful observations upon the pulse and temperature of the body, before, during, and after the wet sheet was applied in three cases, in all of which the rash was present, the pulse high, and the heat of skin great. They appeared to me favorable cases for the trial. The following are the results : — Effects of the “ Wet Sheet ” on Pulse and Temperature {of Axilla) in Three Cases of Scarlatina. The patients were wrapped in a sheet wrung from cold water, which was afterwards surrounded by blankets, etc. The observations were made from 7 to 10 p.m., during June and July 1864. Name, etc. Case CCLIX. Adamson, Female, age 19— copious rash on trunk and ex- tremities on aa- mission, 6th day ; convalescent] 0th day. i Case CCLX. Morrison, Female, age 16— copious rash on trunk and extremities on admission, 5th day ; convalescent 10th day. CaseCOLXI. Baxter, Female, age 19 — scanty rash appeared on legs on 4th day— convalescent 9th day. Day of fever.. . . 6th day 7th day 6th day 7 th day 8th day 3d day 5th day 6th day Length of time \ sheet was ap- > An hour 45 min. 54 mm. 45 mm. 30 min. 30 min. 30 mm. 30 mm. plied ) & a; P. c3 Ph o5 & c3 P. Pi P p w i i 1 in i in I i 00 i CO a H H H (S' H (S H H Ph H Before appli- \ 1 j cation of | 138 lor 130 lOOf 116 1021° 100 101^° 100 102° 114 104° 100 100|° 83 100}° sheet 1 5 min. after- * wards 1 — — - — - 102i° - - 92 101f° — 92 99^° 73 99}“ 10 min _ _ 102^° — — 92 1011° — 1 92 100° 73 99^ 15 min — — — 100° — 102^° — loir 92 101f° 104 1014° 94 100}° 76 99^* ?i0 Tnin 100J° 108 102|° 101^° 96 102' 104 104° 94 100i° 80 99|* 45 min _ _ 102f° An hour 5 min. after \ taking off > 94 99i° 76 98^° sheet.. • ••*... / 10 min 138 lor 102 100^° 96 100° 74 98} 15 miTi 100J° 104° 92 104° ini» 94 100}° 80 994' 30 min 138 101^“ _ 1001° — 102° — 96 102° 110 104° 94 1004° 78 j 99}° An hour ' — — — 1004° 108 102^° — — 96 102§° 112 104° 94 100|" 78 99}° An hour and ) half. S — — 120 1001° - — - - 94 102}° 2 hours 1 2 hours and half — 1 1004° ERYSIPELAS. 961 It follows from these observations that, as regards the pulse, it was diminished two or three beats after the sheets had been applied half an hour, but that, on taking it off, it became, in another half hour, exactly the same as before it was put on. With regard to temperature, the immediate effect of the sheet was to produce a diminution of half a degree, but that, after thirty minutes, the former temperature was regained. On taking off the sheet, the temperature sank one degree, but in thirty minutes had again risen to its previous standard ; in an hour and a half was half a degree higher ; and in two hours and a half was again the same as before. Slight diaphoresis occasionally occurred about an hour after taking off the sheet. I frequently interrogated these patients as to whether they experienced any relief from its application, and it was clear that they did not. They were pleased on its removal, and then felt cool and comfortable for a short time, but soon after were as warm as before. In short, the result of this careful trial led me to the impression that the wet sheet in scarlatina was of no benefit whatever. Erysipelas. Case CCLXIL* — Marion Smails, set. 28 — admitted January 8th, 1851. She stated that on the morning of the 6th she was quite well, but that, after being out for some time, she felt a burning pain in her left cheek, and observed a red spot upon it. This redness gradually extended down towards the neck, and was accompanied with con- siderable swelling. She applied a mustard poultice to her cheek, which relieved the pain somewhat at first, but afterwards caused a great aggravation of it. On admis- sion, besides the local pain, she complained of great thirst and of a bad taste in her mouth. The tongue was moist ; bowels regular ; pulse 66, full and sti'ong. The cheek was ordered to be fomented with a lotion of lead and opium. January Wth . — Swelling and redness are much less, as is also the pain. January I'lth. — Redness of the skin completely disappeared. Complains only of a slight soreness in the throat. Dismissed cured. Case CCLXTII.f — James Maclaren, aet. 59, a porter, of intemperate habits — ad- mitted November 16th, 1851. Eight days ago, was seized with rigors, followed by in- tense febrile symptoms, which prevented sleep. On the 13th he experienced pain in the left side of his nose, accompanied by redness of the integuments, which rapidly spread over the cheek, eye, and brow of the same side. On the following morning the redness appeared on the right cheek, and in the evening had covered the whole face. On admission there is great thirst; loss of appetite; furred tongue ; hot skin ; full and burning pulse, 100 in the minute ; great headache, with drowsiness ; tingling pain in the face, which is of a deep red color, in some places approaching purple. The blush extends over the forehead and anterior part of the scalp, and pits on pressure. Two bulljs have broken, and recently formed scabs on the right side of nose. Ordered an antimonial saline mixture^ and the face to he dusted with flour. November VUh . — Last night there was low muttering delirium, and this morning, vomiting. In the evening, pulse of the same frequency, but more soft. To omit the mixture. November \%th. — Redness more extended over the scalp, and fresh bullae have appeared on the forehead. Pulse 80, soft ; constipation. To have § iij q/ brandy daily, and to take at present half an ounce of castor-oil. November l^th. — To-day much better. Pulse 80, of good strength ; swelling of eyes diminished ; redness fading ; bullae scabbing. From this time he gradually got well, and was dismissed cured, November 30th. Commentary . — The first of these cases was so mild as, perhaps, to merit the name of erythema. The latter was a very severe one, occurring in a man of intemperate habits, but terminating in convalescence on the twelfth day. In this latter case a study of the symptoms will show we * Reported by Mr. T. M. Lownds, Clinical Clerk, f Reported by Mr. A. L. Mackay, Clinical Clerk. 962 DISEASES OF THE BLOOD. have again, as in scarlatina, all the phenomena of typhus fever ; and when erysipelas proves fatal, so in like manner it is by coma and subsequent collapse. Erysipelas, however, is opposed to scarlatina, in being the least infectious of the eruptive fevers, in being the least fatal, and in running a much slower course. In many other respects there is a close analogy between them observable in the kind of fever, the sequelae, and critical discharge of coagulable urine. The general indications for treatment are the same. The special treatment is directed by means of topical applica- tions to diminish the local inflammation. For this purpose numerous remedies have been tried — such as dusting the part with flour, lotion of acetate of lead and opium, cerates, oil, etc. etc. — any of which serve the purpose of cooling the surface, rendering it more soft, and diminishing irritation. There can be no doubt that erysipelas is occasionally a fatal disease, from the intensity of the fever, and amount of integument involved. It is generally supposed that, when it attacks the face and scalp, it is more dangerous than when a similar amount of surface in any other part is affected. This opinion does not appear to be founded on very exact observation. Even when the scalp is extensively invaded, death from erysipelas is a rare occurrence. On going round the wards of the Hotel Dieu in May 1851 with M. Louis, I saw several severe cases of erysipe- las of the scalp, which, I was told, were under no treatment whatever — because, as M. Louis informed me, according to his experience, erysipelas of the scalp was never fatal, unless it occurred in individuals of bad con- stitutions, or was associated with some complication. I need not say that without forming any such exclusive opinion as this, it must be very difficult, in a disease that so generally tends to recovery, to judge how far this or that remedy is beneficial. Mr. Hamilton Bell has recommend- ed fifteen to twenty-five drops of the Tr. Ferri Muriatis every second hour, as a most beneficial remedy in erysipelas. But how this medicine is more successful than the spontaneous operation of nature he did not endeavor to demonstrate. Variola. Case CCLXIY.* — Mary Hogan, aet. 7, was admitted December 9th, 1851. Never had been vaccinated. Felt slightly indisposed December 4th ; and on the following day complained of severe headache, pain in the back, nausea, loss of appetite, and great thirst. These symptoms continued, and, on the afternoon of the Vth, a bright red blush was observed on the face and chest, gradually spreading over all the body. On the 8th the red blush became covered with numerous minute elevated papulae ; and on the 9th when admitted, numerous vesicles could be detected on the face, arms, and legs. Tongue furred, but moist. No dysphagia. TFus ordered a purgative of sul- phate of magnesia, December IMh . — The vesicles are numerous and close together on the face, and in some places confluent. Eyelids much swollen and nearly closed. Bowels are open ; pulse 140 ; tongue florid. The hair was cut short, and mild mer- curial ointment, thickened with starch, spread over the face. She was also vaccinated. December 12>th. — Pustules fully matured and umbilicated over the trunk and extremi- ties. The mercurial paste forms a thick indurated crust over the face. December \Mh. 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 eye- lids disappeared. December 18^4. — Pustules have all burst, except a few on the feet. Was dismissed January 6th, cured. The face scarcely presented any trace of the dis- ease, and afforded a remarkable contrast to those other parts of the skin which had not been covered with the paste. * Reported by Mr. J. L. Brown, Clinical Clerk. VARIOLA. 963 Case CCLXV.* — Michael Hogan, aet. 9, admitted December 10, 1851, a brother of die former case, and also never vaccinated, Felt unwell on the 8th, with shivering, pain in the head, and unusual febrile symptoms. On the next day vomited, and then observed an eruption on tiie 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 16th the pustules on the face were fully ma- tured, and here and there a few of them were observed to be confluent. On the 18th those’on the inferior extremities were in the same condition. Last night he experi- enced again considerable headache, and to-day the pulse is 120, full ; the skin hot, and febrile symptoms well developed. 19i:A.— 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 until January 19th. A few pits existed on the face, where the pustules had been confluent. Commentary . — The general treatment of small-pox is similar to that of the other eruptive fevers. There is a special treatment, however, applicable to it, which deserves some consideration. The Ectrotic Treatment of Variola. Various methods have been proposed for the purpose of arresting the development of the eruption in variola, and preventing the cicatrices which are likely to form. The treatment, called ectrotic {^iKrirpMcrxoy, to render abortive), has been practised principally in France. Serres, Bretonneau, and Velpeau, cauterised each vesicle as it appeared with nitrate of silver, which immediately arrests its further progress. This is a very tedious process, while painting the surface with a solution of the caustic causes so much pain and febrile disturbance that it cannot be safely employed. Sir Joseph Oliffe, of Paris, recommended the vigo- plaster of the French Pharmacopoeia; and having seen, in some of the journals, that mercurial ointment, thickened with starch, had proved very serviceable in the practice of M. Briquet and others, in the Paris hospitals, I tried it in numerous cases which were admitted into the wards, and have seen the good effects of the practice. The two cases you have just had an opportunity of observing, however, especially demonstrate this. Case CCLXIV. presented the most confluent form of the disease I ever saw. The entire face was so crowded with the papules and minute vesicles of the incipient stage, that there was literally not room to place a pin’s head anywhere on the sound skin. It was evident that the whole surface of the face would be one mass of suppuration ; and such of you as have had an opportunity of observing a similar case of the disease must be aware of its horrible aspect, the excessive agony produced, the great swelling of the eyelids, the dreadful suppuration and foetor of the discharge, the violent secondary fever, and the frightful cicatrices with 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 suppuration occurred ; there was no secondary fever ; and on the mask leaving the face there was no pitting or suppu- ration. In other parts of the body the eruption passed through its * Reported by Mr. W. M. Calder, Clinical Clerk. 964 DISEAS'ES OF THE BLOOD. 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 commencement of the eruption, modifies its progress, I caused the girl to be vaccinated on first seeing her. At that time the face, as we have seen, va^ closely covered with papulse 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 alto- gether the influence of vaccination 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 advan- tage of this treatment, the case of the boy (Case CCLXV.) may be con- trasted with that of the girl (CCLXIV.) who also had never been vacci- nated. His was evidently a very mild case, the eruption discrete, and t.he constitutional disturbance slight. I allowed it to run its natural course, and the result was in every respect different from that in which the plaster had been applied to the face. The secondary fever was toler- ably smart, the subsequent prostration proportionally severe ; recovery was delayed to the thirty-ninth day, and notwithstanding the generally discrete character of the eruption a few pits existed on the face. Since I first practised this ectrotic treatment in small-pox, I have met with numerous instances in which slight salivation followed the use of the mercurial plaster. Dr. George Paterson,* formerly of Tiverton, however, published a case in which salivation from the em- ployment of the strong mercurial ointment was excessive and danger- ous. I quite agree with that physician in thinking the occasional occurrence of such violent salivation would seriously compromise the otherwise remarkable advantages 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 in Paris may indeed have supposed that the absorbent powers of the drug constituted the true cause of its success, but it seems to me that another explanation may be ofiered. 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 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 cicatrisation is prevented. The artificial plaster therefore takes the place of the natural scab or clot of blood, protects the parts below, and enables them to heal slowly but more perfectly than if exposed to the air uncovered and uncompressed by superjacent crusts. If this be the correct theory of the ectrotic treatment, the mercurial might be discarded, and any kind of plaster which would concrete on the face might be expected to produce the same beneficial results. In 1854 I determined to try the effects of such a plaster, and after two or three failures succeeded in procuring 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 * Monthly Journal, Dec. 1852. VARIOLA. 965 the patient, during the night, rubbed it off on her pillow or with her hands, and on her recovery she was pitted all over. In auother case I tried carbonate of magnesia saturated with oil. But this also failed. In a third case, however, common calamine {zinci carhonas), 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 effect of the mercurial plaster. The following is one of these ; — Case CCLXVI.* — Alexander Ross, ast. 13, never been vaccinated, was seized with shivering on the 7th January, followed by the usual symptoms of fever. Entered the Infirmary on the 9th, when a few papules were observed on the face and arms. On the 12 th the face was thickly covered with vesicles, which from their closeness would certainly have become confluent. The mask of calamine and oil was now applied. The disease ran its usual course, the eruption being confluent on the arms and trunk. Throughout the progress of the case the application of calamine saturated with oil preserved a firm and coherent crust, and was renewed from time to time. The patient experienced no smarting of the face, there was no swelling of the eyelids, no purulent discharge, or local unpleasant symptoms of any kind. The secondary fever was tolerably smart, delirium being present two days. On the 22d the mask came off, leaving a clean smooth surface, free from all trace of pitting. Dismissed quite well on the 26 th. The following formula, after numerous trials, has been found to con- stitute a 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 recommended by Dr. Graves of Dublin. This answers very well, but caoutchouc, from being more ductile, is still better. The general subject of small-pox opens up to our consideration a multitude of facts, of which we may notice three. 1. There can be very little doubt that of late years small-pox has again become frequent amongst us, a circumstance which some have attributed to a deterioration of the vaccine lymph. That this cause does operate to a certain extent is very probable ; but, for my own part, I have been led to the conclusion, that the terror of the disease which formerly prevailed among the public, has, through the protective dis* covery of Jenner, and the energy with which vaccination was originally pursued, in a great measure declined, and that this is the principal cause. For some time multitudes of the lower orders did not have their children vaccinated, and hence why our hospitals are so frequently encumbered with cases such as those we have just witnessed. The universal feeling that we had no remedy for this but rendering vaccina- tion imperative by penal enactments at length led to the Vaccination Act, of which, as it has only been in operation since last June, it would * Reported by Mr. Bird, Clinical Clerk. 966 DISEASES OF THE BLOOD. be premature to speak. I am informed, however, by Dr. Husband, who takes charge of the vaccinations of the Royal Dispensary of this city, that the Act is working well. Each parent, on registering the birth of a child, receives a notice that, unless it be vaccinated before the expiry of six months, a penalty of one pound will be inflicted. This has been found amply sufiicient. The people generally admit the propriety of the law, and readily bring their children to submit to the operation. A large increase in the vaccinations has already been established, and the best results may be anticipated. For the mode of vaccination, I must refer you to the account given in systematic works on the practice of medicine. It consists, as you know, of making a puncture just sufficient to penetrate the epidermis of the skin, and to enable the vaccine lymph to be applied to the vascular dermis. For doing this surely and rapidly, the little instrument I now show you, invented by Dr. G-raham Weir,* is the best you can employ. It consists of a small handle of ivory, with four needle points projecting from one extremity, and a small curved knife for collecting and sepa- rating the vaccine matter at the other (as shown in the cut). The skin is opened by a crucial scratch with the needle points, 'jyi'f Clab/i J8s^6 -T-T+ Fig. 533. simple invention of i h Fig. 534. Dr. Husband. It which are held verti- cally, and are lightly applied, so as merely to remove the cuticle. The advantages of this instrument over the lancet are said to be that the operation is done more speedily, and that it opposes a larger surface for the absorption of the lymph. The lancet, however, is still pre- ferred in the hands of some skilled practi- tioners. In all cases the lymph is more liable to be washed away when too great an effusion of blood has been caused. The method of preserving lymph is a matter of great na- tional importance, and has been much improved by the consists in employing straight Fig. 532. * Monthly Journal, 184Y-48, p. 69. Fig. 532. Dr. Weir’s scarificator for vaccination. Real size. Fig. 533. Dr. Husband’s tubes charged with vaccine lymph, and their extremities hermetically sealed — (a), various kinds of tubes ; lymph should not be introduced at an expanded end {b ) ; (c), charged from two cases ; (c^), charged from three cases. Real size. VARIOLA. 967 glass tubes, from 2| to 3 inches long, and l-28thof an inch in diameter, which, when dipped nearly horizontally into the vaccine matter, permit its entrance by capillary attraction. The two ends of the tube are then closed by simply melting the glass with the flame of a candle or of a gas jet (Fig. 533). When used, the two ends of the tube are broken off, and the lymph blown out on the punctured or scratched arm. Dr. Husband informs me that experience has shown that good lymph may be preserved in this way for two years, even in warm climates, with the cer- tainty of succeeding in 90 per cent, of the cases in which it is used. This failure of one case in 10 may be still further reduced one-half by charg- ing the glasses from two cases instead of one (Fig. 534, c). It may be even charged from three or more cases (Fig. 534, d ) ; and, by blowing each portion out on separate punctures, the chances of failure are still further diminished.^ It is admitted that the system now so generally practised at the various stations throughout the country, of vaccinating from arm to arm — when the lymph is quite fresh — admits of very few failures. 2. Sometimes small-pox occurs epidemically in a remarkably benign form. It then presents all the characters described by some authors as varioloid. Occasionally it occurs twice, or becomes what is called re- current ; and it has been known to arise frequently after vaccination. In all these circumstances, when mild, it so resembles chicken-pox as not to be distinguished from it. But more than this, it was observed in the epidemic that prevailed in Edinburgh in 1819 and 1820, that small- pox and chicken-pox existed together frequently in different individuals inhabiting the same room, and sleeping in the same bed. Well-authenti- cated cases occurred of individuals inoculated with small-pox in whom the eruption assumed the appearance of chicken-pox ; and again persons inoculated with chicken-pox had small-pox well characterised. The work of Dr. John Thomson, entitled “ An Account of the Varioloid Epidemics in Scotland, 1820,” contains many facts of this description, which were well known at the time, and an account of numerous experi- ments 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 inconsistent to suppose that two distinct contagions should exist at the same time, each of which is protective against the other. Those who admit this doctrine must maintain that, whenever the chicken-pox contagion prevailed, the small- pox contagion was excluded, or the reverse ; or, on the other hand, they must admit that variola is produced by the same contagion that gives rise to chicken-pox. The work of Dr. Thomson furnishes ample proof of the correctness of the latter proposition. Dr. Gregory and others who oppose this opinion do so on the ground of the incubative stage being shorter, the whole disease less prolonged, and the constitutional symptoms being mild. These circumstances, you will observe, only point to difference of degree and intensity, not of kind. Dr. Gregory also alleges that he has seen variola occur after cow-pox, and cow-pox * See Exposition of a Method of Preserving Vaccine Lymph, etc., by William Husband, 12mo, Edinburgh, 1860; and Second Report of the Medical Officer of the Privy Council, 1860. 968 DISEASES OF THE BLOOD. after variola, and therefore they cannot be identical. So far, however, does this appear to me no argument, that, if possible, it confirms Dr. Thomson’s observations. The variola he speaks of occurring after cow- pox is evidently modified small-pox; and cow-pox may, in the majority of cases, be reproduced at pleasure. 3. Dr. Jenner, 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 confirmed by the experiments of Mr. Ceely of Aylesbury, recorded in the “ Transactions of the Provincial Medical and Surgical Association” (vols. viii. and ix.) He showed that, by operating on the mucous surfaces of the animal, the cow readily receives the poison of human small-pox, which the constitution of the animal converts into the vaccine. I need not enter at length into the discussion which has been raised on this subject. Suffice it to say, that the identity of the two diseases appears to me to be established by the following incontro- vertible facts : — 1. The prevalence at the same period of the cow-pox among cattle, and the small-pox among men. 2. The transmission by contagion of the small-pox to cattle, and the consequent development of cow-pox in those animals. 3. The transmission by inoculation of the small-pox to cattle, and the resulting development of cow-pox in those animals. 4. The transmission by inoculation of the cow-pox to man, and the development thereby of a pustule similar in character to the vaccine pox of the cow. 5. The transmission by inoculation of the cow-pox to man, and the consequent development of an eruption similar, if not identical with small-pox. All these propositions have been established by numerous facts, which you will find ably stated in the “ Report of the Vaccination Section of the Provincial Medical Association.” See also Mr. Simon’s Government Report on the “ History and Practice of Vaccination, 1857.” DIPHTHERIA. Case C C LX VII.* — Diphtheria — Recovery, History. — Isabella Speers, aet. 81, married — admitted January 6th, 1865. The patient had scarlatina when a child, and has been somewhat deaf ever since, but other- wise remarkably healthy, till her present illness. On 18th December 1864 she lost a child from “ diphtheria,” and on the 22d she began herself to complain of pain in the throat, accompanied with difficulty in deglutition. On the 24th, two medical men saw her, and prescribed for her a gargle of dilute Condy’s solution — a mixture con- taining chlorate of potash, also Tr. ferri muriatis and brandy, at the same time * Reported by Mr. W. Johnston, Clinical Clerk. DIPHTHERIA. 969 applying caustic to the throat. About 31st December four dirty white patches appeared on her lower lips, and two small ones under the tongue, which were also treated with caustic ; but her throat continuing to get worse, she applied for admis- sion to the Royal Infirmary. Symptoms on Admission.— The posterior wall of pharynx and the greater part of both tonsils are covered with patches of yellowish white purulent-looking matter, a little of which, when removed, is found to be very tough, and when subjected to microscopic examination is seen to be composed of pus-cells embedded in mucus. Great difficulty and pain on deglutition. Appetite bad. Headache. Patient is very deaf, and her spirits depressed. Voice reduced to a whisper. Pulse 130, smaU and weaL Urine copious. No albumen. Other functions normal. Ordered an injection of four ounces of beef -tea and one ounce of wine four times a day. Her throat to he gargled with diluted Condfs liquid, and poultices to he applied externally. Progress of the January lO^A.— The patient’s throat looks cleaner, and she expresses herself as feeling on the whole easier. To have some arrow-root with milk and beef-tea, and the injections twice a day. From this time the patient began to mend both in strength and spirits. The nutritive enemata were suspended on the 20th January, as she was then able to swallow a sufficient quantity of food. On the 7th February she was dismissed quite well, except that her voice was still rather husky. Case CCLXVIII.^ — Diphtheria complicated with SmallrPox — Death — Diphtheritic membrane covering the Mucous Membrane of the Pharynx^ Epiglottis, Larnyx, Trachea, and Right Bronchus — Pulmonary Apo- plexy. History. — Francis Carroll, aet. 28, married, performer in a circus — admitted No- vember 18th, 1860. Has enjoyed general good health up to the 14th instant, when in the afternoon he felt a sensation ot‘ weight in the abdomen succeeded by a restless night. On the following morning he experienced shooting pains in the back and limbs, headache, nausea, loss of appetite, and great thirst. He went to a I’ehearsal at the circus notwithstanding, when he was seized with shivering and vomiting, and went home to bed. On the following day he took a warm bath, and noticed red spots upon his face, arms, and legs. From the commencement there has been coryza, cough, and expectoration, which on the morning of his admission was tinged with blood. Symptoms on Admission. — The face is swollen, of a dusky red color, dotted over with very closely set elevated purple and red papules, mingled with vesicles and pus- tules the size of small peas, some of which are depressed in the centre. Over the chest, abdomen, groins, and extremities, are livid and dusky red patches, also dotted over with smaller pustules, which are very numerous in the groins. The tongue is foul, the gums spongy, tonsils swollen, fauces and pharynx covered with what appears to be a dirty slough. Complains of sore throat and difficulty of deglutition. No appetite ; great thirst ; no nausea or vomiting. Bowels freely open just before ad- mission. Pulse 100, weak. Heart’s sounds normal. There is much cough. Is con- stantly spitting a watery frothy fluid, tinged with blood. On percussion there is dulness over the lower third of right lung, posteriorly, where there is crepitation, tubular breathing, and increased vocal resonance. Over the chest generally inspira- tion is harsh, and expiration prolonged. No headache or wandering of mind. Sleep disturbed. Urine high colored and turbid, of natural quantity, coagulable by heat and nitric acid, and deficient in chlorides. R Pot. Acetatis 3 ij ; Sp. fEiher. Nit. 3 ij ; Mist. Camph. § vss. Ft. Mist. A table-spoonful to be taken three times daily. R Sodce Chloruret. |j; Aquae § xi. Ft. gargarisma. To be used frequently. Beef -tea for drink. Wine | iv a day. Progress op the Case. — November 20<7i. — Tongue brown and dry. Lips and teeth covered with sordes. Has taken nourishment well. Pulse at the visit 74, of good strength. Sibilations heard all over the chest. Pustules on the skin more raised and umbilicated. Throat and other symptoms the same. Has experienced considerable relief from sucking lumps of ice. Urine the same. Face to be smeared frequently with oil. Nov. 21s^. — No change. Nov. 22c7. — Very restless during the * Reported by Mr. C. Henry Allfrey, Clinical Clerk. 970 DISEASES OF THE BLOOD. night. Cough incessant. Sputa less abundant but more tenacious, and of dirty red- dish color. The whole of the mouth and fauces covered with a dirty slough, emitting an oflensive odor. Face more swollen, covered with brown crusts from the dried confluent pustules ; the intervening skin of a dusky red color, in some places livid. Lips and teeth black from collection of sordes. Can still swallow beef-tea and wine readily. Urine still coagulable. Pulse 100, weak. To have half a teacupful of heef- tea with a dessertspoonful of wine every half hour. Nov. 23c?. — Pulse stronger. Pustules somewhat enlarged, though still very small over trunk and limbs ; in many places confluent. Face covered with a uniform brown crust, excoriated below the eye- lids, which are much swollen and closed. Skin generally of a dusky red, in some places livid. Deglutition, though difficult, still performed. Dyspnoea commencing. A table- spoonful of brandy every hoar. Continue nutrients. Nov. 2^th. — Died at 6 p.m. Sectio Cadaveris. — Forty-two hours after death. The surface of the body presented a copious variolar eruption, consisting of small, flat, imperfectly-filled pustules. The skin of the face was covered with a brownish sanguiuolent crust. Throat and Thorax. — The tongue was enveloped with a dirty blackish-brown soft crust. The whole mucous membrane of the velum palati, tonsils, fauces, and pharynx, was covered with a dirty grayish exudation, in some places of a broAvn tint, which on being scraped off exhibited a mahogany red and softened mucous texture below. The epiglottis was very vascular, and partially coated with the same mem- brane, which extended half down the oesophagus, throughout the larynx and trachea, and could be traced to the end of the large divisions of the right and left bronchi. The right pleurae were united by chronic adhesions. The lower third of right lung posteriorly was infiltrated and indurated with extravasated blood, presenting on sec- tion a smooth, dark purplish-red color. Various other patches of coagulated blood, varying in size from a hazel-nut to a walnut, were scattered throughout both lungs. The bronchi throughout were loaded with a dh’ty purulent fluid. The heart and peri- cardium were normal. The clots of blood everywhere very soft. Abdomen. — Abdominal organs healthy. Spleen firm. Commentary , — The two cases here recorded are examples, in dilferent degrees, of an affection which, though previously known in most coun- tries under the name of sloughing or putrid sore throat, angina maligna, etc., was first called diphtheritis (Brettoneau), and now diphtheria, from the parchment-like membrane which covers the mucous passages of the fauces and throat As it occurs epidemically, is frequently rapid in its progress, appears to be infectious, and causes profound alteration of the system, it is generally considered as a blood disease. On commencing, it is not to be separated from tonsillitis or ordinary sore throat. But when it occurs generally among communities, and espe- cially in schools, its presence, if a sloughing tendency be manifested, may be suspected. In severe cases a dirty gray or tough purulent layer of matter spreads rapidly over the tonsils, uvula, and pharynx, not unfrequently over the internal surface of the mouth, and occasionally of the larynx and trachea. It may or may not be accompanied with fever, but sooner or later causes exhaustion from the difficulty it creates to the re- ception of nourishment. Mr. Wade, of Birmingham, pointed out the very frequent presence of albuminuria as a concomitant. The disease is very rare in the Boyal Infirmary, where I have only seen one other case of it in addition to those above reported, in which also it was associated with small-pox. In private practice in Edinburgh, however, it is more common. I have never seen the membrane to contain a fungus such as has been described by some authors, although I am quite familiar with it in the muguet, so common in the infants of foundling hospitals abroad — a disease which bears a close analogy to diphtheria (see Fig. 53). SYPHILIS. 971 With regard to treatment, I Have not found the application of caustic, either solid or in solution, to the diseased part, of any benefit. On the contrary, I think iced water in the incipient stage, and subsequently inhalations of steam, relieve more. Poultices externally, and diuretics internally, when albuminuria is present, are directly indicated (see p. 826). Above all, supporting the strength with nutrients and resto- ratives, so as to gain time and enable the disease to run through its natural progress, is the chief point to be attended to. In case CCLXVII. I believe life was preserved by maintaining the patient for a week on nutritive enemata. Case CCLXVIII, was one of the most frightful I ever witnessed, and its extent, not to speak of the complicated variola and pulmonavy disease, stamped it as fatal from the commencement. I have seen diphtheria associated with scarlatina. When the larynx is diseased and respiration affected, laryngotomy should be tried, which, in the prac- tice of l)r. Jenner, of Dr. M’Leod of Glasgow, and others, has saved several lives ; otherwise a fatal result may occur in a few days, and is seldom prolonged above a week. On the other hand, diphtheria, with only reual complication, may go on till the fourteenth day. For important information on this subject you may consult the reports of Drs. Green- how and Sanderson, Public Health Reports, 1860 ; the translation of Trousseau on Diphtheria, by Dr. Semple, and the excellent little mono- graph by Dr. Jenner — “ Diphtheria, its Symptoms and Treatment,” 1861. SYPHILIS AND MERCURIAL POISONING. Case CCLXIX ."^ — Syphilitic Ulceration of the Face. Anne Bruce, aet. 24 — admitted January 10th, 1852. Her face presented a most frightful appearance, being covered, as well as the neck and upper part of the chest, with circular masses of pustular scabs. These varied in size from a fourpenny-piece to half-a-crown, several being in some places crowded together. Some of the prom- inent scabs were dry, others soft, with foetid pus oozing from their bases. In a few places they had fallen off, exposing circular, unhealthy-looking ulcers. Wherever the skin could be seen, it was of a fiery-red color, and puckered with old cicatrices. The lower lip was swollen and dragged downwards, and the left lower eyelid was ulcerated and everted. The metacarpal bones of the left hand were enlarged, and the skin covering them red and painful. No ulceration of the throat or other com- plaints, with the exception of weakness. External appearance highly cachectic. The history she gave of her case is as follows : About five years ago she con- tracted primary sores from her husband, who had suffered from a very malignant form of them in the West Indies. Shortly after, she was attacked with a minute pustular eruption of the skin. This shortly disappeared, but was succeeded by occasional blotches on the skin, which sometimes broke, but always went away slowly. Eighteen months after the commencement of the disease, one of these appeared on her chin, when, being alarmed, she came to Edinburgh. The prac- titioner she consulted placed her under a mercurial course, and she was salivated for six weeks. The disease in the face, instead of healing slowly as formerly, now ulcerated and began to spread. Six months afterwards, she was again salivated for four weeks, but the whole of the lower half of the face was now involved, and she entered the clinical ward of the Royal Infirmary. She was confident that these are the only occasions on which she has taken mercury. She remained in the house upwards of a month, and went out with the face nearly well, from the use of topical emollient applications, and the internal use of small doses of iodide of potassium. Six weeks afterwards, however, she was exposed to cold and wet, when the blotches, scabs, and ulcers returned in the face, and gradually spread to the neck and chest, as formerly described. * Reported by Mr. G. A. Douglas, Clinical Clerk. 972 DISEASES OF THE BLOOD. She was ordered four grain doses of Iodide of Potassium in a mixture containing ^ i of tincture of Cardamoms^ and § 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 cicatrised all over, but quite well. Commentary . — It is very rarely that we have an opportunity of seeing so frightful a case of mercurial syphilis as the one just noticed ; it fully equalled many of the horrible representations I now show you in the work of Divergie. You will have observed from the history of this patient, that previous to the exhibition of mercury she was subject to the slow formation of boils, which, however, spontaneously disappeared. The moment her system was saturated with that drug the boils and ulcers first became stationary, and then commenced spreading over the integument. This is an important fact too little attended to by those who practise the mercurial treatment. Case COLXX .* — Syphilitic Laryngitis. Margaret Dickie, a staymaker, aBt. 25 — admitted September 9th, 1851, laboring under occasional vomiting, frequent cough, with haemoptysis, and copious purulent expectoration. There was considerable sweating at night, and her general health, owing to want of sleep and the harassing cough, was much broken down. At the commencement of the winter session in November I found her taking an acid mixture to relieve the sweating, a cough mixture to diminish the cough, together with cod-liver oil. The chest had also been blistered. Careful percussion and auscultation convinced me that the thoracic physical signs were perfectly normal. I then examined the fauces, which were covered with purulent mucus, but present- ing here and there red and prominent follicles. The cough was also ascertained to be convulsive, 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 syphi- litic origin. The fauces were freely touched with a solution of nitrate of silver ( 3 ss to J j of water). This was repeated on the following day, and on the next the upper part of the glottis was touched, causing severe convulsive cough. I subsequently passed the sponge, saturated with the solution, into the larynx every second or third day during the month of November, which at first caused very severe and prolonged convulsive cough, that gradually became somewhat diminished. On the whole, however, no great amendment was produced, although the expectoration and cough during the intervals vere lessened. The local applications were then suspended, but it soon appeared that they had been beneficial in checking the symptoms, from their severity again increasing, especially the amount of expectoration streaked with blood, and the want of sleep at night owing to the severity of the cough. In the second week of December, therefore, the topical applications were resumed, together with occasional blisters to the larynx, and once more a certain amount of benefit was obtained. But as this treatment, combined with the internal administration of iodide of potassium and bitter infusions, for a period of four weeks, seemed to produce no further improvement, she was dismissed on January 7th, 1852. Commentary . — Syphilitic disease of the larynx is one of the most common of the secondary forms of the disease, a fact indicated by the hoarse and broken voices so frequently noticed among women of abandoned character. The topical treatment with the sponge, and a solution of nitrate of silver, does not seem to be so useful as in simple laryngitis ; but even here its effects on the mucous membrane are evidently beneficial. * Reported by Mr, C. D. F. Phillips, Clinical Clerk. SYPHILIS. 973 Case CCLXXI .* — Syphilitic Rupia^ followed hy Keloid Growths on the Cicatrices — Syphilitic Psoriasis. History. — John Young, set. 24, boiler-maker, native of New Monklaud — admitted November 29, 1858. The patient states that, until eighteen months ago, he was per- fectly healthy, but at that time, while residing at Kilmarnock, he contracted a chancre upon the prepuce. This was treated by the external application of blackwash ; and he took what he believes to have been mercurial pills internally. The sore under this treatment healed in a week. He then went to Leith, and after remaining there a fort- 1 night, discovered that an ulcer had spontaneously formed exactly where the previous i one had existed. He at this time (July 31st, 1857) entered the surgical wards of the Edinburgh Infirmary, and there took pills which produced soreness of the mouth and gums, and increased salivation lasting for about three weeks. The ulceration of the throat, from which he then also suffered, was frequently cauterized, and black-wash was applied to the preputial sore. This plan of treatment was followed by a course of iodide of potassium. During his residence in hospital an eruption made its appearance, which was evidently rupia, as proved by the numerous large cicatrices which are at present visible all over the surface of the body. He gradually got much better, and was dismissed after six weeks’ residence. At the time of his dismission, however, there were, according to his own account, numbers of adherent crusts of rupia scattered over the greater part of his body. After he left the Infirmary he went to Motherwell, where his throat again became sore ; fresh pustules of rupia formed, many of the old crusts and sores enlarged, and deafness 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 sarsparilla and iodide of potassium, which he has continued to take from time to time until the present date. The medicine did not cure the disease, but kept it, he believes, from “ turning worse.” Six months ago patches of psoriasis commenced to appear on the neck and shoulders, which were soon followed by a similar eruption over other parts of the body. Twelve weeks ago a medical man made three attempts to inoculate him with syphilitic virus, repeated at intervals of eight days, but without success. The operation was performed by scraping some of the matter off a glass upon which it had been dried, and inserting it under the skin by means of a lancet. Symptoms on Admission. — The entire surface is scattered over with round and oval cicatrices of rupia, which are closest on the thighs, are not so common on the breast and abdomen, but pretty general on the back. In the centre of some of the cicatrices on the upper extremities and back are a few flesh-colored solid elevations, some occupying only a portion, others the entire surface of these cicatrices. In the latter case they constitute nodular swellings or tumors of a flesh or pinkish color; smooth on the surface and elevated above the level of the skin from one-eighth to one- quarter of an inch ; they are indurated and tough to the feel, oval or round in form, and vary from one-eighth of an inch to one inch and a half in diameter. The largest of them is situated over the left shoulder, and about a dozen are scattered over the neck, back, and superior extremities ; there are none over the chest, abdomen, or lower extremities. In addition to these there are irregularly-shaped patches of psoriasis scattered over the head, neck, abdomen, arms, legs, and back. On two of the largest patches irregular ulcers have formed, which are about ha f 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. 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-colored blotches, and the intervening portions of the skin, owing to occa- sional baths, became much clearer, and freed from the acne. On resuming my duties. May 1st, I found this man still in the house. In the inter- val he had taken Pot. Iodide, Liq. Arsenic., and Liq. Hydrar. Bichl., for various periods internally, and several of the patches and ulcerations had been treated externally with * Reported by Dr. T. A. Carter, Clinical Physician. 974 DISEASES OF THE BLOOD. nitrate of silver, and solution of cupri sulph. In May he was in no respect better, the patches of psoriasis had now assumed the character of elevated warts of papilloma, of a bi»»wnish-red color, and were so evidently chronic that by his own wish he was dismissed May 11th. Commentary. — This case offers a good example of the inutility of mercury, and perhaps even of the evils it produces on the economy, for no one can say how much of the pustular and scaly disease might not have been owing to the effects of that drug. The keloid growths were evidently fibro-vascular tumors, occurring in the cicatrices, and gave him no inconvenience whatever. It is seldom I have seen the skin of a young man so disfigured, presenting, as it did, circular and oval marks of the former rupia, the pink swellings, and the large copper-colored 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 subsequent course, and the identity of its different forms at various times, have all been keenly disputed. Even at the present day, its exact nature and mode of treatment excite lively discussion; for such are the discordant facts reported and such are the prejudices resulting from education and ex parte statements, that it is extremely difficult to form an unbiassed, not to speak of a correct opinion. All, then, that I shall venture upon here is to communicate some of my own reflections and observations on this subject. The venereal disease presents a great variety of symptoms, which are generally considered as primary and secondary. They may, with more propriety perhaps, be divided into primary, secondary, and tertiary, as follows • — Primary symptoms — 1. Balanitis. n rK ( Simple or ulcerative. 2. Gonorrhoea,- | ^ 3. Chancre, 4. Granular disease of os uteri. i TesteSy Prostate., Rectum., 5. Irritation in other organs, — -< Schneiderian Membrane, ( Conjunctiva, etc. Secondary symptoms, affecting the — 1. Lymphatic glands, — Bubo. 2. Mucous membrane, — Vicerations. 3. Skin, — Ulcerations or eruptions. 4. Eye, — Iritis, etc. Tertiary Symptoms — 5. Disease of bone, — Exostosis, Caries, Necrosis. The forms of syphilitic disease which commonly fall under our notice, in the medical clinical wards, are such as affect the skin, fauces, and larynx. They all require the same constitutional treatment, but the two latter demand also local applications, some of which have been refer- red to when speaking of laryngitis; SYPHILIS. 975 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 color of skin diseases assumes, in those affected with syphilis, a darker or coppery tint. This is especially observed in the scaly eruptions, the patches of which are also smaller, while the scales are thin, and of a gray color, often approaching black. The pustular scabs are hard and thick, of a dark greenish or black color, furrowed on the surface, and deep in the skin. The ulcers are deep, circular, with hard and callous edges. The cicatrices are unequal, round, or spiral, white and depressed. These eruptions may occur all over the surface, but are most common on the forehead, face, nose, back, and shoulders. In children they generally assume the form of maculae or of ulcerations ; in adults, of tubercular and scaly disorders, although ulcers are also very frequent. Diagnosis of Syphilis. ' It has been said by some persons that they can readily detect a syphilitic from all other skin eruptions. But I have known errors made in this respect by the most experienced and eminent dermatolo- gists, 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 Hdpital 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 medical adviser could prevail upon him to wait two days before com- mencing the mercurial treatment, when, however, he had the pleasure of seeing his diagnosis justified by the disappearance of the eruption. Now, I need not say, that if such an error could occur to one so expe- rienced as M. Biett, how much more readily may it happen to a practi- tioner comparatively 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. Bicord was so doubtful, after long practice, of the characters of a common chancre, that he commenced a series of inoculations in 1837-38 to determine which was, and which was not, a true venereal sore. So late as 1857 his views on this subject have undergone a complete revo- lution. I am satisfied also, that individuals whose systems have been impregnated with mercury frequently have ulcers which are constantly mistaken for venereal ones, although really the results of a poison with which the body is impregnated. The following case, which I observed 976 DISEASES or THE BLOOD. twenty-two years ago, was the first which strongly impressed my mind with this truth. A girl, seven years of age entered the surgical hospital in 1836. She had a round ulcer over the tibia, about the middle of the left leg. It presented all the characters of a venereal ulcer, as described by Hun- ter. On inquiry, it appeared that her bowels having been somewhat de- ranged, the mother had gone to a druggist’s shop and asked for some opening powders. She received twelve, which contained a white, finely powdered substance. One was given morning and night. In four days profuse salivation came on. The whole dozen powders were given, how- ever, 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 frequently affecting the shaft than the extremities of a long bone will serve to distinguish syphilitic from scrofulous disease and the existence of caries in conjunction with the peculiar ulcerations formerly alluded to, will confirm our suspicions. You should remember, however, that great caution is always required. The common idea that the gonorrhoea and excoriations in men, which often follow impure connection, are a proof of disease in the female, has led to great error ; as it is now ascertained that they may occasionally arise from the presence of the menses, some unusually acrid discharge, or other non-venereal cause. A hasty opinion given to the effect that this or that eruption is syphilitic has introduced discord into families, and produced incalculable mischief. The tertiary syphilitic symptoms also have frequently been confounded with the deep-seated pains of rheumatism, neuralgia, malacosteon, etc. Moreover, if such opinion leads to the en- tering upon a mercurial course, the original disorder is often replaced by an artificial one, not unfrequently more destructive in character, which is again confounded with syphilis ; and so the error is perpetuated. Propagation of Syphilis. Actual contact from impure connection is the most common mode by 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 communi- cated by the mother to the foetus in utero, — by the infant to the nurse, SYPHILIS. 977 — ^and again by the nurse to the infant. The following case, which was most carefully investigated, and was the subject of legal proceedings, illustrates how nurses may be affected by sypliilitic infants. In 1842 the late Dr. W. Campbell brought to me a woman with a child in her arms, to obtain my opinion whether a skin eruption on the latter was or was not syphilitic. I pronounced that it was, and that the woman should cease to nurse it, although her nipples at that time were in no way affected. The child was the offspring of respectable parents, and had been sent to her to nurse. In consequence of my opinion, the infant was returned to the friends, whose medical attendant maintained the eruption to be non-syphilitic. The woman who applied to me (nurse 1) was received as a wet-nurse into another family, and the child was sent to another nurse (nurse 2). In a week the child died, and a few days afterwards nurse 2 was attacked with sore nipples. Nurse 1, shortly after entering her new situation, also perceived sores round her nipples ; and the medical attendant of the family, after consultation with me, caused her to be discharged. She, in consequence, brought an action against the medical man who had caused the syphilitic infant to be sent to her, and had mistaken the disease. The lawyer she employed then took me to visit nurse 2, whose whole body was covered with a syphilitic tubercular eruption. Both nurses ultimately succeeded in ob- taining compensation from the medical attendant. Pathology of Syphilis, Syphilis is caused by a poisonous virus which, mixing with the blood, taints the constitution, and predisposes it to those forms of secondary and tertiary disorders formerly alluded to. The nature of this virus is involved in the same mystery as that of other animal poisons. All that we know of it is from observation of its effects. Sir A. Crich- ton, adopting Liebig’s view of a catalytic action produced in the blood, pointed out, in 1842, that this catalytic action was soon destroyed in cases of scarlatina, small-pox, and similar acute diseases. Here “ the fever, which de.stroys both the desire for food and the process of chymification, and consequently the supply of new elements for the further formation of new virus, is cut off. 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 production of fresh quantities of poison, and consequently the disease goes on and is protracted indefinitely. ” This theory is supported by the comparatively mild character of the syphilis in warm climates, where the natives live chiefly on vegetable food, and is abundantly proved by the good effects of a low diet and the mast simple m.eans, when contrasted with the effjcts of so-called specifics. OpinioQs in the French and German schools have greatly varied in recent times, and at the present moment are most conflicting. Bicord, having nearly all his life supported the views of Hunter, in 1857 an- nounced his adhesion to the view that there were two venereal contagions, — one connected with the soft, and the other with the indurated chancre. The views of Sigmund of Vienna, of Von Baerinsprung of Berlin, of ' 62 978 DISEASES OF THE BLOOD. Rollet and Diday of Lyons, of Michaelis, and various others, all founded on extensive observation, with numerous inoculations and experiments, are most contradictory. Whether there be one or two poisons is unsettled, and whether they are always distinct or capable of blending and producing mixed sores, equally uncertain. I would refer you to an excellent sum- mary of recent continental opinions by Mr. Hill (British Medical Journal, vol. ii., for 1862). See also the works of H. Lee and Thompson. In the present state of the question too much caution cannot be exercised in forming conclusions regarding it. A few years ago my attention was directed to the skeleton of a dog in the museum of this University, which presented ail the aspects of Fig. 535, tertiary syphilis. Its history is as follows : — The dog lived in the shop of Mr. Ballantyne, eighteen years ago, in Carrubber’s Close. At that time the work carried on consisted almost exclusively in painting with vermilion and lackering Japan articles. The dog, who never left the premises, was frequently seen lapping the vermilion oil paint, and there can be no doubt that in this way there was introduced into his system a considerable, quantity of mercury. After death the dog was dissected. Numerous cancerous-like masses were found in the lungs and internal viscera, and his skeleton was preserved. It will be seen that the shaft of the long bones and not their extremities were attacked (Fig. 535). The disease closely resembles what may be observed in many other specimens of so-called syphilitic disease. (See Figs. 536, 537.) Yet in this dog we have the positive proof that it was caused by mercury, as all attempts to communicate true syphilis to dogs by inocu- lation have failed. For my own part, I believe that the virus of syphilis, if left to itself. Fig. 636. Skeleton of a dog poisoned by mercury. One-fifth real size. SYPHILIS. 979 and if the health of the patient be attended to, will generally wear itself out. Unfortunately we are only commencing to observe the natural pro- gress of syphilis, and consequently we are unable to determine how long, usjder ordinary circumstances, it takes to accomplish this. So far as I know, wo 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 syphilitic poison, and the incalculable mischief it has occasioned, will constitute a curious episode in the history of medicine at some future day. It is now well known that the poison of mercury produces a cachectic disease and secondary sores on the body, which have been to a great extent mistaken for those of syphilis. It conse- quently has happened that mer- cury given to cure primary sores has produced a constitu- tional disorder closely resem- bling that of syphilis ; more mer- ■ -pigr. 536. Fig. 537. cury has been administered, increasing the mischief, and so the disease has been perpetuated. The real fact, however, is, that the syphilitic poison is no exception to the general rule, which informs us that all contagious diseases of the blood run a certain course, and that we have not yet dis- covered 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 pro- portion as its treatment by mercury has diminished and the disorder been left to follow its natural course. When we treat syphilis on the same principles that we do scarlatina and small-pox, it will prove in- finitely less fatal than those disorders. I have previously referred to the great caution which should be exer- cised in adopting the opinions of some pathologists who ascribe all sorts of chronic indurations, puckerings, gummy exudations, waxy degenera- tions, etc. etc., to syphilis, and call them syphilitic deposits, in the same manner that certain other lesions were formerly called typhous deposits. The general result of such a pathology is to increase the horrors of syphilis, and make it even more dreadful than it was rendered by the imaginative writings of Paracelsus and his followers. I believe these views to be founded in error (see p. 503 ). Fig. 536. Exostosis of dog’s femur. Fig. 537. Internal view. One-half real size. 980 DISEASES OF THE BLOOD. Treatment of Syphilis. The treatment of syphilis may be said to be of two kinds, namely, the simple and mercurial. The profession are rapidly deciding in favor of the first, although some of its members still give mercury in inveterate cases. Many of the cases we meet with, therefore,^ have taken the drug, and we have to eradicate the eflects of the mineral poison as well as of the original disease. The Simple Treatment is divided into internal or medical, and external or surgical. The first consists in the observation of certain hygienic rules, and the employment of general therapeutic means. The diet must be light and mild — meat and all stimulating viands retarding the cure ; even with the lightest diet, the hunger should never be quite ap- peased. The regimen must be the more diminished and rigid in propor- tion to the youth and vigor 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 aftections. 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 frequently re- newed. The greatest benefit is derived from the external use of a con- centrated solution of opium (in the proportion of about 3 ij to J j of water) ; it soothes excessive irritability in all cases. When the suppura- tion is moderated and the surface of the ulcer cleansed, stimulating dressings, consisting of solutions of the sulphates of alum and copper, the nitrate of silver, and sub-acetate of lead, favor cicatrisation. In inveterate cases, more especially those laboring under tertiary symptoms, the iodide of potassium, which was introduced by Dr. Wallace of Dublin, and used by him with considerable success, may be employed. I have myself given it in numerous cases with benefit, in doses of 5 gr. three times a-day, conjoined with emollient applications to the affected parts. The Mercurial Treatment used to consist in keeping up slight salivation by means of the internal administration of blue pills or some other form of mercury, sometimes conjoined with mercurial frictions or fumigations, 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 sys- tem generally. It is necessary during decided salivation that the patient do not ex- SYPHILIS. 981 pose himself to cold. A certain irritability is produced, and the con- stant soreness of the gums, the metallic taste in the mouth, not to speak of the inconveniences of profuse salivation, which occasionally occurs, render this species of treatment anything but agreeable to the patient. Both kinds of treatment have now been extensively tested. In the year 1822 the Boyal Council of Health in Sweden, having been charged by the king to conduct a series of experiments upon the different modes of treating venereal diseases, reports from all the civil and military hos- pitals were ordered to be drawn up annually. These reports establish the inconveniences of the mercurial system, and the superior advantages of the simple treatment. In the various hospitals of Sweden 40,000 cases had been under treatment, one-half by the simple method, the re- maining 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. Fricke’s experiments in the Hamburg general hospital were first made public in 1828. In four years, out of 1649 patients of both sexes, 582 were treated by a mild mercurial course, and 1067 without mercury ; the mean duration of the latter method was 51 days, and that by mercury 85. He found that relapses were more frequent, and secondary syphilis more severe, when mercury had been given. When the non-mercurial treatment was followed, they rarely occurred, and were more simple and mild when met with. He tells us that he has treated more 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 following his treatment, and in all cases which have come under his care, much mer- cury had been given. In 1833 the French Consul of Health published the reports sent in by the physicians and surgeons attached to regiments and military hos- pitals in various parts of France. Some of the reports are in favor of a mild mercurial course, others - in favor 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 Strasburg for five or six years. In the various reports now published more than 80,000 eases have been submitted to experiment, by means of which it has been perfectly established that syphilis is cured in a shorter time, and with less pro- bability of inducing secondary syphilis, by the simple than by the mer- curial treatment. These facts are now very generally admitted, and malignant syphilis is gradually disappearing. Thirty years ago the most frightful secon- dary and tertiary cases were met with, and the usual treatment was pro- fuse salivation. At present such cases are rare. Abroad, owing to wise police regulations, the disease is infinitely more innocent than it is 982 DISEASES OF THE BLOOD. even at present in Scotland ; and under the salutary influence of a mild and simple treatment its virulence is daily abating. In appreciating the value of this important revolution in practice, we should not forget to eulogise those who had first the boldness to introduce it. The credit of this is mainly due, in England, to Mr. Fergusson and other British army surgeons, who practised it during the Peninsular campaign (Medico-Chir. Trans., vol. 4) — and to Mr. Bose of the Coldstream Guards (Ibid., vol. 8). In Scotland the writings and lectures of the late Professor John Thomson of this Uni- versity were mainly instrumental in convincing Scotch practitioners of the evils of mercury in venereal diseases. In England the Hunterian theory and practice have been deeply rooted, and in Ireland have been supported by the writings of Carmichael and Collis. Mercury in con- sequence 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 CCLXIX. to CCLXXI.), unless the patient’s system has been contaminated with mercury. For an account of the treatment by inoculations, or what is called “ syphilisation,” in Italy, France, and Norway, which was apparently commenced in Case CCLXXI., I must refer you to papers by Brs. 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. Beview, vol. 45, p. 118 ; and Dr. Boeck’s pamphlet, “ Be la Syphilisation : etat actuel, et statistique ” 1860. I have en- deavored to impress upon you the great difficulties which exist in forming a correct diagnosis of syphilis. Until this is made more certain nothing can positively be determined with regard to the results of ino- culation as a therapeutic procedure. Again, may not the alleged suc- cess which has attended it be explained by the disease going through its natural progress, syphilisation, according to Dr. Boeck, acting best when neither mercury nor other remedies have been employed ? BHEUMATISM AND GOUT. General Fathology 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), while 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 tissue 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 EHETJMATISM AND GOUT. 983 two affections. In both there is a certain constitutional state, dependent on deranged digestion, during 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 laboring population. In gout the causes are good diet, indolence, repletion, or indigestion, and its subjects are for the most part the rich and sedentary. The local manifestations in both are acute wandering pains, with 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 complications of the internal viscera, which are more or less dangerous to life. . The general indications of treatment are, in both diseases — (1st), So to regulate the nutritive functions as to ensure a due balance between the amount of matters entering the blood as the result of digestion, primary or secondary, and the amount of matters discharged from the economy by the excretory organs. (2), To conduct the acute attack to a favorable termination, carefully watching the internal viscera, and being prepared to act with vigor should these become affected. Hence the treatment of these diseases resolves itself into what may be called curative 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 whole as cor- rect, we are not yet enabled to explain by it the symptoms of an acute attack of the disease, where, in addition to the constitutional disorder, we have local pain, occasional heat, redness, and swelling, with febrile symptoms. Most practical men have attributed these phenomena to a superinduced inflammation, although it has not been shown that exuda- tion occurs, or that it is followed by the usual results of that condition. Besides, its erratic character is opposed to what we know of the process of true inflammation, and calling it an unhealthy inflammation in no way 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 affected tissues is absolutely necessary. So far as I am aware, this has never yet been attempted, if we except some observations by Hasse on the structure of the bones in rheuma- tism (see Monthly Journal of Medical Science for June 1847). Our treatment of this disease, therefore, is purely empirical, some- times directed against the pain, at others against the supposed inflamma- tion ; now attempting to combat the pathological condition of the blood, then striving to remedy its effects by acting on the excretions, and not unfrequently giving specifics, in the hope that any change in the con- stitution, however produced, may be beneficial. In no disorder, pro- bably, 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 useffil prescription (Warren). The latest author on rheumatism endeavors to explain the fact by ob- 084 DISEASES OF THE BLOOD. serving that this need not to be wondered at by “ those who consider the true nature of the disorder, and the variety of circumstances under which the physician may be called upon to minister to his patient’s relief. The bleeding, which in the young, plethoric, and robust, may be necessary to allay excessive vascular action and cause free secretion, may in the weakly induce irritability of the heart, and a consequent attack of cardiac inflammation. The opium, which in one person may prove of the greatest service in promoting free perspiration, and in allaying the general irritability of the system, may in another check the biliary and other secretions, and thus prevent the elimination of the rheumatic poison. The continued use of calomel, and the constant purging, which may be beneficial to one patient by removing large quantities of unhealthy 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 use- ful at one time proves useless, or positively injurious, at another ; and the conclusion is forced upon us, that what is wanted ‘ is far less the discovery of untried methods of treating disease, than of discriminative canons for the proper use of those we possess; ’ — far less the discovery of any new medicines, than the adaptation of our present remedies to the exigencies of each case ” (Fuller on Kheumatism, p. 73). These judicious observations may serve to explain the cause of our failure ; but until we obtain more exact information regarding the special pathology of rheumatism, it is in vain to hope for a rational treatment. Occasionally I have tried the effects of special remedies in this disease, 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 Nitrate of Potash. During the session 1851-52 I made another trial of this kind with the nitrate of potash, a remedy formerly recommended by Dr. Brock- lesby, and which had been given with good effect by M. Gendrin in the wards of La Pitie in Paris, as recorded by Dr. Henry Bennet (Lancet, 1844, vol. i. p. 374). It has more lately been pressed on our atten- tion by Dr. Basham (Medico-Chir. Trans., vol. xxxii.), who tells us that from one to three ounces of the salt, if freely diluted in water, may be taken by the patient in the course of twenty-four hours, without any injurious results, but with the effect of relieving in a marked manner the swelling, heat, and pain in the joints. In the following cases the remedy was tried in much smaller doses, and it appears to me with more than average success. Case CCLXXIL* — Mrs. Anderson, a?t. 48, sick nurse — admitted December 3d, 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 sub- jected to much fatigue in her occupation as a sick nurse, and had been exposed to * Reported by Mr. William Broadbent, Clinical Clerk. rheumatism: and gout. 985 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. TMs occurred in the latter part of October last, and from that time up to November 20th she suffered from slight shivering and uneasiness ; transient pain in different parts of the body ; nausea and vomiting. About a fortnight before admission, she had a distinct rigor, followed by heat of skin and other febrile symptoms, with very severe pain in the joints especially, much increased by any attempt at motion. The 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 tits of copious clammy perspiration, of acid smell ; no oedema of the joints. Urine scanty, dark-colored, deposits crystals of the triple phosphates, with some mucus. Tongue loaded ; anorexia ; thirst ; occasional vomiting ; no tenderness on pressing the epigastrium ; bowels confined ; pulmonary functions normal. Mariatis Morphia semigranum ; Fulveris Aromatici grana quinque. M. Ft. pulv. Mittantur tales sex. One to be taken every half hour. December Ath . — She took three of the powders last night, after which she fell asleep; and this morning feels somewhat better; she has also had the bowels emptied by an enema, and is now using a diuretic mix- ture. December hth. — 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. December 6/A. — Had an exacerbation last night, the pain in the joints and limbs being excruciating. Potassce Nitratis semiunciam ; Aquae uncias sex. Misce et signetur — a table- spoonf al every four hours. December *lth. — Has taken three doses of the medicine ; she perspired a good deal during the night ; urine not increased in quantity ; pain is less severe. December d>th. — Still sweats a good deal ; pains much the same as yesterday. Adde misturae Nitratis Potass. 3j- December ^th . — Pains better; copious perspiration; urine increased in quantity ; increase of the nausea and vomiting and of the thirst. December \0th . — 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 articular rheumatism, of a fortnight’s standing when she entered the house. There was still, however, great pain on the slightest movement, which, during two days, in no way yielded to morphia, diaphoretics, and diuretics. On the exhibition of the nitrate of potash, profuse diaphoresis came on, which was apparently kept up by the medicine, with marked amendment to the rheumatic pains, followed by rapid recovery. The improvement could not be attributed to the occurrence of any critical day in this case ; and the night previous to the exhibition of the remedy there had been a marked exacerbation. Every one who saw this case felt persuaded that the good effects were attributable to the nitrate of potash. Case CCLXXIII.*— Jane Irvine, set. lY, servant, admitted 19th December 1851. States that seven days ago, whilst engaged at her usual occupation, she was suddenly seized with severe febrile symptoms, and constant pain in the left ankle, which was increased by pressure and motion ; it was red and tumefied. On the following day the right ankle became similarly affected, and then in succession the knees, shoulders, wrists, and fingers ; the pain still continuing, but modified in severity in the parts first attacked. She had been undeigoing treatment by diaphoretics, without, however, having experienced any relief from them. On admission the pulse is 100, full and soft. A soft bellows murmur, synchronous with the radial pulse, accompanies the first sound, heard loudest at the base, and is propa- * Reported by Mr. J. L. Brown, Clinical Clerk. 986 DISEASES OF THE BLOOD. gated along the course of the large arteries. Cannot sleep from the pain, u hich is general, and is causing intense sutfering. 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 colored, deposits a slight sediment of lithates. Skin moist, from copious perspiration; knees and ankles are swollen and painful on the least pressure. The right wrist, especially near the metacarpal bone of the thumb, is at present the seat of greatest suffering, and is red, painful, and swollen. Ordered to be bled to § xvj, and to have a -purgative enema. December ‘■10th . — Is much worse to-day; the pains in the wrist and hands are especially aggravated. Copious perspiration still continues, Potass. Nitratis § ss ; Aquce § vj, A table-spoonful every four hours. December 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. December lid. — Still continues taking the Potass. Nit. ; the improvement more marked, and she can allow the limbs to be moved about to-day, December l^d. — She presents quite a cheerful appearance to- day, and is entirely relieved from pain ; all the joints can be moved quite freely with- out exciting uneasiness. Pulse 68 ; skin cool ; tongue clean ; appetite returning ; bowels regular ; urine natural — some sediment. Cardiac murmur is more distinct to- day. — Convalescence proceeded satisfactorily from this date till January 6th, 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 rheumatism, which was in no degree benefited by diaphoretics, and a large bleeding on the seventh day. On the 8th day she was if anything worse, and then nitrate of potash was given, producing marked relief on the follow- ing day. On the eleventh day of the disease, and third from the exhibition of the salt, the disease was subdued and she became convales- cent. Here, again, the period of improvement cannot be confounded with critical days, and strictly corresponds to the administration of the remedy. The bleeding may have assisted its efi'ects, but certainly was not followed, as is usually the case, by any evident amelioration. This girl had an endocardial murmur on admission, which continued during the progress of the case, and I ascertained from the medical practitioner who sent her into the house that she had labored under this before the attack of rheumatism came on. Was this, therefore, an anemic murmur independent of the general disease, or produced by it? We may ask another question — viz.. Are all the endocardial murmurs occurring in conjunction with rheumatism caused by endocarditis, and attributable to the rheumatic diathesis ? These questions demand more careful atten- tion 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 mis- taken 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 CCLXXIY.* — Janet Wright. This woman had been admitted October 22d, 1851, laboring under the usual symptoms of acute rheumatism, and had been undergoing treatment by Dover’s powder, diuretics, leeching, etc., up to the 6th December, without any benefit whatever, when on that day she was ordered 1^ Potass. Nitratis 3 iij ; Aq. 3 vj. Misce. A table-spoonful every three hours. December ^Uh. — 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 Reported by Mr. William Broadbent, Clinical Clerk. EHEUMATISM AND GOUT. 987 also in the knees. December 8th. — Pain still continues. Adde miaturce Potass. Ni- ty'atis 3j. December 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. December 18th. — Still continues the medicine. No return of pain in the knees ; greatly relieved in shoulders, etc. ; the increased secre- tion from the skin and kidneys continues. The improvement continued up to the 16th, when she was dismissed for disorderly conduct. Commentary. — In this case the nitrate of potash, after being taken for three days, had caused much diaphoresis and diuresis, followed by diminution in the rheumatic pains, and rapid improvement at the time she was dismissed. Case CCLXXY.* — James Rough, aet. 26, blacksmith, admitted December 29, 1851. States that he has suffered on two former occasions from attacks of rheumatism. During his last attack, three years ago, he was treated in this hospital, and it lasted five weeks. The present attack came on nine days ago with great severity, having been preceded by febrile symptoms, wliich 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 palpitation of the heart ensues after much exertion, or indulgence in ardent spirits ; but in his or- dinary condition he is not troubled with it. At present the pain in the joints is not severe, unless on attempting motion ; pressure on the right shoulder and ankle causes considerable tenderness. The cardiac dulness measures a few lines more than two inches across ; the apex strikes the thoracic parietes in the normal position. A very distinct bellows murmur accompanies the first sound, is heard loudest at the apex, and is not prolonged along the course of the great vessels ; the second sound is more sharp and abrupt *than natural. The radial pulse is not synchronous with 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 diarrhoea. The urine is normal. Skin is moist, but no excessive perspiration, R Potass. Nitratis § ss ; Aq. | vj. M. A table-spoonful to be taken, diluted with much water, three times a day. Decem- ber 81st. — 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. January 'Id, 1852 (Thirteenth day). — Has no pain to-day. Continues to perspire a good deal ; and the urine deposits a copious precipitate of the lithate of ammonia. Pulse 68, soft and regular. Complains much of weakness. After this date, the amend- ment continued uninterruptedly, although only one bottle of the Nit. of Potash mix- ture had been used, and he was dismissed cured on the 12th January. Commentary, — The employment of the nitrate of potash was followed by apparently marked effects in this case, producing diaphoresis and evident benefit on the twelfth day, and removal of pain on the thirteenth day of the disease. As the attack commenced nine days before admis- sion, we cannot suppose that the recovery was owing to the occurrence of a critical day. Besides, the good effects were apparent the day after the exhibition of the salt, and on the following day the pains had disappeared. The valvular murmur with the first sound at the apex, and the character of the pulse, could leave little doubt as to the mitral incompetency ; and as he had been previously subject to rheumatism, there is every probability that the cardiac lesion was the result of pre- vious attacks of the disease. In a large number of cases which I have subsequently treated with nitrate of potash, I have satisfied myself that the disease is more readily subdued by this treatment than by any other. * Reported by Mr. William Calder, Clinical Clerk. 988 DISEASES OF THE BLOOD. Treatment of Rheumatism hy Lemon-juice. Case CCLXXVI.*—* Abigail Rankin, a servant, aet. 39 — admitted 15tli Decemlber 1852. Had rigors on the '7th, followed by febrile symptoms and acute pain in all the joints. On admission, pulse 100, full and strong ; heart sounds normal ; considerable febrile symptoms ; acute pains and swelling in all the joints increased on motion; much sweating at night. Other functions healthy. - Habeat Succ. lAmonnm ^ ij ter indies. On the I'Zth she was ordered 3j of Dover’s powder. December 20th. — The pains have continued as acute as ever till to-day, although she has taken f vj of lemon- juice every twenty-four hours. At present she experiences somewhat less suffering on moving the joints. Habeat Succ. Limonum f iij ter indies. December 22d — There was great sweating last night, and to-day she is much better. Habeat Sticc. Limonum § i ter indies. Some swelling of the left wrist joint remained until the 23d, on which day all pain had left her. Dismissed well, January 6th, 1853. Case CCLXXVII.f — Catharine Rooke, 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 every joint in the body. On ad- mission 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 perspi- ration ; febrile symptoms, with the exception of increased pulse, well-marked ; a con- siderable deposit of lithates in the urine. Other symptoms noimal. ^ Pulv. Doveri gr. X statim smnend. ^ Sol. Mur. Morph. 3 ss ; Potasses Bitart. § ss ; Sp. HEther. Nit. § j ; Aquee 3 j ; Pt. haust. kora somni sumendus. On the 25th, purgatives of calomel and jahip were ordered. Dec. 2Uh. — The pain and swellings of the joints have somewhat diminished, but are still very acute. Habeat Succ. Limon. §j ter indies. Jan. 2, 1853. — The pains have slowly subsided since last report, but there is still considerable soreness and stiffness of the knees. The arthritic swellings have everywhei’e disappeared. Jan. 47A. — Acute pain has returned in the right arm, which she cannot move. Jan. ^th. — Acute pain has extended to the right arm and back. Omittatur Succ. Limonum. Potasses Nitratis ^ ss ; Agues '^\v. M. Sumat ex agues | iv ter indies. Jan. 0th. — The pains have now disappeared ; marked improvement. No critical discharge. Dismissed well, January 7th. Case CCLXXVIII.f — Thomas Aitken, aet. 30, blacksmith — admitted December 25th, 1852. Fourteen days ago, after exposure to cold, he was attacked by rigors, followed by febrile symptoms and pain in his joints, which have continued up to this date. On admission, pulse 74, rather weak. A blowing murmur wdth 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 there is pain in all the joints, more or less of an erratic character. Febrile symptoms very slight. Slight bronchitis. Habeat Succ. Limonum 3 ss ter indies. On the 28th, the dose of lemon- juice w^as increased to |j. On Jan. 'id he was much better; but on the 4th the pains returned, but not so violently. On the 12th, he was free from pain, having had some diarrhoea, and taken a two-scruple dose of Dover’s powder. On the 22d the pains returned, but again subsiding on the 24th, he was dismissed. Case CCLXXIX.f — James Ollason, set. 20, clerk — admitted January 4th, 1853, with organic disease of the heart of old standing, and chronic rheumatism of an erratic character, sometimes violently attacking one joint and sometimes another, accom- panied 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 which lemon -juice was given, although in two six ounces and in one nine ounces were taken daily, did it appear to me that the disease was in any way con- trolled or alleviated by the remedy. In Case CCLXXVI. 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, per- * Reported by Mr. F. M. Russell, Clinical Clerk. f Reported by Mr. Alexander J. Macarthur, Clinical Clerk. RHEUMATISM AND GOUT. 989 haps, than from the effects of the juice. In case CCLXXVTI. the remedy was continued for ten days, and until the 21st day of the disorder was fairly passed. The nitrate of potash was given with the immediate effect of relieving the symptoms — although here also it is not improbable that a natural crisis of the disease was then established. In any case the inefficiency of the lemon-juice appeared manifest. Cases CCLXXVIII. and OCLXXIX. 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 favorable, and is strongly contrasted with the good effects of nitrate of potash, which I formerly brought before you. Case CCLXXX.* — Diaphragmatic Rheumatism. History. — John Robinson, a bookbinder, set, 24 — admitted February 5th, 1858. He says that on Sunday last, January 31st, he caught cold when at a funeral, and experienced some pain across the back and chest, especially on the right side. He felt extremely weak, and experienced great difficulty in breathing. On the following 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 treatment. Symptoms on Admission. — Pain on inspiration over right side, laterally and pos- teriorly, Slight cough with scanty expectoration. Percussion good and ecjual 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 op the Case. — Feb. ^th. — 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. \hth. — Has now no pain, and complains of weakness only. R Quince Sulph. gr. i. ; Acid. Nitric, m. x. ; Aquae ^ j ; M. Ft. haustus ter in die sumendus. Dis- missed well, March 10th. Commentary. — Deep-seated rheumatic pains in the chest are very apt to be mistaken for pleural or pulmonary diseases. In the present case I found most of the clinical clerks disposed to consider the disease a pleuro-pneumonia, and they had framed a report which gave con- siderable color to their opinion. A careful examination of the chest, however, 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 rheumatism. The treatment, therefore, was governed by this view of the case, and we saw the usual phenomena of critical discharge by urine and skin on the seventh day of the disorder. He was of weak constitution, however, and lingered in the house some time longer. In the same manner intercostal rheumatism is very likely to be mistaken by inexperienced persons for pleurisy, especially if they are not sure of the non-existence of friction or other physical sign in the chest, which their pre-conceptions have suggested to them exists there. But if they carefully compress and rub the muscles between the ribs, while the chest is at rest, pain will be elicited, even to a greater extent than occurs during inspiration ; a symptom which is diagnostic. Such cases formerly must have frequently been mistaken for pleurisy, and bled of course with the effect of ultimately causing a cure. In agricultural * Reported by Mr. Adolphe Baraud, Clinical Clerk. 990 DISEASES OF THE BLOOD. districts, slight intercostal or diaphragmatic rheumatism is most common at certain seasons of the year among laborers, who used consequently 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 vene- section was supposed by both practitioner and patient to have cut short an incipient pleurisy. Case CCLXXXI.* — Rheumatic Iritis^ following Acute Rheumatism — Recovery. History. — John Duffy, ast. 25, Ordnance surveyor — admitted April 6th, 185Y. 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. Dover! and Tr, Colchici internally, and had Tr. lodini applied locally. On taking charge of the case in May I first administered Nitrate of Potash ; subsequently he was ordered warm baths, and then quinine and wine with 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 25th of May, both internally and externally, and the quinine was discontinued. Occurrence of Iritis and Progress of the Case. — June ^th.— 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, immediately around the cornea, is surrounded by a zone of straight vessels, radiating outwards. Inferior half of conjunctiva of uniform red color. To be cupped over right temple, and § v of blood extracted. Extract of belladonna to be applied externally round the eye. June 11th. — The whole of right conjunctiva of a deep uniform vermilion, and zone of vessels round the cornea of a darker shade. Atropine to be dropped into the eye to ensure dilation of the pupil. To wear a large shade. Jime IZth . — 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 eye at night. June 14:th. — To-day iritis and conjunctivitis have appeared ill the left eye. Much pain in head, and restlessness during the night. Appetite bad ; tongue coated ; pulse 7 6, 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 l^th. 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 § j of Castor-oil, which not having operated, was ordered to-day, 01. Croton, gutt. unam et Ext. Colocynth. Co. gr. x. June 20^A.— Both irides, which naturally are of a light-blue color, present a dark, dirty green color. The pupillary margins are thick, and that of the right side irregular, especially at one place where an adhesion has formed. Both conjunctivae are of a uniform dense vermilion color. There is considerable pain in the head ; photophobia and lachrymation. Discontinue quinine. ^ Pulv. Cinchon. Ruhr, et Pulv. Sodce Bicarb, aa gr. v. Ft. pulv. to he taken three times a day. July ^ith. — To-day the right eye is much improved, redness of conjunctivae diminished, adhesion of pupillary margin disappeared, and vision perfect. Left eye the same as before, but an adhesion has formed, which has rendered the pupil irregular for some days. Cephalalgia has been sometimes better, sometimes worse. Belladonna has been constantly applied. Applicent. hirudines iij tempor. sinist. July 14th . — The right eye is now quite well. Left eye appears if anything worse. The pupil is dim, greatly contracted, and its margin much thick- ened. Vision also is nearly gone ; he sees as if through a thick cloud. Applicent. hirudines ij tempor. sinist. July 22c?. — 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 28?A. — 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 ^ Reported by Mr. Stewart Lockie, Clinical Clerk. EHEUMATISM AND GOUT. 991 weak. AuguH \0th . — Has been quite well for some days; vision in left eye is still slightly dim, but is getting clearer daily. Dismissed. Commentary . — This case of double rheumatic iritis, with conjuncti- vitis, was of the most severe description. So much, however, has been said about the danger of allowing such cases to run their natural course, and of the necessity of treating them with specifics, more especially with colchicuin and mercury, that I resolved to treat this case without them. It was watched on this account with great interest by the clinical class, especially as it was seen from time to time by my friend, the ophthalmic surgeon to the Infirmary, who predicted the worst consequences. Yet notwithstanding the weakened condition of the patient when iritis came on, the severity of the disease in both eyes, and the apparent closure which was about to take place in one pupil, I persevered, and the result in perfect recovery justified my expectations. It may be argued, how- ever, that the case would have got well much sooner if mercurials had been given. It is very difficult to determine this point, because few oculists have informed us what is the ordinary course of a severe rheu- matic iritis with conjunctivitis. According to Wharton Jones,* if taken in time before much exudation has occurred, and properly treated, it may be cured in three or four weeks. What are called active remedies were not applicable in this case, even according to the principles of those who use them, and the amount of exudation was considerable. The complete recovery of the right eye, therefore, in five weeks, and of the left eye in six weeks, seems to me to have baen on the whole a short period, considering all the circumstances, although on this point further observations are required. In the meantime, the case demonstrates that the most severe attacks of rheumatic iritis may get well, altogether inde- pendent of mercurials and active antiphlogistics. A similar conclusion had been previously arrived at by Dr. Williams of Boston, U. S., from a pretty extensive field for observation. (See p. 318.) 1 have now treated four other cases of rheumatic iritis in the Infirmary without mercury, and they have all recovered. Case CCLXXXII.f — Chrojiic Gout with Tophaceous Deposits m all the Joints. History. — Thomas Burns, a tobacco-pipe maker — admitted November 4th, 1857. Says he first became ill in Glasgow about ten years and a half ago, with pain and swelling in both his big toes. Soon afterwards the ankles and knees became affected. He was confined for a month, being unable to walk, or even to put on his shoes. Since then he has had on an average three such attacks every year, spring and autumn being the worst seasons; but he has rarely been confined by them more than a week. The attacks have generally commenced with rigors, followed by more or less fever and swelling in one or other of the joints. Almost every joint in his body has suffered in this way at one time or another. At the first attack, he says, chalk stones formed in his toes, and since then they have appeared in his feet, knees, elbows, and hands. The right hand especially has been much deformed by them. He is in the habit of cutting down upon, and extracting them, whenever they approach the surface and are unusually painful. He has been twice in the Infirmary, and on both occasions dis- missed 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 accus- tomed to drink a good deal of porter, as well as of spirits, until three weeks before his first admission, in June, 1856, since which time he has been more temperate. ^ Ophthalmic Medicine and Surgery, p. 150. f Reported by Mr. Wilkes, Clinical Clerk. 992 DISEASES OF THE BLOOD. Symptoms on 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 stretched integument, about the size of millet seeds. The elbow and knee joints are similarly affected, with several deposits over the olecranon and patella of each limb. The toes are not so distorted as the hands. There is pain on pressure over the right lumbar region, with a slight trace of albumen in the urine. Other functions normal. Foiassce Acet. 3 iiss ; Sp. uEther. Nit. 3 ss ; Tr. Colchici 3 j ; Mist. Camph. ad | viij. M. § j be takoi three times a-day. Progress of the Case. — November 25^A. — Small abscesses have appeared over the patella and heel, to which poultices have been applied. The mixture has been apparently of no service and is to be discontinued. Dec. 18th. — Last night was seized with severe lumbar pain, and general febrile symptoms, and on examining the urine it was found to be highly albuminous. The sediment contained numerous epi- thelial cells from the kidney, with granular and desquamative casts of the tubes. § v of blood to be extracted from the loins by cupping^ and to have at night Pulv. Doveri gr. X. Dec. 21sL — Is much better. Albumen in the urine diminished. 3 Ammon. Phosphat. li\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. 6^/q 1868. — Since last report has been comparatively free from 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. 9>th . — He has been perspiring much, and is better, although pains in joints are still very severe. The poultices have brought away several fragments of the tophi near the surface. They are of a pale yellow color, friable, and when examined under the micro- scope present a mass of needle-shaped crystals of urate of soda. 1^ Ammon. Phos- phatis 3 ss; Tr. Colchici 3 j ; Aquee ^ vj M. A third part to be taken three times a day. Jan. 22d. — The pains in the joints have now been absent for ten days, and he was dismissed. Commentary . — The above is only the third case of gout I have seen in the wards of the Royal Infirmary, and it is a matter of general obser- vation that the disease is one from which the people of Scotland are re- markably free. This has generally been attributed to their 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 considerable quantity of spirits besides.” * Now, it is curious that this is what the man, whose case is before us, seems to have done, and to this habit, therefore, we may fairly ascribe the occurrence of the disease. He admitted that for some years he was accustomed to drink upwards of half a gallon of porter, besides from four to eight ounces of whisky daily. There was no hereditary tendency. The numerous local attacks frequently gave rise to excretion of the morbid products by the kidneys, with all the symptoms of Bright’s disease, including albuminous urine, and desquamation of cells with casts of the tubuli. In a week or so, however, they disap- peared, and he enjoyed a temporary immunity from uneasiness. As to treatment, nothing seems to have been of permanent benefit, the topha- ceous 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. * Library of Medicine, vol. v., p. 219. SCORBUTUS. 993 SCORBUTUS. Case CCLXXXIIT.* — James Dermot, set. 21, railway laborer — admitted May 2Yth 1847. Has been working on the Caledonian line of railway for nine months, and enjoyed good health till three months ago, when he received a blow on the right tibia. This produced a sore, and an ulcer formed. His diet consisted of bread, coffee, ham, butter, and sugar ; but no milk or fresh vegetables. On admission, an elliptical-shaped ulcer, about two inches in length, is seated over the middle of the tibia, covered with irregular livid granulations, and surrounded by a raised purple edge. Another ulcer, the size of a shilling, is seated below this, and a third similar one on the outside of the leg. Eighteen months ago his left leg was burnt, and over the seat of the old cicatrix a number of ulcers, similar to those on the opposite leg, exist. One of these, towards the lower part of the leg, is the size of half-a-crown, and more livid than the others, which are smaller. The gums are swollen and fleshy, but not livid. Pulse 74, soft. Bowels constipated. To have full diet. B Aluininis 3 i ; Aquce ^ viij. Solve. Ft. Gargarisma. B linionis 3 iij ; Sacchari §iss; Aquae § iss. M. Sumat pro potu ex aqua indies. June ‘Id. — Ulcers looking more healthy. Their surface to he touched with nitrate of silver. July Tlth. — Has slowly got well since last report, and is now discharged. Case CCLXXXIV.* — John M‘Kenzie, aet. 26, railway laborer — admitted July 7th, 1847. During the last two months his diet has consisted chiefly of coffee or tea, with bread, butter, and sugar, but no milk. Two weeks ago pain and swelling came on in his left leg. Soon afterwards the right leg was also affbcted, and both became dis- colored. 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 color chiefly on its anterior and inner aspect. The right leg is similarly affected, but to a less degree. H« com- plains of pain and stiffness in both limbs, especially about the ankles. The gums are slightly swollen, and livid at the edges, but do not bleed on masticating food. Pulse 80, soft. Tongue clean. Bowels regular. To have full diet. July ‘2.0th. — Since ad- mission the symptoms have gradually disappeared, and to-day he was dismissed cured. Commentary. — During the year from October 1846 to October 1847 no less than 231 cases of Scorbutus entered the Royal Infirmary, of whom 30 also labored under continued fever. Of the entire number, nine were females, and seven died. In the previous year only one case entered the Infirmary, and in the following one only six. I myself treated between seventy and eighty of these patients, having succeeded Dr. Christison in the charge of a long shed which contained a large number of them, besides seeing others who came into my other wards. At the same period, there existed a most extensive epidemic of typhoia or typhus fever. Yet it is singular that the causes which produced scurvy, mostly in the able-bodied population, and especially among the class of laborers 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 laborers, the truck system, and establishment of local stores where provi- sions of inferior quality were given on a ruinous system of credit or ex- change, greatly assisted the absence of vegetables in causing the disease. The previous winter had been severe and protracted; so that whilst food of all kinds was high priced, the work and exposure of the laboring popu- lation were unusually severe. But scanty and improper diet, and * Reported by Mr. J. Robertson, Clinical Clerk. 63 994 DISEASES OP THE BLOOD. 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 suificient to give the full diet of the house (Case CCLXXXIII.), to which in unusu- ally severe cases, two or three ounces of lemon-juice with wine were added (Case CCLXXXIV.) This if the individual was not too prostrated before admission, produced a cure in a period varying, according to tlie intensity of the disease, from three to six weeks. Most of the cases entered the house between the months of January and August. Dr. Christison, who has given a most able history of the epidemic as it was observed in Edinburgh and in the Perth Penitentiary,^ conclu- sively shows that to the absence of milk, or its equivalent nitrogenous constituents, much of the disease was owing. In the Perth Penitentiary treacle water had been given instead of it, and on restoring the milk no fresh cases occurred. Dr. Lonsdale again showed that in the agricultu- ral valleys of Cumberland milk was abunclant,f and that the absence of potatoes and fresh vegetables was the evident cause. The probably cor- rect 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 oc- casion the disorder. The observations of Dr. Christison unquestionably prove the anti-scorbutic properties of milk, and of the full diet of the Edinburgh Infirmary, as these very frequently constituted the only treat- ment of individuals who recovered rapidly. The following table shows the nutritive proximate principles in ounces I. HEALTHY. Non-Nitrogenoxjs. Nitrogenous. Totfll. Siarch. Sugar. Fat. Gl ten. Legum. Album. Casein. Mus. fin Total. 1. Scott. Prison standard 25-2 17-8 1-32 0-11 3-96 0-13 0-03 1-36 0-55 6*03 2. Glasgow Pris’n, 3d rate 25.0 18-2 0-82 0-16 4-07 0-13 0-04 1-36 0-23 5-83 3. Edinburgh Prison, do. 24-3 17-8 1-56 0T3 3-89 0-25 0-04 0-38 0-23 4-79 4. Millbank Prison, 1821 25-0 19-4 . . 0-55 3-01 0-47 0-36 1-21 5-05 5. Do. Convicts, 1840 . 23-1 17-9 0*57 3-06 0-23 0-40 0-99 4-74 6. Dublin Bridewell, 1847 19-5 13-4 0 03 0-60 2-93 T57 0-94 5-49 II. CONVALESCENT. 7. Edin. Inf. full diet . 194 11-6 1-10 1-26 2-33 , . 0-01 1-50 1-65 5-52 8. Fever conval. diet . 20-1 11-1 1-50 3-88 1-82 •• 0-49 0-03 2T6 4*40 I ,III. SCORBUTIC. 1 1 9.' General Prison, 1846 24*2 17-8 1-56 1-11 3-96 0-13 0-03 0-07 0-55 4-40 1 10. Millbank Prison, 1823 20-9 16-6 . . 0-20 3-80 .. 0-30 3-98 11. Do. Soldiers, 1840-41 12. Do. do. improved, 1841 18-9 15-3 , , 0-38 2-97 0-23 , . 0-78 3-78 19-2 15-0 • • 0-38 3-04 0-21 0’04 • * 0-64 3-89 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 scuiA’y, while the military prisoners were attacked under the diet. No. 11. The data given by Dr. Baly, physi- cian to ‘the prison. 6. The present diet of the Dublin Prison, where male convicts are kept for long terms. 7. Edinburgh Boyal Infirmary full diet, under which scorbutics promptly re- covered. 8. Convalescent diet of a fever patient of the wealthy ranks, rapidly recovering j fiesh and strength. 9. Diet of the General Prison before the scurvy broke out. 10. Ditto before the Millbank epidemic at London in 1823. 11. Ditto before the military prisoners in Millbank Penitentiary were attacked with scurvy in 1840-41. 12. Improved diet on that occa- sion, but found ineffectual. _ , , The individuals subjected to the dietaries in the I. and III. Divisions were all m confine- ment for long terms.— ( Christison.) j * Monthly Journal of Medical Science, June and July 184'7. See also Dr. Ritchie on Scorbutics, as it appeared in Glasgow at the same time. July and August 1847. f Op. t itat., August 1847. POLYDIPSIA, 995 avoirdupois of the various dietaries, healthy, convalescent, and scorbu- tic. Dr. G-arrod,'^ from an examination of the composition of food, under the use of which scurvy was capable of occurring, as well as of such substances 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 this way he shows — 1st, That potash is deficient in scorbutic diet; 2d, That all bodies proved to be anti-scorbutic, including fresh meat and vegetables, milk, lemon-juice, etc., contain a large amount of potash; 3d, That in scurvy the blood is deficient in potash, and the amount of that substance thrown out by the kidneys is less than what takes place in health ; 4th, That scorbutic patients, when kept under a diet which gave rise to the disease, recover wlmn a few grains of potash are added to their food. The salts of potash, such as the nitrate, oxalate, and bi- tartrate, are well-known anti-scorbutics, but the efficacy has always be«n ascribed to the acid rather than to the alkali ; 5th, That deficiency of potash in the system seems capable of explaining some of its symptoms, especially muscular weakness, as potash is a necessary constituent of the muscular system. These views undoubtedly merit attention, and it is much to be regretted that they were not made known until the epidemic which had called them forth had disappeared. POLYDIPSIA. Ca.se CCLXXXV.f — Sudden Polydipsia — Incur alle. History. — Margaret Shearer, a French polisher, set. 34 — admitted May 31st, 1854. States that a year and a half ago she went to work at six o’clock, a.m., in her usual state of good health, and at eight o’clock, two hours afterwards, was suddenly seized with great thirst, which has continued ever since, accompanied by excessive discharge of urine. About three months afterwards she was obliged to give up work on account of a pain in the loins. At various times she has experienced loss of appetite, nausea, fulness of the abdomen, palpitations, constipation, or diarrhoea. Thinking that her strength had diminished of late, she entered the Infirmary. Symptoms on Admission. — On admission, the amount of urine passed in twenty- four hours was 424 ounces — pale in color — 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 coun- tenance, furred tongue, and dry skin ; but in every other respect is quite healthy. Dr. Alison, who first treated her, ordered warm baths and astringents, and afterwards galvanic shocks to be passed through the epigastric region. On taking charge of the case in the middle of June I ordered bitter tonics, and the diet was carefully arranged, and the amount of water drank limited, and mixed with milk and a little magnesia. No change, however, occurred, and she confessed that she could not admit of restraint with regard to the amount of drink. During the whole month of July she was weighed daily, and the amount of water drank and emitted from the kidneys carefully measured. Her average weight was eight stone, which underwent little valuation. The amount of water drank varied from 370 to 520 ounces, the average being 440 ounces. The amount passed varied from 350 to 500 ounces ; and it was observable that it was always from 20 to 50 ounces less than the quantity 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 day, and the Btool was of normal consistence and healthy appearance. 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 solu- tion of morphia. Under this treatment she frequently appeared drowsy and stupid, * Montlily Journal of Medical Science, January 1848. f Reported by Mr. James Thorbum, Clinical Clerk. 996 DISEASES OF THE BLOOD. but sound sleep was never prolonged, and no diminution of the thirst and diuresis wai 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. 22c?. — All other treatment was suspended, and she was ordered to take ten minims of the liq. iodinei comp., which was continued to the 14th of September without any effect. On the 16th she was ordered 1^ Mass. jnl. aloes et myrrhce ; Ferri. sulph. 3ij. ; Ext. liyoscyam. 3ij. Ft. massa in xij dividenda. Two pills to be taken twice daily. On the 26th there was diarrhoea, when the pills were discontinued, and an astringent mixture ordered. The report on the 1st of October was — “ general health good,” and from an observation made for the first seven days of this month, it appears that the thirst and diuresis had somewhat diminished, the amount of urine varying from 280 to 350 ounces. There was no further change up to October 10, when she left the house. Commentary. — -I prefer calling this case polydipsia to diabetes insi- pidus, as frequent careful inquiry established the fact that it commenced with thirst, and that the increased flow of urine was a simple result of the quantity of water drank. In the present state of science no reason- able theory can be conceived explanatory of the fact, that a woman, apparently in good health, is suddenly seized with great thirst, and thereupon drinks two or three gallons of water daily, passes a corre- sponding quantity of urine, and that this continues for nearly two years without any marked change in her health. Where there is no scientific indication, the treatment is wholly empirical, and even the results of experience are wholly negative and useless. Astringents, diaphoretics, galvanic shocks, narcotism by means of opium, cod-liver oil, iodine, and purgatives, all failed. The latter, by increasing the alvine discharges, diminished somewhat the excretion of urine, but we could not flatter ourselves that she was in any way benefited by her four months’ treat- ment in the Infirmary. Case CCLXXXVI."^ — T oly dip ma during the last two months of Preg- nancy — Disappearing after Delivery. History. — Mary M‘Donald, set. 34, married — admitted November 26th, 1860. She is nowin the seventh month of pregnancy, and two months ago her attention was di- rected to a strong craving she experienced for drinking water. She frequently took two or three tumblers full at a time, and during the twenty-four hours swallowed half a pitcher full, or about 200 oz. This has continued ever since, and latterly she has been troubled with cough and expectoration. Symptoms on Admission. — Her digestive system is in every respect healthy, with the exception of inordinate thirst, which is greatest in the morning, and after every meal, even when for the most part fluid, as tea. Before she drinks there is expe- rienced a sensation of dryness in the mouth, tongue, and fauces, and a feeling of dis- comfort arises if prevented from gratifying her desire. Three or four tumblers full of water generally cause satisfaction and a feeling of satiety. She passes a large quantity of urine, which is voided frequently. The desire to micturate comes on immediately after drinking a large quantity of water, and the fluid is passed in a full and prolonged stream, over which she has no control. Percussion over the chest is everywhere resonant, but on auscultation, loud sibilating and sonorous rales are heard with expira- tion, on both sides over the upper two-thirds of both lungs. Cough severe and paroxysmal. Sputum copious and watery. Pulse 104, weak. Skin dry. Other functions normal. ^ Sp. EEther. Sulph. 3 ij ; Chlorodyne 3 j ; Mist. Scillce c. § yj M. Ft. 3Iist. A tahle-spoonfxd to he taken when the cough is troublesome. Progress of the Case. — During November and December the bronchitis gra- dually got better, and had disappeared on the 20th of the last-named month. She drank, in addition to a certain amount of fluid taken at meals, from 90 to 130 oz. of Reported by Mr. Kenneth M‘Leod, Clinical Clerk. POLYSAECIA OK OBESITY. 997 water daily, and passed from 130 to 250 oz. of urine, clear and watery-looking, sp. gr. 1003. December '•21th . — She was delivered of a healthy boy, the labor being natural and quick. December 2d>th . — Her thirst and dryness of mouth have greatly dimiu- ishtid, December 2^ih . — Has no thirst ; urine only 60 oz. She recovered rapidly. The polydipsia has disappeared, and she passed from 40 to VO oz. of urine daily up to 3d of January, when she, with her infant, was dismissed quite well. Commentary . — In this case the same condition existed as in the last, but not to the same extent. Her pregnancy forbade all active remedies, and no curative trial was made. She informed us that during the latter period of her previous pregnancy the same excessive thirst had occurred which immediately disappeared after delivery, I therefore merely treated the bronchitis, and we saw the polydipsia cease on the birth of her child. POLYSARCIA OR OBESITY. Case CCLXXXVII.* — Great Obesity — Fatty Degeneration of Heart and Muscular System generally — of Liver and Kidneys — Hyper- trophy and Dilatation of Heart. History. — Anne Gilchrist, aet. 42, a cook — admitted June IVth, 185V. With the exception of an attack of rheumatism when 13 years of age, she has enjoyed good health until three years ago, when she ruptured a blood-vessel in the lung from over- exertion. Last March she caught a cold, and shortly afterwards observed a swelling of the feet, gradually extending up the exti-emities. 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 drank at least a bottle of porter daily. She has always been exposed to large fires in the kitchen, and in con- sequence of corpulence, has taken little exercise. Symptoms on Admission. — The woman is of an unwieldy size from corpulence. The circumference of the body at the umbilicus is 61 inches, of the calf of the leg 20 inches, and of the ankle 13 inches. She can lie on either side, but is very uneasy on the back. Slight exertion produces dyspnma. The sounds of the lungs and heart are normal. Percussion of the latter organ is unsatisfactory, in consequence of the un- common 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 is indurated and coarse. The scales of the house will only weigh 25 stone, and she is much heavier than this. To have a scruple dose of Bitartrate of Potash three times a-day. Full diet and 4 oz. of wine daily. Progress op the Case. — June 21s;;. — Since admission pulse better, and passes more urine — yesterday voided 30 oz. July 2th. — Has passed from 20 to 30 oz. of urine daily, and the legs have ceased to be oedematous. Complains of loss of appetite. Pulse 80, weak. To have 3 vj. of wine daily. July 10i!/i. — Urine again scanty, only passed 10 oz. yesterday. To have a squill and digitalis pill three times daily^ in auui- tion to the powders. July \lth. — At the visit to-day found lying on the right side, too w'eak to raise her head, and breathing with ditficulty, the respirations being short and labored. The urine was again deficient in quantity, and there was constipation. A drachm of the compound Jalap powder was ordered to be taken immediately. In the afternoon, before the powder had operated, she suddenly grew livid in the face, a tracheal rattle was heard, and in two minutes she expired. Sectio Cadaveris. — Forty-four hours after death. External Appearances. — Body of enormous size, owing to excessive development ’ of adipose tissue. The head appeared to emerge without any neck from the trunk. Mammie enlarged, each above the size of an adult’s head. The following measure- ments were taken : — * Keported by Dr. John Glen, Kesident Physician. 998 DISEASES OF THE BLOOD. Height ..... 65^ inches. Circumference of chest below nipple 64 Breadth from shoulder to shoulder 36 Circumference of abdomen 69 „ mammae at base 36 >> „ upper arm 19 „ lower arm 16 „ thigh . 28 „ leg below the knee 20| „ ankle 13 Thickness of integument over sternum 2 5) ,, „ abdomen 6 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 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 1 1^ inches. Ardomen. — 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 color. The two kidneys weighed 13| oz. They were of soft consistence and pale color. 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 Examination. — The muscular tissue of the heart was seen to be in an advanced stage of fatty degeneration. The cells of the liver were crowded with large drops of oil, and the nuclei of many of them were absent. The cells of the kid- ney were also very fatty. Commentary . — The circumstances in wliich this poor woman was placed were exactly those most favorable 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 digestive organs, she indulged largely in eating and drinking, whilst always more or less in a heated atmosphere. It is much to be re- gretted that her exact weiglit was not ascertained. When standing on the Infirmary scale, which only allowed us to weigh to the extent of 25 stone, it seemed as if she was at least 5 stone more. In a table of obese persons given by Dr. T. K. Chambers,* one man is said to have weighed 36 stone, but he was 6 feet 1 inch high ; two others, a man and a woman, weighed 28, and another woman 26 stone. In the case before us the increase of fat had certainly arrived at an extent seldom witnessed in the human subject, and with the result of gradually causing fatty degenera- tion of internal organs essential to life. Latterly, from fatty degenera- tion of the kidneys, albuminuria made its appearance, with cedematous limbs. From this, however, she might have recovered, had not the ad- vanced fatty degeneration of the heart and liver so enfeebled the circu- lation 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. Mr. Banting, in a pamphlet on Corpulence, London, 1864, tells us, that acting by the advice of his medical attendant, he reduced his weight in twelve months from 202 lbs. to 156 lbs., by abstaining from bread, butter, milk, sugar, beer, and potatoes. Though this plan of diet un- questionably diminishes obesity, care should be taken to adapt it to the exigencies of particular cases. The not following this precaution has already led to injurious effects in many persons (see p. 322). * On Corpulence. 1850. P. 139. CONCLUSION* The Ethics of Medicine. Gentlemen, — After a lengthened period of study, and a series of examinations, intended to test the amount of your knowledge, you have received the degree of Doctor in Medicine, the highest academic honor 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, 1 hope, ceasing to be students, you become members of a liberal and highly honorable profession. Such an event constitutes an important epoch in the life of every man, and is well calculated to excite not only deep feelings of reflection in yourselves, but those of lively emotion in all who are concerned (and who is not ?) in the progress of that art which is directed to the prolongation of life and the cure of diseases. It will not, then, be considered superfluous if, in obedience to established usage, before you leave this institution, a member of the medical faculty seizes the opportunity of offering to you a few words of advice, of point- ing out the importance of your future profession, and describing to you the spirit in which it ought to be practised. I. The first piece of advice that I shall take the liberty of offering is, always to cherish a feeling of deep responsibility . A medical man is the earthly arbiter of life and death. He is the guardian of our race through the dangers of birth and the perils of infancy. He is called upon to treat the different maladies which can afflict the human frame, under every circumstance of climate, age, sex, or condition ; and lastly, when all means fail to prolong life, it is his duty, if possible, to alleviate those pangs and diminish those sufferings which accompany the separation of the soul from its present dwelling-place. If, then, we regard him as the soother alike of the entrance and the exit of this life, as the first and the last friend of frail humanity, and if we further consider him, in the social scale, as the superintendent of all public and private institutions for the sick and the insane, as the adviser of legal tribunals in the administra- tion of justice, and as the regulator of the sanitary conditions of armies, fleets, and, indeed, of nations, it is scarcely possible to conceive a voca- tion in which every feeling of duty and honor ought to incite to activity * An address delivered as Promoter of the Medical Faculty to the graduates in medicine. August 1, 1849. 1000 CONCLFSION. 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 otiF, and which ought to press, with enormous force, upon those who are newly called upon to decide concerning the awful affairs of life and death. A fellow-creature having received some violent accident, or being attacked by acute disease, calls upon you for assistance. There may be no more experienced practitioner near; there is none to consult with; the danger is imminent, and you feel conscious that not only something must be done immediately, but that what is done may save or destroy. Then there rushes upon your mind a peculiar feeling of dread and anxiety, rendered more embarrass- ing, perhaps, by the conviction that your future prospects may be in- fluenced 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 com- mencement of your career, and it is then you will perceive, that the only true support to be depended on is a consciousness that you are enabled to put in practice all those means which the present condition of the science and the art of medicine have recognised as being correct. At such moments there will be impressed upon you the conviction that the good of your patients, and your own mental tranquillity, are intimately united ; you will see the advantage of having studied your profession, 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 en- ables you to do good and to relieve suffering — not with a vain effort at exhibiting your superior knowledge, but with that humility which is the necessary result of true wisdom. The object of medicine is to preserve health, prolong life, cure diseases, and thereby to forward the happiness of mankind ; and it is evidently the duty of those who practise it to lose no opportunity, and to adopt every means of prosecuting that object to its fullest extent and in its widest signification. With this view, gentlemen, your past studies have been directed to the acquirement of various kinds of knowledge, the purpose of which has been not merely the obtaining of professional rules, but en- larging the mind and cultivating the reasoning powers. The time has now arrived when you must concentrate the miscellaneous information you have gathered together, in order better to carry out that particular kind of practice which you in future intend to pursue. Any of the so- called accessory sciences may (should your tastes allow) be still further prosecuted, but not to the exclusion of more important matters. Your duty is to cure the sick and relieve suffering, and not to be distinguished as a chemist, a botanist, or a naturalist. Neither is it expected that you should have all the knowledge which each of your teachers possesses in his especial department, but that from the whole you should have obtained such a sum of learning, and such an available kind of information, that you may undertake the serious duties of a medical practitioner with credit to yourselves and advantage to the public. 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 THE ETHICS OF MEDICINE. 1001 your education is not complete ; indeed, in one sense, it may be said to be only beginning. Hitherto, you have depended on others, now you must advance by yourselves — the information of collegiate life must be perfected and elaborated, in order to meet the exigencies of every-day affairs. You must prune away those imaginings 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 acquirements 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 importance of practising the art and cultivating the science of medicine in a spirit of sincerity and of truth — li is a well-known fact, that whilst the public can judge with tolerable correctness of merit in any other profession, it is wholly incapable of forming an estimate of ability in medicine. The structure of the human body, the functions it performs, the laws which regulate it, and the derangements which affect it, are to mankind in general completely 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 opera- tions of nature as distinguished from those of art, that they are especially liable to be led into erroneous conclusions. In consequence, unprincipled persons, from time immemorial, have successfully practised on public credulity, and some specious but shallow theory, some vaunted nostrum, some peculiar accomplishment, or some singularity of manner, have 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 imperfections where such truly exist, and prefer a frank avowal of ignorance to a false assumption of knowledge. There is one great difficulty you will have to encounter, viz., that the rules and principles which guide the profession in the course of time undergo a considerable variation. The arts and luxuries of life, the physical changes of the globe, and the differences of education and civilisation, 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 be alive to the importance of following the progress of h*ls art, and not imagine that at any time he has learnt all that is 1002 CONCLUSIOJT. useful, or that he can ever reach that point at which improvement is not to be gained. At the same time, he must learn, amidst the multitude of suggestions, the number 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 confident plausibilities, especially where such are advanced, not in their true character as hypotheses, but as estab- lished laws which are to regulate your practice at the bed-side. It is sometimes allowable to give a certain rein to the imagination, and cultivate that power of generalisation which has led to the most im- portant and brilliant results in science ; but if this be not controlled within its proper limits, nothing can be more mischievous, especially when the errors may affect the lives of mankind. Strive, then, so to improve your intellectual resources and observing powers, that you may be enabled to shun error and admit truth, especially avoiding all those easy and fallacious paths to knowledge into which the interested endeavor to entrap the unwary. A desire to practise your profession in sincerity and truth will also lead you, in cases which you have not particularly studied, or which demand special kinds of treatment, to require the assistance of some brother practitioner. No two persons prosecute their study in exactly the same direction; and the subject of medicine is so extensive, so complicated, and requires so much application, that it is almost im- possible for a single individual to become master of the whole. Vanity and- self-conceit, it is true, have led some men to maintain the con- trary; 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 circumstanced hereafter as to do the same. If so, you will necessarily be often consulted in cases where you must feel internally convinced that you cannot do full justice to your patient, and then it will be right to bear in mind that, if you possess a greater share of information in some respects than others, they in certain particulars know more than you. Do not, then, be deterred by a false feeling of shame, or a desire for gain, from consulting your medical brethren; reciprocal services beget mutual kindness, and it is at all times better to resign the treatment of a case you do not understand, than subject yourselves, by undertaking it, to a perpetual series of mortifications and disappointments. By exercising your profession, then, in a spirit of sincerity and truth, you will be animated 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, with- out a scrupulous regard to its being correct. You will, while retaining the right of thinking boldly for yourselves, not forget that observation is difficult, theory imperfect, and experience frequently fallacious. You will not, therefore, rashly substitute your own authority for that of those whose knowledge is more extensive, or commit yourselves to the ephemeral doctrines of the day, by which a few otherwise respectable men have lost their professional reputation. You will remember that the conclusions of youth are almost always modified by the experience THE ETHICS OF MEDICINE. 1003 of age , and that the wisest and most eminent men of science have given the best proofs of a solid understanding by the readiness with which they have acknowledged their own ignorance. III. The third and last point to which I shall direct your atten- tion is, that you ought to le strongly imbued with a sense of duty and of moral obligation. No profession demands that its members should be governed in their practice by purer principles of honor than our own. The medical man is received into the bosom of private families, where he is intrusted with matters of such a nature that, if they were dis- closed, 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 there- fore especially enjoined upon those who treat the sick. It is true, you will labor among scenes ot woe, and have to watch incurable diseases and loathsome maladies ; but he whose sensibility is thereby blunted, and who can look with indifference on the agonies of a fellow-creature, will seldom feel that anxiety, or experience that watchfulness, which is so necessary for detecting the true condition of his patient. Self- interest is the worst of all models for a medical practitioner, and is a vice which our profession may proudly claim exemption from. You, I trust, will never experience it, but rather those pleasurable emotions which result from lessening human suffering, without thought of profit, and from exercising friendly offices with that politeness and delicacy of sentiment which 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 and undeservedly charged with committing errors. All men are liable to misrepresentation ; and although I do not, at such periods, advise you quietly to submit to insult, I strongly recommend great cir- cumspection in manifesting resentment. “ Unjust suspicions may attach to an innocent man ; the general consistency and integrity of his life will wipe them away ; the imprudences of youth may be repaired by the circumspection of middle age ; but if you once lose your reputation for professional prudence and honor, you will find, whatever be your at- tainments, that your influence is gone, and that you are, in all respects, lost and ruined men.” In addition to the duties which you discharge to the public at large, there are others of no less importance which you owe to your- selves. Opportunities will frequently occur where you may, by looks or words, seriously injure the reputation of some brother practitioner, when in reality he does not deserve it. The period of the disease, or the circumstances which have occurred, may enable you to do what your pre- decessor could not. Every good feeling demands that under such circum- stances you should explain the cause of your success to the patient, and not allow him to suppose his previous attendant was in fault. Besides, the most scientific and experienced physician may sometimes err unavoidably. 1004 CONCLUSION. and you must never attempt to aggravate the consequences of his failure by adding to the patient’s dissatisfaction. Conduct of this kind will cause the offender to be shunned, and sooner or later to feel that no success, and no wealth, can compensate for the absence of self-esteem or the good opinion of the enlightened and honorable men of his own pro- fession. Gentlemen, habitually engaged as you will be at the bed-side of the sick and the dying, you will have abundant opportunities of rightly esti- mating the insufl&ciency of mere worldly considerations. I think you will find, notwithstanding what is said to the contrary, that there is no class of society in which the true spirit of religion is more extensively diffused than among members of the medical profession. True, they shrink from an officious and public manifestation of it, and their habits of thought teach them to distinguish between trifling forms and essen- tial 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 endeavor, 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 ear- nestly 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 labor under a deep sense of respon- sibility, that you will always act in sincerity and truth, and ever be governed by a high feeling of duty and of moral obligation Let us hope that you will regard your past teachers as your future friends, and that in whatever part of the world, however distant, your lot may be cast, we shall still be united by a chain of good feeling and mutual es- teem, which, however it may be lengthened, can never be cut across. We desire that you will consider the reputation of this University as in some degree identified with your own, and whilst on the one hand you take care never to sully the degree she has this day conferred, on the other you will, by constant good conduct, and by well-directed endeavor, add fresh lustre to the reputation she holds among the academic institu tions of this great country. TABLE OF CASES DISEASES OF THE NERVOUS SYSTEM. OX8B PaOI I. Acute hydrocephalus — Recovery ..... 36C II. Acute hydrocephalus in a scrofulous child — Recovery . 861 III. Acute hydrocephalus — Phthisis pulmonalis— Death — Effusion into the lateral ventricles— Non-inflammatory softening of the cen- tral parts of the brain — Meningitis at the base of cranium — General tuberculosis ...... 362 IV. General acute meningitis supervening on pleuro-pneumonia . 867 V. Acute meningitis at the base of brain — Serous effusion into the venti icles, with white softening of cerebral substance — Phthisis 868 VI. Acute meningitis at the base of the brain — Effusion of serum into the lateral ventricles— Effete tubercle in the pons varolii and lungs . . . . . . _ . . 869 VII. Chronic meningitis — Serous effusion into the ventricles — Tuber- cular mass in the left lobe of the cerebellum — Cretaceous tuber- cle in the lungs, with fibrous cicatrix .... 373 VIII. Chronic cerebral meningitis — Induration surrounded by softening of a portion of the left cerebral hemisphere . . . 374 IX. Acute cerebritis — Abscesses in the brain — Old tubercle in various organs — Chronic peritonitis . . . * . 376 X. Acute cerebritis — Abscesses in the brain — Pulmonary tubercle — Abscess in the kidney ...... 377 *XI. Chronic cerebritis — ^Epileptiform convulsions — Hemiplegia of the right side — Loss of smell- -Blindness of the left eye — Amyloid bodies in the brain ....... 380 XII. Chronic meningo-cerebritis— Sudden convulsions — Hemiplegia of left side — Softening of anterior lobe of right cerebral hemisphere — Adhesions of arachnoid ...... 382 XIII. Chronic cerebritis of the right hemisphere — Cancerous ulcer of the oesophagus and neighboring glands — Fatty heart . , 384 XIV. Paralysis of the abducens occuli and auditory nerves— Exophthalmia — Tumor at the base of the cranium — Partial recovery . . 386 XV. Paralysis rapidly becoming general — Old apoplectic cyst in right corpus striatum — Softening of pons varolii — Clot obstructing basilar artery — Pneumonia of left lung .... 390 XVI. Apoplexy — Hemiplegia of left side — Convulsive attacks — Cardiac and renal disease — Old clot in the right cerebral hemisphere, with surrounding softening ..... 392 XVII. Two sudden attacks of Apoplexy — Hemiplegia— Cardiac disease — Persistent albuminuria — Enlarged and diseased spleen — Cere- bral softening — Anasarca — Atheroma of arteries — Obstruction of middle cerebral artery ...... 395 XVIII. Apoplexy, followed by hemiplegia of left side — Recovery . . 400 XIX. Apoplexy, followed by hemiplegia of left side — Recovery . . 400 XX. Palsy — Hemiplegia of the left side — Recovery . . . 401 XXL Sudden Paralysis of face and left arm — Pneumonia — Bright’s dis- ea^se — Recovery ....... 402 XXII. Apoplexy — Extravasation of blood into the left corpus striatum — Pneumonia — Arrested tubercle of lung .... 408 XXIII. Apoplexy — Hemiplegia of left side— Hemorrhage into right cere- bral hemisphere — Diseased heart— Pneumonia . . . 404 XXIV. Apoplexy — Hemorrhage at the base of the brain in a boy aged 14 years ........ 405 XXV. Apoplexy, followed by delirium, and proving fatal in eight hours — Hemorrhage into the meninges of the brain . , . 406 1006 TABLE OF CASES. Case XXVI. Hemorrhage into the right crus cerebri — Meningitis at the base of the encephalon — Serous effusion into the lateral ventricles — Chionic phthisis — Vertigo — Paralysis — Spasms of the jaw— Delirium and coma ...... XXVII. Apoplexy — Hemorrhage into right optic thalamus, causing hemi- plegia on left side — Progressive recovery — Two months after- wards, hemorrhage into pons varolii and membranes on right side — Death in seven hours ..... XXVIII. Five years before admission, hemiplegia, followed by recovery — Four months before admission, apoplexy, with convulsions and partial recovery — Pulmonary disease — Death by asphyxia — Chronic softening of right corpus striatum — More recent hem- orrhage into the pons varolii— Cardiac hypertrophy, with mitral constriction — Hemorrhage into the lungs XXIX. Three attacks of apoplexy — The first dependent on hemorrhage into the right corpus striatum, in May 1861 ; the second on hemor- rhage into the left cerebral lobe and right optic thalamus, No- vember 1861 ; and the third on hemorrhage into the arachnoid cavity, March 1862 — Atheroma of the blood-vessels — Hyper- trophy of heart — Chronic disease of lungs, liver, and kidneys . XXX. Cancer of the brain, spinal cord, liver, and bones . XXXI. Chronic hydrocephalus — Paracentesis capitis — No benefit . XXXII. Otorrhoea — Sudden lumbar and cervical pains — Convulsions — Spinal meningitis ....... XXXIII. 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 XXXIV. Slight paraplegia — Recovery ...... XXXV. Paraplegia — Partial recovery ...... XXXVI. Paraplegia — Incurable ....... XXXVII. Paraplegia — Chronic myelitis ...... XXXVIII. Paraplegia — Tubercular caries of dorsal vertebrae — Myelitis — Pul- monary tubercle ....... XXXIX. Paraplegia — Cancer of vertebral bones — Softenkrg of the cord from pressure — Cancer of lung, liver, and lumbar glands — Ulceration of urinary bladder ..... XL. Neuralgia of the suborbital nerve and subsequent irritation and paralysis of various nerves at the base of the cranium, fi-om cancerous disease of the bones — Catarrhal pneumonia . XLI. Partial amaurosis — Spectral illusions — Perversions of hearing, smell, and touch — Spinal irritation .... XLII. Delirium tremens — Recovery ...... XLIIl. Delirium tremens with ocular spectra — Recovery XLIV. Delirium tremens with convulsion and coma — Recovery XLV. Coma and death from excessive drinking — Opacity of arachnoid — Subarachnoid effusion — Fluid blood .... XLVI. Poisoning by opium — Recovery ..... XLVII. Poisoning by opium — Recovery ..... XLVIII. Poisoning by hemlock — Death ..... XLIX. Poisoning by lead — Painter’s colic — Lead paralysis — Partial re- covery ........ Pag» 408 411 412 414 421 424 427 428 430 431 431 432 434 438 441 445 455 455 456 456 458 459 459 464, DISEASES OF THE DIGESTIVE SYSTEM. L. Tonsillitis ....... . 466 LI. Follicular pharyngitis ....... 467 LII. Stricture of the oesophagus from epithelioma . - . 467 LIII. Epitlieliomatous ulceration of the oesophagus, communicating with the lung— Pneumonia terminating in gangrene . . . 468 LIV. Carcinomatous stricture of oesophagus — Cancer of the liver — Pul inonary emphysema and tubercle — Pneumonia . . , 470 liV. Dyspepsia ....... 472 LVI. Dyspepsia — Oxaluria ....... 473 LVII. Dyspepsia — Hypochondriasis — Oxaluria .... 474 LVIII. Dyspepsia — Vomiting of fermented matter containing sarcime . 479 LIX. Dyspepsia — Vomiting of fermented matter containing sarcinae . 481 LX. Chronic ulcer of the stomach — Recovery .... 481 TABLE OF CASES. 1007 Case LXI. LXIL LXIII. LXIV. LXV. LXVL LXVII. LXV I II. LX IX LXX. LXXI. LXXII. LXXIII. LXXIV. LXXV. LXXVI. LXXVIL LXXVIII. LXXIX. LXXX. LXXXI. LXXXII. LXXXIII. LXXXI V. LXXXV. LXXXVI. LXXXYIL LXXXVIII. LXXXIX. XC. XCL XCIT. XCIIL XCIV. XCV. XCVI. Chronic ulcer of the stomach — Cure ..... Chronic ulceration and perforation of the stomach — Peritonitis — Limited pneumonia with gangrene — Abdominal abscess, simu- lating pleurisy — Death ...... Chronic ulceratlbn in the stomach — Perforation occasioned by a fall (?) — Recovery ....... Cancer of stomach, pancreas, and mesenteric glands — Cystic atrophy of right kidney ...... Colloid cancer with perforating ulcer of stomach — Peritonitis Poisoning by o::jalic acid — Recovery ..... Poisoning by sulphuric acid — Recovery .... Poisoning by corrosive sublimate— Recovery A-cute congestion of the liver — Hepatitis — Recovery Acute jaundice — Albuminuria — Recovery .... Abscess of the liver, bursting into the right thoracic cavity, and into the retro-peritoneal cellular tissue — Pneumonia and gan- grene of right lung — Pneumo-thorax .... Impaction of a gall-stone in common bile-duct — Atrophy of the substance of the liver — Jaundice — Death Jaundice — Compression of the ductus communis choledochus from a cancerous tumor, composed of epigastric and lumbar glands -—Occlusion of cystic duct — Enlargement of gall-bladder — Can- cer of the pancreas — Biliary congestion of the liver — Cancerous exudation into various organs — Slight leucocythemia Jaundice — Cancerous tumor 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 ....... Enlargement of the liver — Ascites — Albuminuria — Recovery Fatty enlargement of the liver ..... Cirrhosis with atrophy of the liver — Ascites Cirrhosis with enlargement of liver — Hypertrophy of spleen — Slight leucocythemia — Jaundice — Constriction of arch and descending aort^a ....... Cancerous exudation into the liver — Cancerous ulceration of oeso- phagus — Simple stricture of pylorus — Profuse haematemesis — Aneurism of thoracic aorta, bursting into the left pleura Hydatid cyst of the liver diagnosed by means of the microscope — Its puncture — Discharge of Echinococci — Recovery Diarrhoea — Recovery ...... Diarrhoea — Recovery ...... Acute dysentery — Recovery ...... Sub-acute dysentery — Recovery ..... Chronic dysentery — Ascites and oedema of the legs — Leucocythemia — Cirrhosis of the liver — Cancer of the lung Obstruction of the large intestine — -Cancer of stomach, liver, peri- toneum generally, and mesenteric glands . . ’ . Strangulation of the small intestine from inguinal hernia — Gan- grene, ulceration, and perforation of the intestine— Peritonitis . Tape-worm treated by the ethereal extract of the male shield fern Tape-worm expelled by the ethereal extract of the male shield fern ......... Tape-worm expelled by the same remedy .... Tape-worm expelled by kamala— Return of the parasite — Ultimate cure by means of the male shield fern .... Acute peritonitis — Recovery ...... Acute peritonitis from bursting of Graafian vesicles into the peri- toneum — Pleurisy — Interlobular pneumonia Tubercular peritonitis with great deposit in parietal layer — Tubercle and hepatisation of lungs— Pleuritis — Adherent peri- cardium — Commencing fatty degeneration of heart — Biliary congestion and fatty degeneration of liver — Slight leucocy- themia . . . . . Cancer of various abdominal organs and of the lungs, producing symptoms of peritonitis ...... Cancerous peritonitis — Ascites and hydrothorax — Paracentesis abdominis — Arrested phthisis pulmonalis Page 482 483 487 489 491 495 496 496 497 498 501 504 506 509 510 511 514 514 518 522 524 524 526 527 527 534 535 542 543 543 544 545 546 549 551 554 1008 TABLE OF CASES. DISEASES OF THE CIRCULATORY SYSTEM. Case XCVII. Acute pericarditis — Recovery ..... XCVIIL Pericarditis and endocarditis— Hydropericardium XCIX. Acute pericarditis followed by acute double pneumonia — Reco- very — Aortic incompetence — Subsequent articular rheumatism — Sudden death — Adherent pericardium — Fatty enlarged heart — Thickening of aortic valves . . . . C. Acute pericarditis supervening on phthisis CL Ascites — Anasarca — Adherent pericardium with fatty atrophied heart — Congested liver ...... CII. Rheumatic pericarditis ...... cm. Rupture of aortic valves ...... CIV. Incampetency of aortic valves — Dilated hypertrophy of left ven- tricle — Dilatation of ascending portion of aortic arch — Chronic arteritis with aneurismal pouches .... CV. Incompetencj^ of aortic valves — Hypertrophy of left ventricle and auricle — Obstruction and incompetency of mitral valve — pneumonia ....... CVI. Incompetency of mitral valve ..... evil. Incompetency of mitral valve — Pulmonary hemorrhage — Hydro- thorax ........ CVIII. Mitral incompetency — Hypertrophy of left ventricle — ‘Attack of acute rheumatism, followed by aortic incompetency . CIX. Mitral incompetency — Hypertrophy of left ventricle — Aortic incompetency and obstruction — Angina . . CX. Incompetency of the aortic valves with musical murmur — Hy- pertrophy with dilatation of left ventricle — Pneumonia — Pul- monary hemorrhage ...... CXI. Mitral incompetency — Hypertrophy of left ventricle — Dilatation and disease of arch of aorta — Aortic incompetency CXII. Great constriction of mitral orifice — Dyspnoea, palpitation, cough, and haemoptysis — Loud prae-systolic (or diastolic-mitral) murmur — Death following abortion — Enlargement of the two auricles and right ventricle — Atrophy of left ventricular walls CXIII. Constriction of mitral and tricuspid orifices — Aortic incom- petency — Anasarca — Hydrothorax — Collapse of left lung — Bright’s disease of kidney . . . . . CXIV. Constriction of mitral and tricuspid orifices — (mdema — Hemor- rhage into the lungs . . . . • . CXV. Soft' adherent polypus, causing incompetency of the mitral orifice — Anasarca ....... CXVI. Enlarged foramen ovale — Phthisis .... CXVII. Aneurism of aortic valve, coincident with a systolic murmur at the base of the heart — Pneumonia-meningitis . CXVIII. Aneurism of the ascending arch of the aorta — Incompetency of aortic valves — Hypertrophy of left ventricle CXIX. Aneurism of ascending aorta immediately above the aortic valves — Incompetency of aortic and mitral valves — Hypertrophy of left ventricle — Waxy kidneys — Pulmonary hemorrhage — Ana- sarca ........ CXX. Aneurism of ascending arch of aorta — Chronic pericarditis — Dis- ease of aortic valves — Great hypertrophy of heart — Anasarca CXXI. Large aneurism of the ascending arch of the aorta, causing ab- sorption of a portion of the third rib, and bursting into the pericardium — Chronic pericarditis — Incompetency of aortic valves — Hypertrophy of left ventricle . . . _ . CXXII. Varicose aneurism of the ascending aorta communicating with the pulmonary artery — Jaundice and nutmeg liver CXXIII. Aneurism of the arteria innominata eXXIV. Aneurism of transverse aortic arch — Chronic pericarditis with effusion — Tubercular lungs — Anasarca — Former popliteal an- eurism cured by compression ..... eXXV. Aneurism of lower portion of the thoracic aorta, pressing on the thoracic duct — aneurism of abdominal aorta — Chronic ulcer of stomach — Chronic tubercular abscesses of liver and right kid- ney — Liver and left kidney waxy — Leucocythemia eXXVI. Aneurism of the superior mesenteric artery and aorta — Obscure aneurism of descending thoracic aorta — Treatment by the method of Valsalva — Pleuritis — Caries of the vertebrae, soft- Page 5.59 560 561 564 566 568 576 577 577 579 579 580 581 588 584 585 587 588 590 592 601 602 603 605 606 608 613 616 618 TABLE OF CASES. CjUB Page ening of spinal cord and paraplegia — Sudden death by poison- ing with the tincture of aconite ..... 620 CXXVII. Phlebitis of the left iliac vein, supervening on cancer of the sto- mach and oesophagus ...... 634 CXXVIII. Angio-leucitis, supervening on rupia— Recovery . . . 635 DISEASES OF THE RESPIRATORY SYSTEM. CXXIX. Acute laryngitis — Treated by topical applications — Recovery , 638 CXXX. Chronic laryngitis— Topical applications — Recovery . . 639 CXXXI. Acute oedema of the glottis— Chronic pharyngitis and laryngitis — Sudden death . . . . . . . 642 CXXXII. Acute laryngitis supervening on ascites, and cirrhosis of liver — Sud- den death from asphyxia ...... 644 CXXXIII. Chronic laryngitis and pharyngitis — Tracheotomy — Recovery . 646 CXXXIV. Pertussis — Violent paroxysms — Bronchitis — Collapse of the lungs — Recovery ..*..... 649 CXXXV. Acute bronchitis ....... 651 CXXXVI. Chronic bronchitis — Acute peritonitis — Collapse of the lung . 653 CXXXVII. Chronic bronchitis — Emphysema — Acute laryngitis . • . 654 CXXXVill. Chronic bronchitis — Emphysema — Injection of the bronchi with a solution of the nitrate of silver ..... 657 CXXXIX. Acute pleurisy — Recovery ...... 660 CXL. Acute pleurisy without functional symptoms — Rapid recovery . 661 CXLI. Chronic pleurisy on both sides— Bronchitis .... 663 CXLII. Empyema, with fistulous openings between the lung and pleural cavity, and between the pleural cavity and external surface ^ . 667 CXLIII. Chronic pleuritis and pneumo-thorax, without symptoms— Articu- lar rheumatism— Pericarditis — Recovery . . 669 CXLIV. Empyema, follovving chronic phthisis — Paracentesis thoracis — Pneumo-thorax — Singular mode of death from enormous dis- tention of the stomach and emphysema of its coats — Tubercular pleuritis — Adherent pericardium — Waxy spleen — Tubercle in the kidneys ... .... 671 CXLV. Chronic pleurisy, with fluid in the left chest, forcing the heart into the right thoracic cavity — Recovery .... 677 CXLVI. A similar case — No improvement . _ . . . . 677 CXLVII. Pneumonia on right side and slight pleuritis — Recovery . . 678 CXLVIII. Double pneumonia, with urgent symptoms, and full strong pulse — Pleuritis on left side — Recovery in nine days . . 679 CXLIX. Double pneumonia — Great dyspnoea— No bleeding — Local warmth and stimulants — Rapid recovery ..... 681 CL. Pneumonia on the right side — Early bleeding — Slow recovery . 682 CLI. Double pneumonia — Treatment by mercuiy, which caused profuse salivation before admission — Prolonged recovery . . 684 CLII. Pneumonia — ushered in by violent vomiting and gastric pain — Re- covery in five days ....... 685 CLIII. Bronchitis and pulmonary congestion, from morbus cordis, resem- bling pneumonia, but no absence of chlorides in the urine . 688 CLIV. Chronic pneumonia of upper thiid of right lung — Gangrenous abscess — Recovery . . . . . . .713 CLV. Chronic pneumonia of both lungs, with ulceration — Death — Great condensation, with cavities and pignientary deposits in the lungs — Chronic tubercle in various organs — Disease of both supra- renal capsules, without bronzing of the skin . . . 714 CLVI. Gangrene of the lungs — Dysentery ..... 716 CLVII. Gangrenous abscess of the right lung, caused by swallowing a piece of chicken bone four and a half years previously . . 718 CLYIII. Phthisis pulmonalis in its last stage, with incompetency of the aortic valves — Cod liver oil and nutrients — Complete recovery . 722 CLIX. Phthisis pulmonalis — Amendment from treatment and disappear- ance of symptoms — Their subsequent return — Death . . 725 CLX. Phthisis pulmonalis — Large vomica on left side — Cirrhosis ot lung — Canes of left wrist-joint — Scrofulous nephritis . 727 CLXI. Chronic phthisis — Enlarged liver — Albuminuria — Large excava- tion in left lung — Cicatrices and induration of right lung — Waxy liver and kidneys — Tubercular ulceration of intestines . 731 64 iOiO TABLE OF CASES. Case Paqi CLXII. 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 . . 7S9 CLXIII. Cancer of the lung, thyroid body, and lymphatic glands of the neck — Bronchitis — Leucocythemia .... 754 CLXIV. Carbonaceous lungs with black expectoration . . .756 C LX V. Carbonaceous lungs with black expectoration in a female . . 757 DISEASES OF THE GENITO-URINARY SYSTEM. CLXVI. Ovarian dropsy — Frequent paracentesis— Excision of both ovaries — Strangulation of the intestine — Phlebitis — Death from ileus the seventieth day after the operation .... 763 CLXVII. Ovarian dropsy — Spontaneous ulcerative opening of the cyst into the bladder, and evacuation of its contents — Recovery . . 770 CLXYIII. Ovarian dropsy which gradually emptied itself spontaneously by opening through the Fallopian tube — Singular attempt at im- position of pigs' bladders, for cystic formations in the uterus . 772 CLXIX. Ovarian dropsy — Perforation of the descending colon from without inwards — Death from ichorhaemia and persistent diarrhoea . 774 CLXX. Acute nephro pyelitis — Recovery ..... 782 CLXXI. Subacute nephritis, with great anasarca — Recovery — Acute nephri- tis of left kidney — Recovery ..... 784 CLXXII. Acute desquamative nephritis, proving rapidly fatal from diminish- ed flow of urine, general anasarca, and oedema of the lungs . 785 CLXXIII. Acute desquamative and hemorrhagic nephritis — Hydrothorax — Collapse of the right lung — Pulmonary oedema and bronchitis, with symptoms of pneumonia ..... 787 CLXXIV. Acute nephritis — Chronic pneumonia— (Edema of the lung and anasarca proving fatal — Perforating ulcer of the duodenum, without symptoms ....... 7’89 CLXXV. Nephritis follow'ed by the formation of a large abscess in the right kidney, opening into the lumbar cellular tissue— Ulceration of ureter and bladder — Thickening of mitral and tricuspid valves — Partial atrophy of lungs, with and without induration — Par- tial oedema ....... 791 CLXXVI. Scrofulous nephritis and abscesses in the kidneys — Extensive deposition of tubercle in the lungs and intestines . . 793 CLXXVII. Calculous nephritis and gangrenous abscess of the right kidney — Waxy liver — Recto-vesical fistula .... 795 CLXXVIII. Chronic pyelitis, and cystic kidneys — Dilatation of ureters — Fun- goid ulceration of urinary bladder . . . ,797 CLXXIX. Albuminuria — General anasarca — (Edema of lung — Recovery . 801 CLXXX. Albuminuria — (Edema of both feet and legs, left arm and hand — Recovery ........ 802 CLXXXI. Albuminuria — (Edema — Ascites and general anasarca— Coma and convulsions — Recovery ...... 804 CLXXXII. Third attack of general anasarca with albuminuria — Enormous dropsical distention of the abdomen, scrotum, and inferior ex- tremities — Complete recovery under the action of supertartrate of potash . . . . . . . . 805 CLXXXIII. Second attack of albuminuria with anasarca — Dismissed relieved . 807 CLXXXIV. Second attack of albuminuria after an interval of tw^enty-nine years, with anasarca — Bronchitis — Dismissed relieved . . 808 CLXXXV. Third attack of albuminuria with anasarca— Dismissed relieved . t09 CLXXXVI. Albuminuria, with general anasarca, terminating fatally — Waxy kidneys, spleen, and liver, with extensive deposition of tubercle 8x0 CLXXXVIl. Albuminuria— Excessive amount of urine — Phthisis pulmonalis — Waxy liver, kidneys, and spleen ..... 811 'LXXXVIII. Albuminuria with great increase of urine — Waxy kidneys, spleen, and liver . . . . . . . . 813 CLXXXIX. Albuminuria— Syphilitic ulcerations of throat— Enlarged spleen and liver — Leucocythemia — Waxy degeneration of kidneys, liver, and spleen . . . . . . . 814 CXC. En aiged liver and spleen — Leucocythemia, and fibrinosis of the _luod — Albuminuria — Waxy kidneys .... 815 TABLE OF CASES. 1011 Cask CXCI. Albuminuria, with phthisis pulmonalis, terminating fatally — Ex- tensive deposition of tubercle and colliquative diarrhoea — Atro- phied fatty kidney — Ulcerated intestines .... DISEASES OF THE INTEGUMENTARY SYSTEM. CXCII. Favus of the scalp in an adult— Incurable . . , . CXCIII. Favus of the scalp of three years’ standing — Cured. CXCIV. Favus caught in the ward from Case CXCII. — Cured CXCV. Favus of the scalp of four years’ standing, cured by a sulphurous acid lotion ........ CXCVI. Limited favus of the cheek, cured by cauterisation; with nitrate of silver ........ CXCVII. Parasitic pityriasis — Incurable ..... CXCVIII. Pityriasis versicolor — with the microsporon furfur of Eichstadt — Cured by pitch ointment ...... DISEASES OF THE BLOOD. CXCIX. Leucocythemia discovered after death — Hypertrophy of the spleen, liver, and lymphatic glands— Absence of phlebitis and of puru- lent collections in any part of the body .... CC. Leucocythemia detected during life — Hypertrophy of the spleen — Ascites ......•• CCI. Commencing leucocythemia determined during life — Enlarged spleen and liver — Ascites . . . - • CCII. Eczema of the trunk and limbs — Enlarged lymphatic glands — Leucocythemia, which sensibly diminished CCIII. Chlorosis and anaemia — Cured . . . • . CCIV. Acute articular rheumatism — Multiple abscesses in the joints, in the muscles, within the cranium, &c. .... CCV. Diabetes mellitus ....... CCVI. Diabetes mellitus— Phthisis pulmonalis — Death CC VII. Diabetes mellitus — Improvement from the use of sugar CCVIII. Diabetes mellitus, treated with sugar — Great improvement for a time, followed by cataract, phthisis, and death CCIX. Diabetes — Treatment by sugar — Phthisis .... CCX. Diabetes — Treated in various ways ..... CCXI. to CCXIII. Cases of diabetes tabulated .... CCXIV. to CCXVJI. Cases of febricula CCXVIII. Relapsing fever ....... CCXIX. Typhoid fever — Convalescence on the forty-second day eeXX. Typhoid fever — Fatal on the twenty-fifth day CCXXI. Typhoid fever — Fatal from perforating ulcer of the intestine CCXXII. Typhus fever, with cerebral complication — Fatal CCXXIII. Typhus fever — Terminating on the fourteenth day . CCXXIV. Typhus fever — Terminating on the twenty -third day . CCXXV. Typhus fever, with petechise — Convalescent sixteenth day . CCXXVI. Typhus fever — Convalescent the twenty-fourth day . CCXXVII. Typhus fever — Convalescent the fourteenth day CCXXVIII. Typhus fever — Convalescent the fourteenth day CCXXIX. Typhus fever, complicated with bronchitis and collapsed lung — Fatal on the twelfth day ...... CCXXX. Typhus fever — Convalescent on the twelfth day CCXXXI. Typhus fever — Convalescent on the twenty-first day CCXXXII. Typhus fever — Convalescent on the twenty-second day CCXXXIII. Typhoid succeeded by typhus fever ..... CCXXXIV. Typhoid fever — Convalescent on the twenty-first day CCXXXV. to CCL. Typhoid and typhus fevers, 1862-63 CCLI. Infantile remittent fever ...... CCLII. Tertian intermittent cured by quinine .... CCLIII. Scarlatina with angina ...... CCLIV. Scarlatina with violent delirium . . . . . CCL V. Scarlatina treated with moist warmth . . . . CCLVI. and CCLVII. Scarlatina — The skin kept cool and dry . . CCLVIII, Scarlatina with diminished urine and coma .... Faob 817 847 848 848 849 849 864. 865 868 873 878 879 900 902 907 908 912 912 913 914 915 921 923 924 925 926 927 928 928 929 929 980 930 930 931 931 931 937 938 940 949 951 954 954 956 958 959 1012 TABLE OF CASES. Case Page CCLIX. to CCLXI. Scarlatina treated with the wet sheet . , • 960 CCLXII. Erysipelas — Recovery on the eleventh day . • ^ 961 CCLXIII. Erysipelas in an intemperate man — Slow recovery , , 961 CCLXI V. Variola — Severe confluent case ..... 692 CCLXV. Variola discreta ....... 963 CCLXVI. Variola — Ectrotic treatment ...... 965 CCLXVII. Diphtheria— Recovery ...... 968 CCLXVIII. Diphtheria complicated with small-pox — Death — Diphtheritic' membrane covering the mucous membrane of the pharynx, epiglottis, larynx, trachea, and right bronchus — pulmonary apoplexy ........ 969 CCLXIX. Syphilitic ulceration of the face ..... 971 CCLXX. Syphilitic laryngitis ....... 972 CCLXXI. Syphilitic rupia, followed by keloid growths on the cicatrices — S^hilitic psoriasis ...... 973 CCLXXII. to (jCLXXV. Treatment of acute rheumatism by nitrate of potash 981 CCLXXVI. to CCLXXIX. Treatment of rheumatism by lemon-juice . . 988 CCLXXX. Diaphragmatic rheumatism ...... 989 CCLXXXI. Rheumatic iritis, following acute rheumatism — Recovery. . 990 CCLXXXII. Chronic gout with tophaceous deposits in all the joints . . 991 CCLXXXIII. and CCLXXXIV. Scorbutus 993 CCLXXXV. Sudden polydipsia — Incurable ..... 995 CCLXXXVI. Polydipsia the last two months of pregnancy— disappearing after delivery ........ 996 IICLXXXVII. Great obesity — Fatty degeneration of heart and muscular system generally— Of liver and kidneys — Hypertrophy and dilatation of heart ••••••.. 99T IITDEX Abdomen, auscultation of, 73 ; inspection of, 37 ; post-mortem examination of, 32 ; view of the viscera in, 34 Abscess, pathology of, 166 ; resolution of, 173 ; in the brain, cases of, 376 ; in the abdomen, 483 ; in the liver, cases of, 501, 618 ; in the lung, cases of, 713 ; in the kidney, cases of, 791, 793, 795 Acarus scabiei, description and treatment of, 842 Achorion Schoenleinii, history of the, 850. See Favus Acne, diagnosis of, 832 ; treatment of, 839 Aconite, case of poisoning by, 620, 628 ; symp- toms of, 629 ; influence of on the heart, 338, 453 Address to graduates in medicine in 1849, 999 Adenoma, 206 Adhesions between serous surfaces, pathology of, 165 ; of arachnoid, case of, 374 ; of peritoneum, case of, 549 ; of pericardium, 566 ; of pleura, 665 Albumen and oil considered as types of nutritive substances, 126 Albumen, detection of in urine, 110 ; in solution, 246 ; membranous, 247 ; fibroid, 247 ; celloid, 248 ; molecular, 249 Albuminous degeneration, 246 ; concretions, 273 Albuminuria, persistent, cases of, 801 ; pathology of, 819 ; diagnosis of, 823 ; treatment of, 825 Aliment, 125 ; conditions regulating, 125. See Food. Alison, Dr., his views as to blood-letting in in- flammations, 302 ; Dr. Scott, his stetho-gonio- meter, 48 ; his differential stethoscope, 64 ; his hydrophone, 65 Alkaline lotions in skin diseases, 837 Amaurosis, case of partial, 445 Ammonia, urate of, microscopic appearance of, 104 Amphoric resonance in cases, 669, 671 Amyloid and amylaceous concretions, 282 ; in the auditory nerve, 283 ; in the pancreas, 283 ; in the brain, 380 Amyloid degeneration, 250 Andral’s opinion of the expression “ inflamma- tion,” 160 Anaemia, case of, 900 ; pathology and treatment of, 901 Aneurism, nature and varieties of, 216 ; cases of in aortic valve, 601 ; in arch of aorta, 601 ; varicose, communicating with pulmonary ar- tery, 603 ; of arteria innominata, 613 ; of tho- racic aorta, 618 ; of superior mesenteric artery, 620 ; general diagnosis of, 630 ; pathology of, 633 ; treatment of, 633 ; Valsalva’s treatment of, 662 Angina pectoris, 600 ; case of, 581 Angionoma, 216 Angio-leucitis, 635 Animal heat, 135 Anorexia in phthisis, treatment of, 750 Antimonials, treatment of pneumonia by large doses of, 694, 695 Anxiety and despondency in phthisis, treatment of, 753 Aorta, disease of, 584 ; cases of aneurism of, 602, See Aneurism Aortic valves, disease of, 583 ; aneurism of, 601 ; rupture of, 576 Apoplexy, definition of, 353, 448 ; cases of, 390 ; predisposing cause of, 416 ; histology of, 417 ; diagnosis of, 418 ; pathology of, 397 ; treatment of, 420 Appetite, treatment for loss of in phthisis, 750 Arteries, cerebral disease from obstruction of, 390 ; pathology of, 397 ; fatty degeneration of, 256 ; mineral degeneration of, 269 Arteritis, chronic, case of, 577 Ascites, microscopic appearances in fluid of, 103 ; from enlargement of liver, 510, 566 ; from peritonitis, 550 ; from abdominal cancer, 553 ; from cirrhosis, 527 ; from ovarian disease, 776 ; treatment of, 517 Asthma, causes of, 655 ; treatment of, 657 ; injec- tions of the bronchi in, 697 Assimilation of the food, 128; effects of bad assimilation, 136 Atelectasis, 654 Atheroma, cystic, 199 ; of blood-vessels, 256 Atrophy of face, remarkable case of, 155 Auscultation, general rules for practice of, 63 ; of abdomen, 73 ; of circulatory organs, special rules for, 70 ; sounds elicited in health and disease, 7 1 ; modifications of healthy sounds, 72 ; new or abnormal sounds, 73 ; of pulmon- ary organs, special rules for, 66 ; sounds elici- ted by, 66 ; altei’ations of natural sounds, 67 ; new or abnormal sounds, 68 ; of the large vessels, 74; relative value of sounds iu, 66 ; of aneurisms, 631 ; rules derived from in diseases of the circulatory system, 557 ; rules derived from in diseases of the respiratory system, 636 Bael, Indian, use of in dysentery, 529 Bathing, therapeutic uses of, 328 Bile, detection of, in urine, 110; bile acids. 111 Biliary calculi, 274 Bladder, percussion of, 62 ; urinary calculi in^ 276 ; opening of ovarian cyst into, 770 ; fun- goid ulceration of, 797 Blood, appearance of, under the microscope, 91 ; in thickened blood, 92 ; in haematocele, 92 ; in leucocythemia, 93, 882, 887 ; appearance of, in a case of cholera, 92 ; formation of, from alimentary matters, and the changes it under- goes in the lungs, 128 ; determination of, 130 ; chemical alterations in disease of the, 133 ; formation of, 128 ; reabsorption of transformed tissues into the, 131 ; circulation of, 130 ; pas- sage of fluid from, to be transformed into the tissues, 130 ; chemical constitution of healthy, 132 ; function of the, 132 ; morbid conditions of the, 132 ; chemical alterations of, in disease, 133 ; diseases of the, 136, 882, 887 ; causes of disease in the, 136 ; principle of treatment of, 137 ; post-mortem examination of, 32 ; micro- scopic examination of, 91 ; mixture of pus with, 896 Blood corpuscles, relation between the colorless and colored, 882 ; origin of the, 884 ; ultimate 1014 mDEX. destination of the, 890 ; structural alterations in, 93 Blood-forming glands, structure of, 128, 881; functions of, 128 Blood-letting, diminished employment of in treatment of acute inflammations, 302 ; former reasons for, erroneous, 306 ; local, observations of. Dr. John Struthers on, 310; can the ma- teries morbi in the blood be diminished by ? 306 ; can it diminish the flow of blood to the inflamed part ? 308 ; can it diminisli the amount of blood in an inflamed part ? 309 ; should it be indicated by the character of the pulse? 312; in acute pneumonia, 316, 692; useful as a palliative, 313 ; and in over-disten- siou of the right side of the heart, venous congestion, engorgement, etc., 317 ; in func- tional nervous disorders, 454 Blood-vessels, changes in previous to inflamma- tion, 156 ; new formation of, 219 ; fatty degen- eration of, 256 ; mineral degeneration of, 269 Bone, fatty degeneration of, 259 ; formation of new, 227 ; morbid growths of, 225 Eorborygmi, 73 Bowditch, Dr. H., on thoracentesis, 675 Brain, distinction between pressure on and com- pression of, 149 ; proper functions of the, 139 ; effects of removal of, 140; amyloid concre- tions in the, 282, 381 ; softenings of the, 353 ; abscess in the, 376 ; chronic inflammation of the, 380 ; obstruction of arteries in the, 390 ; hemorrhage in the, 400 ; cases of tubercle in the, 369, 373 ; cancer of the, 421 ; dropsy of the, 424 ; acute inflammation of the, 376 ; functional disorders of the, 447 Breathing, bronchial or tubular, 68 Bright’s disease, 801; casts of uriniferous tubes in, 105, 824 ; cases of, 801 ; pathology of, 819 ; forms of, 819 ; diagnosis of, 823 ; treatment of, 825 Bronchi, injections of the, in pulmonary diseases, 658 Bronchitis, acute cases of, 651 ; nature and ti’eatinent of, 652 ; chronic, cases of, 653 ; causes of, 655 ; treatment of, 656 Bronchophony, 67 Bronzing of the skin. Dr. Addison on, 264 Bruit de diable, 601 Bulla, definition of, 828 Calculi, biliary, 274 ; urinary, 275 ; renal, 275 ; vesical, 276 ; prostatic, 278 ; intestinal, 280 Callosities, 210 ; cause of, 210 Cancer, general description of, 229 ; scirrhous, 229 ; encephalomatous, 230 ; cells in simple and compound, 230 ; reticulare of Muller, 230 ; colloid, 232 ; chimney-sweeps’, 213 ; villous, 215; of the brain, 421; of the liver, 518; of the lung, 754 ; of the skin, 109 ; of the oesopha- gus, 470 ; of the stomach, 489, 534 ; of mesen- teric glands, 534 ; of abdominal organs simu- lating peritonitis, 551 ; of the peritoneum, 554 ; of vei’tebral bones, 437 ; of cranial bones, 441 Cancerous, growths, 229 — (see Cancer) ; cyst of the liver, 522 ; peritonitis, 554 Cancrum oris, 171 Canman’s stethoscope, 64 Cantharides, action of, 453 Capillaries, changes which take place in, pre- ceding-inflammation, 156; contraction of the, note, 156 ; new foimation of, 219 Carbonaceous lungs, 756; morbid anatomy and pathology of, 759; treatment of, 762 Carcinoma, 229. See Cancer Cardiac sounds, 70 ; diseases, rules for the diag- nosis of, 557 Caries, scrofulous, 436 ; cancerous, 437 ; from pressure of aneurism, 620 Cartilage, morbid growths of, 220 ; ulceration of, 223 ; fatty degeneration of, 259 Cartilages, loose, 194 Cartilaginous growths, 220 ; forms and structmn of, 221 ; in articulations, 223 Cases, method of taking, 30 Casts of the tubuh uriniferi, varieties of in Bright’s disease, 105, 824 Catalepsy, definition of, 449 Cell therapeutics, 307 ; theories of organisation, 115; theory of Schleiden and Schwann, 161; of Goodsir, 117 ; of Huxley, 117 ; of the author, 118 ; change of type theory, fallacy of, 299 Cells, importance of in practice, 20 ; fatty dege- neration of, 253 ; cell fibres, 189 ; fusiform, 189 ; plastic or pyoid, 165 ; gi-anule, 167 ; fibre, 168, 189 ; of cancer, 229 ; development of morbid growths by, 235 ; pigment, 266, 267 ; transfor- mation of exudation by, in pneumonia, 690 ; in pericarditis, 175; in pleurisy, 165; on mucous membranes, 166 ; in the brain, 167 ; in healing granulations, 168 ; enlargement of, in pregnant uterus, 189 ; atrophy of, after delivery, 256 ; in malacosteon, 259 Cephalalgia, treatment of, 453 Cerebellum, structure and functions of, 142 ; effects of removal of, 143; disease of, 373 Cerebral and spinal softenings, pathology of, 353 ; origins and varieties of, 354 ; necessity for microscopic examination of, 358 ; cases of, 359, 380 Cerebral disease from obstruction of arteries, cases of, 390 ; pathology Of, 397 Cerebral disorders, classification of functional, 447 Cerebral hemorrhage, cases of, 400 ; predisposing cause of, 416 ; microscopic appearances of, 417; diagnosis of, 418 ; treatment of, 420 Cerebral meningilis, cases of, 367 ; seat of, 370 ; microscopic appearances, 371 ; diagnosis of, 371 ; treatment uf, 371 ; pathology of, 372 Ccrebritis, acute, cases of, 376 ; chronic, cases of, 380 ; pathology of, 387 Ccrebro-spinal disorders, classification of func- tional, 449 Cerebrum, structure and functions of, 139; olfects of removal of, 140 Chest, inspection of, 36 ; mensuration of, 45 ; motions of during respiration, 37 ; post-mor- tem examination of, 31 ; view of viscera in, 34; percussion of, 54 ; auscultation of, 66 Chicken-pox, identical with small-pox, 967 Chlorides in urine, detection of, 112 ; absence of in pneumonia, 686 Chloroform not an anaesthetic, 452 ; inferior to cold as a true anaesthetic, 454 Chlorosis anaemia, cases of, 900 Cholera, microscopic appearance of blood in a ca se of, 92 Cholesteatoma, 202 Chorea, definition of, 448 Chyle, formation of, 128 ; of a dog, 743 ; of a cat, 885 Chylification, 128 Cicatrisation, process of, 190 Cicatrix, structure of, 190 Circulation, 129 ; static force of the heart and arteries in, 130 Circulatoi’y system, examination of, 26 ; action of medicine's on the, 339 ; diseasee of the, 557 ; rules for diagnosis of, 557 Circulatory organs, auscultation of, 70 ; sounds elicited by, in health and disease, 71 ; modifi- cations of healthy sounds of, 72 ; new or abnor- mal sounds in, 73 Cirrhosis of liver, cases of, 514 ; pathology of, 516 ; treatment of, 517 Clinical course, mode of conducting, 6 ; micro- scope of Dr. Beale, 80 Climate, therapeutic uses of, 325 ; influenc of in phthisis, 746 ; in producing fatty liver, 512 Clothing, therapeutic uses of, 327 Cod-liver oil in tuberculosis, 184 ; as a nutrient, 321 ; as increasing molecular elements, 336 ; introduced as a remedy for phthisis by the author, 744 ; mode of action, 745 ; in favus, 864 INDEX. 1015 Colchicum in scarlatina, 959 Cold, therapeutic uses of, 326 ; action of en the nervous system, 454 ; in inflammation, 176; in cephalalgia, 327 ; in fever, 946 Collapse of lung, 653 College of Physicians of Edinburgh, its sale of licenses, 17 Collier’s lung, 756 ; pathology and treatment of, 758 Colloid cancer, 232 Colostrum of human female, 90 Complemental nutrition, 135 Compression and pressure, distinction between, 149 Concretions, 272 ; albuminous, 273 ; fatty, 273 ; biliary, 274 ; pigmentary, 274 ; mineral, 275 ; urinary, 275 ; renal, 276 ; vesical, 276 ; prosta- tic, 278 ; hairy, 279 ; vegetable fibrous, 280 ; intestinal, 280 ; amyloid and amylaceous, 282 Condylomata, 212 Congelation a true ansesthetic, 454 Congestion preceding inflammation, 155 ; of the right side of .the heart, bleeding useful in, 317, 711 Congestive disorders of the nervous system, 450 Conium. See Hemlock Constipation, causes and treatment of, 525 Contagion, defini*tion of, 953 Contractility defined, 148 Convulsion, definition of, 353, 448 Cord, spinal, cases of structural diseases of the, 427 ; pathology of, 438 ; functions of the, 144 ; functional disorders of the, 448 Corns, 210; causes of, 210 Corpuscles of the blood, 91 ; in thickened blood, haematocele, and cholera, 92; in leucocythemia, 93, 871 ; relation between the colored and colorless, 882 ; origin of the, 884 ; ultimate destination of the, 890 Corpuscles, pus, appearance of in healthy pus, 94 ; in scrofulous pus, 94 Corpuscles, salivary, 88 ; tubercle, 95, 179 Corrosive sublimate, poisoning by, 496 Coryza, nature and treatment of, 652 Cough and expectoration in phthisis, treatment of, 749 Countenance, inspection of the, 36 Cracked-pot sound, 56 Cranium, amount of fluids within the, 148 ; views of Drs. Munro, Abercrombie, and Wat- son, 148 ; experiments of Bonders and Kellie, 149 ; observations of Dr. Burrows, 150 ; obser- vations of Dr. John Peid, 151 Curative action of remedies, 335 Cutaneous eruptions, microscopic examination of, 107 ; classification of, 828 ; diagnosis of, 831 ; treatment of, 836 ; on the scalp, 835 Cystic duct, occlusion of, 506 Cystic growths, 199 ; simple, 199 ; compound, 200 ; contents of, 200 ; hygromatous, 200 ; col- loid, 201 ; melicerous, 202 ; cholesteatomatous, 202 ; atheromatous, 203 ; hairy, 203 ; with teeth, 203 ; osseous, 204 ; cancerous, remark- able case of, 518 Cystine, microscopic appearance of, 105 Cystoma, 199 Debility in phthisis, treatment of, 753 Degeneration, albuminous, 246 ; general patho- logy find treatment of the, 252 ; colloid, 251 ; fibroid, of Handfield Jones, 247 Degeneration, fatty, 252 ; of cells, 253 ; of mus- cle, 254 : of blood-vessels, 256 ; of the placenta, 258 ; of Cartilage, 259 ; of bone, 259 ; of the exudations, 260 ; of morbid growths, 261 ; of the heart, 598 ; general pathology and treat- ment of, 261 Degeneration, mineral, 269 ; of blood-vessels, 269 ; of the exudations, 271 ; of nervous text- ure, 2” ) ; of morbid growths, 272 Degeneration, pigmentary, 262 : general patho- logy and treatment of, 2 J7 Degeneration, waxy, 249 Degenerations of texture, morbid, 24 i Deln’ium tremens, cases of, 455 ; pathology and treatment of, 457 Dermatophyta, diagnosis of, 833, 335. Sea Favus Dermatozoa, 853 Despondency and anxiety in phthisis, treatment of, 703 Determination of blood, theory refuted, 308 Diabetes Mellitus, cases of, 907 ; theories regard- ing the nature and treatment of, 909 Diagnosis, eftects of advanced knowledge o^ 287 Diagnosis, microscopic, of saliva, 88 ; ndlk, 90 ; blood, 92 ; pus, 93 ; sputum, 94 ; vomited mat- ters, 97 ; faeces, 99 ; uterine and vaginal dis- charges, 100 ; mucus, 102 ; dropsical fluids, 103 ; urine, 103 ; cutaneous eruptions and ulcers, 107 ; the knowledge derived from an improved, 297 Diagnosis, general, of cardiac diseases, rules for the, 557 ; of thoracic aneurisms, 630 ; ol abdominal aneurisms, 633 ; of pulmonary diseases, rules for, 637 ; of skin diseases, 831 ; of continued fevers, 931 Diarrhoea, cases of, 524; varieties and causes of, 525 ; pathology; of, 530 ; treatment of, 525 ; treatment of in children, 533 ; treatment of in phthisis, 751 Diastaltic or reflex movements, 147 ; classifica- tion of disorders, 451 Diet, irregularity in, the most common cause of disease, 126 ; causing scui’vy, 993 Dietetica, 320 Digestion, in the stomach and intestines, 127 ; kinds of, 131 ; disorders of, 472 ; pathology and treatment of derangements of, 475 Digestive system, examination of, 26 ; action ol medicines on the, 341 ; diseases of the, 466 Diphtheria, 968 Discharges, uterine and vaginal, microscopic examination of, 100 Disease, definition of, 114 ; natural progress of, 295 ; Bright’s, cases of, 801 ; cerebral, from obstruction of arteries, 390 ; general laws of nutrition in, 124 ; general law's of innervation in, 137 ; irregularity in diet the most common cause of, 126 ; importance of a knowledge of the causes of, 284 ; cause of recent changes in the treatment of, 284 ; of nutrition, 136 Diseases of the nervous system, 352 ; of the diges- tive system, 466 ; of the circulatory system, 547 ; of the respiratory system, 637 ; of the genito-urinary system, 763; of the integumen- tary system, 827 ; of the blood, 867 Drainage, as a cause of fevers, 943 Drinks, therapeutic uses of, 322 Dropsical fluids, microscopic examination of, 103 Dropsy, 246 ; general, 566, 784, 805 ; of the brain, case of, 424 ; of the pericardium, 560 ; of the chest, 579, 587 ; of the abdomen, 510, 514 Dropsy, ovarian, cases of, 763 ; pathology of, 775 ; diagnosis of, 779 ; treatment of, 780 ; pro- ducts found in fluid of, 103 Duodenum, perforating ulcer of, 789 Dyspepsia, cases of, 472 ; pathology, treatment and causes of, 475 Dysentery', cases of acute, 526 ; case of chronic, 527 ; pathology of, 530 ; treatment of, 533 Eclampsia, definition of, 449 Ecthyma, diagnosis of, 832 ; treatment of, 833 Eczema, diagnosis of, 832 ; treatment of, 837 Electricity, therapeutic uses of, Mi) Embolismus, 399 Emboli, in the brain, pathology of, 397 ; in the lung, 721 Emphysema, pathology of, 655 ; cases of, 654, 657 ; treatment of, 658 Emprosthotonos, definition of, 448 Empyema, cases of, 667 ; paracentesis for, 675 1016 INDEX. Encephaloma, 230 Enchondroma, 220 ; structure of, 221 ; diagnosis of, 222 Endocarditis, 575 Engorgement, bleeding useful in, 317, 711 Entozoon folliculorum, description of the, 845 Ephelis, diagnosis of, 833 ; treatment of, 840 Epilepsy, definition of, 353, 449 ; case of relieved by galvanism, 452 ; case of, from chronic cere- britis, 376 Epithelial growths, 210. See Epithelioma Epithelial, scales in saliva, 88 ; ulcer, 109 ; growths, 210 Epithelioma, 210 ; principal forms of, 210 ; struc- ture of, 213 ; of the lip and tongue, 213 ; of the lymphatic glands^ 214 ; of the urinary bladder, 215 ; pathology of, 236 Epithelium, fringe-like, 89 Epulis, 226 Eremacausis, 171 Ergot of rye in paraplegia, 434 Eruptions, cutaneous, microscopic examination of, 107 Erysipelas, cases, diagnosis, and treatment of, 961 Erythema, diagnosis of, 832 ; treatment of, 837 Ethics of medicine, 999 Examination of patient, 24; by interrogation, 24 ; by inspection, 36 ; by palpation, 43 ; by mensuration, 45 ; by succussion, 44 ; by per- cussion, 48 ; by auscultation, 63 Examination, post-mortem, 30 ; method and order of, 30 ; object of, 30 ; of external appear- ances, 31 ; of head, 31 ; of spinal column, 31 ; of neck, 31 ; of chest, 31 1 of abdomen, 32 ; of blood, 32 ; by microscopic examination, 32 ; hints for carrj ing out post-mortem examina- tion, 32 ; knowledge required for correct ex- amination, 33 ; necessary to determine the value of remedies, 627 ; Dr. Sibson’s “ Medi- cal Anatomjr,” 34 Exanthemata, definition of, 828 ; diagnosis of, 832 ; treatment of, 837 Excrescence, cauliflower, 213 Excretion of matters from the body, 133 ; amount of, 134 Exercise, therapeutic uses of, 323 Exophthalmia, case of, 384 Exostosis, 225 ; from poisoning with mercury, 978 Expectoration and cough in phthisis, treatment of, 749 Experience, past and present, in the treatment of inflammation, 304 Exudation, definition of the term, 162, note.; production of, 158 ; theory of, 159 ; cancerous, 235 ; tubercular, 181 ; death of the, 169 ; gen- eral treatment of, 176, 184 ; fatty degenera- tion of the, 260 ; mineral degeneration of the, 271 ; essential to inflammation, 303, 304 ; transformation of, in pneumonia, 689 ; in cerebritis, 387 ; in pericarditis, 174 ; in pleuri- tis, 665 ; seat of in dysentery, 532 Face, remarkable case of atrophy of, 155 Fatty concretions, 273 Fatty degeneration, 252 ; of cells, 253 ; of muscle, 25.4 ; of blood-vessels, 256 ; of the placenta, 258 ; of cartilage, 259 ; of bone, 259 ; of the exudations, 260 ; of morbid gi'owtbs, 261 ; of the brain, 354 ; of the liver, 512 ; of the cardiac valves, 597 ; of the heart, 598 ; of the kidney, 821 Fatty growths, 196 ; steatomatous and lipoma- tous, 197 ; fibro-lipomatous, 197 Favus crust, composition of, 108 Favus of the scalp, diagnosis of, 834 ; cases of, 847 ; history of favus as a vegetable parasite, 850 ; mode of development and sj-mptoms of, 850 ; causes of, 853 ; pathology of, 855 ; treat- ment of, 862; on the face of a mouse, 853, note Febricula, characters o£i 920 ; cases of, 92* Febrile symptoms in phthisis, treatment of, 732 Fern, male shield, as a vermifuge, 542 Fever, continued, changes of type in, 305, symptoms of, 918; forms and characters of, 920 ; diagnosis of, 931 ; morbid anatomy of the Edinburgh epidemic of, during 1816-7, 934; causes of, 942 ; treatment of, 945 Fever, intermittent, case of, 951 ; nature of, 952; treatment of, 952 Fever, relapsing, character of, 920 ; case of, 923 ; identical with the synocha of Cullen, 924 Fever, remittent, case of, 949 ; nature and treat- ment of, 950 Fever, therapeutic action of quinine in, 948 Fever, typhoid, character of, 920 ; cases ofi treated by quinine, 924 ; diagnosis of, 931 ; nature of, 937 ; morbid anatomy of, 934 etiology of, 937 Fever, typhus, character of, 920 ; case of, treat^J* by quinine, 927 ; cases of, treated withoirt quinine, 930 ; diagnosis of, 931 ; treatment ofj 945 Fevers, eruptive, 953 Fibres, molecular, 189 ; nuclear, 189 ; cell, 189 Fibrin, in the blood, 92 ; not altered by vene- section, 133 Fibroma, 188 Fibrous growths, 188 ; molecular, nuclear, and cell, 189 ; fibro-nucleated and fibro-cellular, 190 ; sarcomatous or soft, 191 ; dermoid or hard, 193 ; neuromatous, 195 Fistula, recto-vesical, 795 Fluctuation, examination of patient by, 44 Faeces, microscopic examination of, 99 ; in diar- rhoea, 525 ; in constipation, 526 ; characters of in disease, 530 Food, various kinds of, 125 ; circumstances regu- lating, 125 ; assimilation of the, 128 ; effects of bad assimilation, 136; effects of improper quantity or quality of, 154 ; therapeutic uses of, 320 ; in scorbutus, 993 Foramen ovale, enlarged, case of, 592 Force, attractive and selective, 131 Freckle, diagnosis of, 833 ; treatment of, 840 Functions, influence of derangement of one over another order of, 154 Functions of the body, influence of predominant ideas on the, 285 Fungus haematodes, 230 Fungus from a favus crust, 108 ; in the ear, 108 Gangrene, moist, 169 ; dry, 171 ; of the intes- tine, 535 ; of the lungs, 716 ; from obstruction of pulmonary artery, 721 ; of the kidney, 795 Gall-bladder, with gall-stones in, 504, 509 ; en- largement of, 506 Gall-stone, 273 ; case of impaction of, in com- mon bile-duct, 504 ; passage of into the gall- bladder, 506 Gastric glands, organic changes in, 493 Genito-urinary system, examination of, 27 ; action of medicines on the, 342 ; diseases of the, 762 Gland, thyroid, liability of to new formation of tissue, 208 ; enlargement of, in bronchocele, 251 Glands, mesenteric, liability of, to increased growth, 208 Gland, prostate, calculi found in the, 278 Glands, structure of blood-foiming, 886 Glandular grovdhs, 206 ; forms of, 207 ; structure of, 207 ; of the thyroid gland, 208 ; of the lymphatic glands, 208 ; causes of. 209 Glottis, cases of acute oedema of the, 642 Glycohaemia, cases of, 907 ; theories regarding the nature and treatment of, 909 ; treatment of by sugar, 912 ; tabulated cases of, with analysis, etc., 914 Gout, general pathology and treatment of, 982 case of chronic, 991 Granulations, formation and structure of, 168 INDEX. 1017 Granule cells, 167, 253 Granules and molecules, deposition of fatty, 253 Growths, morbid, 185 ; classification of, 187 ; ultimate elements of, 186 ; general pathology of, 233 ; origin of, 233 ; development of, 234 ; propagation of, 237 ; malignancy and non- malignancy of, 238; curability of, 239; Van der Kolk’s views of causes of propagation of, 241 ; decline or degeneration of, 242 ; general treatment of, 242 ; means of retardation and resolution of, 243 ; means of extirpation of, 243 ; necessity for microscopic examination of, 243 ; constitutional treatment of, 244 ; M. Velpeau on the permanent removal of, 245 ; fatty degeneration of, 261 ; mineral degenera- tion of, 271 Growths, morbid, of texture, 185 ; fibrous, 188 ; fatty, 196 ; cystic, 199 ; melicerous, 199 ; cho- lesteatomatous, 202 ; atheromatous, 203 ; glan- dular, 206 ; cartilaginous', 220 ; erectile, 218 ; steatomatous encysted, 202 ; epithelial, 210 ; vascular, 216 ; osseous, 225 ; myeloid, 226 ; cancerous, 229 ; distinction of cancerous from other, 229 Gruby’s pocket microscope, 79 Haematocele, appearance of altered blood cor- puscles in the fluid of an, 92 Haemoptysis in phthisis, treatment of, 751 Hairy, formations, 215 ; concretions, 279 Hammer, Dr. Winterich’s, 49 Head, post-mortem examination of, 31 Headache, definition of, 447 ; treatment of, 453 Headland, on the actions of medicines, reviewed, 333 Healing process, results of the, 185 Health and disease, general laws of nutrition in, 124 ; general laws of innervation in, 137 Heart, functional disorders of the, 600 ; treat- ment of, 601 Heart, rules for the diagnosis of diseases of the, 557 Heart, sounds of the, 71 ; percussion of the, 56 ; mechanical injuries of the valves of, 594 ; exu- dation into or on the surface of the valves of, 595 ; deposition of fibrin on the valves of, 597 ; degeneration of the valves of the, 597 ; fatty degeneration of the, 598; hypertrophy ot the, 598 ; inflammation of the substance of the, 599 Heart, valvular diseases of the, 575 ; cases of, 576 ; causes of, 594 ; pathology of, 594 ; treat- ment of, 599 ; dislocation of the, 677 Heat, source of animal, 35 ; therapeutic uses of, 326 Hemiplegia, definition of, 448 ; cases of, 392 ; pathology of, 418 ; treatment of, 420 Hemlock, case of poisoning by, 459 ; sjTnptoms of, 462 ; physiological action of, 463 ; death of Socrates by, 464 ; identity of ancient with modern, 464 Hemorrhage, cerebral, cases of, 400 ; predispos- ing cause of, 417 ; microscopic appearances of, 417 ; diagnosis of, 418 ; treatment of, 420 Hepatitis, case of, 497 Herpes, diagnosis of, 832 ; treatment of, 838 Hooping cough, 649 Homy productions, 216 Husband, Dr., his mode of preserving vaccine lymph, 966 Hutchinson’s spirometer, 48 Hydatid cyst of the liver cured, 522 Hydrocele, 200 Hydrocephalus, acute, cases of, 360 ; nature of, 364 ; treatment of, 365 Hydrocephalus, chronic, case of, 424 Hydro-pericardium, 560 ; pathology of, 570 ; treatment of, 573 Hydrophobia, definition of, 448 Hydrophone, 65 Hydro-thorax, 579, 587 Hygienica, 323 Hypertrophy, 186 ; of the liver, 510 ; of th« heart, 598 Hypnotism, 290 Hysteria, definition of, 448 ; treatment of, 454 Ichorhaemia, case of, 902 ; theories regarding the nature of, 904 Ichthyosis, diagnosis of, 833 ; treatment of, 840 Ideas, predominant, influence of, on the func- tions of the body, 284 Ileus, case of, 535 ; following ovariotomy, case of, 763 ; pathology of, 537 ; treatment of, 538 Illusions, spectral, cases of, 445, 455 ; theory o^ 290 Impetigo, diagnosis of, 832 ; treatment of, 838 Incompetency of aortic valves, cases of, 577 ; ol mitral valve, cases of, 579 ; of tricuspid valve, cases of, 587 Induration, 186 Infection, definition of, 953 ; purulent, 886 Inflammation, Andral’s opinion of the expres- sion, 160 Inflammation, 155 ; phenomena of, 155 ; theory of, 158 ; definitions of, 160 ; terminations of, 164 ; general treatment of, 176 ; fallacious character of past experience in the nature and diagnosis of, 303 ; unchangeable nature of, 305 ; natural progress of, 313 ; diminished employment of blood-letting in acute, 302 ; former reasons for bleeding erroneous, 306 ; cannot be cut short, 313 ; value of bleeding in, 315 ; effects of general and local blood-letting in, 309 ; character of the pulse as an indica- tion for blood-letting in, 312 ; real use of blood-letting in, 317 ; effects of mercurials in, 318 ; antiphlogistic practice injurious in, 318 ; blood-letting controversy in, 319. See also Exudation Influenza, nature and treatment of, 652 Innervation, general laws of, in health and dis- ease, 137 Innervation, function of, 137 ; influence of dis- ordered nutrition on, 154 Inoma, 187, 188 Insalivation, 126 Insanity, definition of, 447 Inspection, examination of patient by, 36 ; of the general posture, 36 ; of the countenance, 36 ; of the chest, 36 ; of the abdomen, 37 ; of the pharynx, 38 ; of the larynx, 39 ; of the posterior nares, 42 Integumentary system, action of medicines on the, 343 ; diseases of the, 872 Integumentary system, examination of, 27 Intestinal concretions, 280 Intestine, case of obstruction of the large, 534 Intestines, percussion of, 60 ; diseases of the, 524 ; condition of, in typhoid fever, 935 Intestine, small, case of strangulation and per- foration of, from inguinal hernia, 535 Iritis, case of rheumatic, 990 Irritation, spinal, definition of, 448 Itch, insect, description and treatment of the, 842 Jaundice, cases of, 498, 504, 506, 509 Kamala, as a vermifuge, 545 Keloid growths, case cf, 973 Kidney, perenssion of the, 61 ; waxy degenera- tion of the, 249 ; calculi in the, 275 ; inflam- mation of the, 782 ; abscess in the, 791 ; scrof- ulous abscesses in, 793 ; calculous inflamma- tion and gangrene of, 795 ; chronic inflamma- tion of, and cystic, 797 ; origins of cystic dis- ease of the, 799 ; Bright’s disease of the, 801 ; remarkable case of Bright’s disease of the, recovering under the influence of super-tait- rate of potash, 805 ; atrophied, 817. See Bright’s disease, also Nephritis Laryngismus stridulus, 651 1018 INDEX. Laryngitis, cases of, 638 ; method of applying topical remedies in, 640 ; symptoms of, 642 ; diagnosis of, 647 ; treatment of, 648 Laryngitis, syphilitic, case of, 972 Laryngoscope, 39 Larynx, inspection of the, 39 ; appearance of in health, 40 ; in disease, 41 Lead, case of poisoning with, 464 ; treatment of, 465 Lenses, objective, of microscopic, 81 Lentigo, diagnosis of, 833 ; treatment of, 840 Lepra tuberculosa, diagnosis of, 833 ; vulgaris, diagnosis of, 833 ; treatment of, 839 Leucocythemia, 867 ; definition of, 868 ; cases of, 868 ; pathology and treatment of, 880 ; dis- covery of, 892 ; appearance of blood in, 93 Lichen, diagnosis of, 833 ; treatment of, 839 Life, Bedard’s definition of, 114 Light, therapeutic uses of, 329 Lime, oxalate of, microscopic appearance of, 104 Lipoma, 197 Lithic acid calculi, 276 Liver, percussion of, 57 ; waxy degeneration of the, 240, 514 ; diseases of the, 497 ; case of acute congestion of the, 497 ; abscess of the, 501, 618 ; cases of enlargement of the, 510 ; fatty enlargement of the, 511 ; cirrhosis of the, 514 ; cancer of the, 518 ; nutmeg, 517 ; hyda- tid cyst of the, cured, 522 ; syphilitic deposits in, 503 Lungs, percussion of, 53 ; abscess of the, 713, 718 ; case of gangrene of the, 716 ; condition of, in typhus fever, 934 ; fistulous openings in, 667 ; partial atrophy of the, 791 ; compression of the, in empyema, 674 ; collapse of the, 653 ; oedema of the, 785 ; hgemorrhage into the, 579, 583 ; infiammation of the. See Pneumonia, and names of special diseases of the Lungs, cancer of the, case of, 754 ; foims, diag- nosis, and treatment of, 755 Lungs, carbonaceous, cases of, 756 ; nature and causes of, 758 ; treatment of, 762 Lupus, diagnosis of, 833 ; treatment of, 840 Lymph, plastic formation and structure of, 165 Lymphatics, inflammation of, 635 Maculae, definition of, 829 ; diagnosis of, 833 ; treatment of, 840 Magnesia, triple phosphate or ammonio-phos- phate of, microscopic appearance of, 104 Magnetism, animal, 287 Malignancy, in morbid growths, discussed, 237 Mamma, compound cystic sarcoma of, 200 ; cause of increased growth in, 209 Mastication, 126 Materia medica, 331 Medical bill which passed the legislature in 1858, 14 Medicine, relation of the science to the art of, 2 ; present state of practical, 20 ; principles of, 114 ; ethics of, 999 Medicines, curative actions of, 335 ; action of on the ultimate elements of the tissues, 336 ; action of, on the nervous system, 337 ; action of, on the respiratory system, 339 ; action of, on the circulatory system, 339 ; action of, on the digestive system, 341 ; action of, on the genito-ui inary system, 342 ; action of, on the integumentary system, 343 ; general theory of the action of, 344 Melanin, 267 Melanoma, 265 Meningitis, cerebral, cases of, 367 ; seat of, 370 ; microscopic examination of, 371 ; diagnosis of, 371 ; treatment of, 371 ; pathology of, 372 Meningitis, spinal, case of, 427 Menstrual discharge, microscopic appearance of, 100 Mensuration, examination of patient by, 45 Mentagia, diagnosis, of, 834 ; treatment of, 838 Mercurial poisoning, 971 ; of neuro-spinal func- tions, 453 ; in a dog, 978 Mercury, inutility of, in inflammations, 177, 318 ; in acute hydrocephalus, 366 ; in jaundice, 505 ; in pericarditis, 574 ; Graves’ extravagant praises of, opposed by facts, 575 ; injurious in syphilis, cases of, 971, 973 ; treatment of syphi- lis by, 980 ; not necessary in iritis, 991 Mesenteric artery, aneurism of, 620 Mesenteric glands, in typhoid fever, 936, 209 ; hypertrophy of, in leucocythemia, 868 Mesmeric mania of 1851, 294 Mesmerism, 285 Metallic tinkling, 69; in pneumo-thorax, 669, 671 ; cause of, 675 Micrometer, 84 Microscope, use of the, in examination of pati- ent, 75; Oberhaeuser’s, 77 ; Gruby’s compound pocket, 79 ; Beale’s clinical, 80 ; objective lenses of, 81 ; eye-piece, 82 ; methods of illu- mination, 82 ; test objects for the, 83 ; methods of mensuration and demonstration, 83 ; how to observe with a, 85 ; principal ap))lications of, to diagnosis, 87 ; necessity of employing, to determine the nature of cerebral and spinal softenings, 352 ; examination of the saliva, 88 ; milk, 89 ; blood, 91 ; pus, 93 ; sputum, 94 ; vomited matters, 97 ; faeces, 99 ; uterine and vaginal discharges, 100 ; mucus, 102 ; dropsical fluids, 103 ; urine, 103 ; cutaneous eruptions and ulcers, 107 Microscopic objects, physical characters which distinguish, 85 Milk, microscopic examination of, 89 Mind, evolution of the power of, dependent on the hemispherical ganglion, facts in proof of, 139 Mineral substances essential to nutrition, 125 Mineral degeneration, 269 ; of blood-vessels, 269 of nervous texture, 270 ; of the exudations, 271 ; of morbid growths, 272 Mineral concretions, 275 Mitral valve, cases of disease of, 579 Molecules and granules, deposition of fatty, 253 ; basis of the tissues, 119 ; agency of, in genera- tion, 120 ; in nutrition, 121 Molecular theory, of organisation, 115 ; of the author, 118 ; opposed to that of the cell patho- logists, 121 ; the basis of the arts of horticul- ture, agi’icultiu’c, and medicine, 123 ; well il- lustrated, 135 ; importance in therapeutics, 351 Moles, diagnosis of, 833 Molluscum contagiosum, 201 ; diagnosis of, 833 Mono-ideism, note, 292 Moore’s test for sugar in urine. 111 Morbid growths, 185. See Growths Mortification, or moist gangrene, 169 Motion, contractile, diastaltic, and voluntary, 147 Motions, irregnlar, definition of, 448 Mouth, diseases of the, 466 Movements, contractile, diastaltic or reflex, and voluntary, 147 Mucus, gelatinous, structure of, from os uteri, 100 ; microscopic examination of, 101 Muscle, fatty degeneration of, 254 Mugnet, minute structure of exudation in, 89 Murmurs, laryngeal and tracheal, 67; bronchial, 67 ; vesicular respiratory, 67 ; cavernous, 68 ; amphoric, 68 ; sonorous, 69 ; dry vibrating, 69 ; sibilous, 69 ; bellows, 73 ; exocardial and endo- cardial, 73 ; pericardial or friction, 73 ; val- vular or vibrating, 73 ; musical, in heart, 73, 583 Muscular sense, 143 Myelitis, acute case of, 428 ; chronic cases of, 432 Myocarditis, 599 Nsert, diagnosis of, 833 ; treatment of, 840 Nares, posterior, inspection of, 42 Nausea and vomiting, treatment of in phthisis, 750 Neck, post-mortem examination of, 31 ^ Nephritis, acute, cases of, 782 ; desquamative, INDEX. 1019 785 ; haemorrhagic, 787 ; scrofulous, 793 ; cal- culous, 795 ; chronic, 797 Nerves of special sense, definitions of irritation of, 449 Nerves, structure and fxinctions of, 145 ; gan- glionic system of, 146 Nervous system, examination of, 26; general anatomy and physiology of the, 138 ; structure and arrangement of the, 138 ; reflex and dias- taltic actions of, 139 ; functions of the brain, 139 ; functions of spinal cord, 144 ; general pathology of, 148 ; eftects of stimuli or disease on the functions of the, 152 ; influence of rapid and slow lesions of, on symptoms, 153 ; in- fluence of seat of disease on nature of pheno- mena, 152 ; production of similar phenomena in various lesions and injuries of the, 153 ; in- fluence of, on nutrition, 154 Nervous system, diseases of the, 352 Nervous system, functions of the, 139 ; action of mediciues on the, 337 ; functional disorders of the, 445 ; classification of, 447 ; pathology of, 449 ; causes of, 450 ; treatment of, 453 ; case of, 445 ; congestive disorders of the, 450 ; dia- staltic or reflex disorders of the, 451 ; toxic dis- orders of the, 452 Nervous texture, mineral degeneration of, 370 Nervous trunks, effects of direct mechanical in- jury on, 154 Neuralgia, deflnition of, 449 ; from cancer of cranial bones, 441 ; treatment of, 445 Neural disorders, classification of, 449 Neuroma, 191, 195 Neuro-spinal disorders, classification of, 449 Nihilismus, 23 Noli me tangere, 213 Noma, 171 Nutrition, complemental, 307 Nutrition, general laws of, in health and disease, 124 Nutrition, function of, 124 ; division of process into five stages, 125 ; introduction of appro- priate alimentary matters, 125 ; formation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs, 128 ; pas- sage of fluid from the blood to be transformed into tissues, 130 ; disappearance of transformed tissues, and their re-absorption into the blood, 131 ; excretion of these effete matters from the body, 133 Nutrition, importance of albumen, oil, and mineral substances in the process of, 125 Nutrition, diseases of, 136 ; causes of, 137 ; prin- ciple of treatment of, 137 Nutrition, disordered, influence of, on innerva- tion, 154 Oberhaeuser’s microscope for medical men, 77 Obesity, 196 ; case of, 907 Oidema, of the brain, 356 ; of subarachnoid cel- lular tissue, case of, 380 ; of the legs, from cirrhosis, 527 ; from cardiac disease, 587 ; of the glottis, 642 ; of the lungs, 785 ; from albu- minuria, 802 G£gophony, 69 (Esophagus, case of stricture of from epithelioma, 467 ; cancer of, 384, 470, 518 Oil and albumen, importance of in the process of nutrition, 125 Oligocythemia, 902 Opisthotonos, definition of, 448 Opium, case of poisoning by, 458 Organs, circulatory, auscultation of, 70 ; sounds elicited by, iu health and disease, 71 ; modifi- cations of healthy, sounds, 72 ; new or abnor- mal sounds, 73 Organs, natural position of, 33 ; displacement of, remarkable cases of, 35, 674 Organs, pulmonary, auscultation, 66 ; sounds produced by, 66 ; circulatory, auscultation of, 70 ; sounds produce'd by, 71 ; abdominal, aus- cultation of, 73 Osseous growths, 225 ; seats of, 225 ; myeloid, 226 ; new, 227 ; in the eye and other textures, 227 Osteochondrophytes of Cruveilhier, 221 Osteoma, 225 Osteoma, cystic, of femur and tibia, 204 Osteo-sarcoma, 191, 222 ; observations of Goodsir and Eedfem on, 223 Otorrhcea, 427 Ovarian dropsy, cases of, 763 ; pathology of, 775 ; diagnosis of, 779 ; treatment of, 780 Ovariotomy, case, 763 Oxalic acid, poisoning by, 495 Oxalui’ia, cases of, 473 Painters’ colic, case of, 464 Palpation, examination of patient by, 43 ; of aneurisms, 630 Palpitations of the heart, causes and treatment of, 600 Pancreas, cases of cancer of, 489, 509 ; Bernard’s views of the functions of, 510 Papilloma, 211 Papulae, definition of, 829 ; diagnosis of, 833 ; treatment of, 839 Paracentesis capitis, 425; thoracis, 671; abdo- minis, 764 Paralysis, definition of, 353 ; cases of, 386, 428 ; definition of local, 449 ; of abducens oculi and auditory nerves, 386 Paraplegia, definition of, 448 ; cases of, 430 ; cause and treatment of, 436 Parasites, animal, 842 ; vegetable, 847 Pathology, effects of advanced knowledge of, 297 Patient, method of examination of, 25 ; circula- tory system, 26 ; respiratory system, 26 ; ner- vous system, 26 ; digestive system, 26 ; genito- urinary system, 27 ; integumentary system, 27 ; antecedent history, 27 ; hints for carrying out examination, 28 Patient, examination of by inspection, 36 ; by mensuration, 45 ; by fluctuation, 44 ; by pal- pation, 43 ; by percussion, 48 ; by auscultation, 63 ; use of microscope in examination of, 75 ; use of chemical tests in examination of. 111 Pectoriloquy, 67 Pemphigus, diagnosis of, 832 ; treatment of, 838 Percussion, examination of patient by, 48 ; dif- ferent sounds produced by, 50 ; sense of resist- ance produced by, 51 ; general rules for prac- tice of mediate, 51 Percussion of particular organs, special rules for, 53 ; of lungs, 53 ; of heart, 56 ; of liver, 57 ; of spleen, 59 ; of stomach and intestines, 60 ; of kidneys, 61 ; of bladder, 62 ; of aneur- isms, 630 Percussion hammer, utility of, 49 Perforation of the stomach, cases of, 483 ; of the duodenum, 789 ; of the intestine, from hernia, 535 Pericarditis, changes which take place in the exudation of, 174 ; cases of, 559 ; pathology of, 570; diagnosis of, 571; complication of, 573 ; treatment of, 573 Peritonitis, cases of, 545 ; acute, 545 ; tubercular, 549 ; cancer of abdominal organs, resembling, 551 ; cancerous, 554 Pertussis, 649 Pharyngitis, case of follicular, 467 Pharynx, diseases of the, 466 ; inspection of the, 38 Phlebitis of left iliac vein, 634 Phlcbolites, 194 Phosphorus, in spinal diseases, 433 Phthisis of colliers, appearance of sputum in, 97, 266 ; cases of, 756 ; nature and causes of, 758 ; treatment of, 762 Phthisis pulmonalis, cases of, 722 ; natural pro- gress of, tendency to ulceration, and modes of arrestment of, 733 ; pathology and general treatment of, 741 ; indications for the treat- ment of, 742 ; cod-liver oil as a remedy for, 744 ; value of microscopic examination of 1020 INDEX. sputum in, 95 ; special treatment of, 749 ; cough and expectoration, 749 ; loss of appetite, 750 ; nausea and vomiting, 750 ; diarrhoea, 751; haemoptysis, 751 ; sweating, 751 ; febrile sjanp- toms, 752 ; debility, 753; despondency and anxiety, 753 Picrotoxine, effects of, 453 Pigmentary degeneration, 262 ; general patho- logy and treatment of 267 ; concretions, 274 Pigment, formation and varieties of, 262 ; causes of, 267 Pityriasis, diagnosis of, 833 ; treatment of, 840 ; parasitic, cases of, 864 Piorry’s pleximeter, 49 Placenta, fatty degeneration of the, 258 Pleuritis, cases of, 660; pathology, diagnosis, and treatment of, 664 ; cluonic cases of, 663 Pleurosthotonos, definition of, 448 Pleximeter of M . Piorry, 49 Pneumonia, acute, microscopic appearance of sputmn in, 96, changes which take place in, 173 ; natural progress of a, 316 ; treatment by bleeding, 692 ; results of antiphlogistic treat- ment of, 693 ; results of dietetic ti-eatment of, 694 ; results of treatment by large doses of tartar emetic, 694 ; results of mixed treatment, 695 ; results of restorative treatment directed to further the natui'al progress of the disease, 696; bleeding, a palliative m, 711; cases of, 678 ; a table of 129 cases of, 698 ; diagnostic value of the absence of chlorides from the urine in, 686 ; general pathology and treat- ment of acute, 692 ; chronic cases of, 713 Pneumo-thorax, cases of, 669 ; remarkable death in a case of, 671 ; metallic tinkling in, 675 Poisoning by alcohol, 455 ; by opium, 458 ; by hemlock, 459 ; by lead, 464 ; by oxalic acid, 495 ; by sulphuric acid, 496 ; by corrosive sub- limate, 496 ; by aconite, 628 ; by meremy, 971. Polycythcemia, 902 Polydipsia, cases of, 995 Polypus, soft, 193 ; hard, 194 ; in the heart, 590 Polysarcia, 997 Porrigo, definition and varieties of, 835 Post-mortem examination,30 ; method and order of, 30 ; hints for carrying out, 32 ; knowledge required for, 33 Posture of patient, inspection of, 36 Pisesystolic murmur, 585, 586 Pressure and compression, distinction between, 149 Probang, method of using, in laryngitis, 640 Prostatic concretions, 278 Prurigo, diagnosis of, 833 ; treatment of, 839 Psoriasis, diagnosis of, 833 ; treatment of, 839 Psychologists, their mode of studying insanity, 142 Pulmonary organs, special rules for auscultation of, 66 ; sounds produced by, 66 Pulmonary diseases, injections of the bronchi in, 658 ; case of, 657 Pulmonary artery, varicose aneurism of, 608 Pulse, characters of, 26 ; as an indication for bleeding, 312 Purgatives, use of, in intestinal disease, 526 Purpura, diagnosis of, 833 ; treatment of, 840 Pus, microscopic examination of, 93, 166 ; forma- tion of, in pneumonia, 173 ; scrofulous, micro- scopic appearance of, 94, 166 ; efi'ects of mix- ture, with the blood, 904 ; injection of, into the blood, 906 Pustulae, definition of, 828 ; diagnosis of, 832 ; treatment of, 838 Pyaemia, case of, 902 ; theories regarding the nature of, 904 Pyelitis, cases of, 782 Pyi’osis, 479 Quain’s stethometer, 45 Quinine in continued fever, therapeutic action of, 948 ; in intermittent fever, 952 ; in hectic fever, 753 Rammollissement. See Softening Battles, moist, 68 Recto-vesical fistula, case of, 79 Remedies, indications for the use of, 297. Se# Medicines Renal calculi, 257 Resolution, 173 Resonance, vocal, 66 Respiration, motions of chest during, 36 Respiration natural and exaggerated, 66; puerile, 67 ; alterations of, 67 ; function of, 129 ; Dr. E. Smith’s experiments in, 129 ; effects of, on the blood, 129 Respiratory sounds, 66 ; alterations in natural, 67 ; new or abnormal sounds of, 68 Respiratory system, examination of, 26 ; action of medicines on the, 339 ; diseases of the, 637 ; rules for the diagnosis of, 637 Rest, therapeutic uses of, 324 Reticulum of cancer, 260 Rheumatism, general pathology and treatment of, 982 ; treatment of, by nitrate of potash, 984 ; treatment of, by lemon-juice, 988 ; dia- phragmatic case of, 989 Rhinoscope, 42 Ringworm, 841 Roseola, diagnosis of, 832 ; treatment of, 837 Rupia, diagnosis of, 832 ; treatment of, 839 Saliva, microscopic examination of, 88 ; function of, 126 Sanguification, 128 Sarcina ventriculi, 98 Sarcoma, 191 ; cystic, 205 : compound cystic, of the mamma, 200 ; osteo, 191, 222 Scabies, diagnosis of, 832 ; treatment of, 838 Scalp diseases, treatment of, 840 Scarlatina, cases of, 954 ; diagnosis and treat- ment of, 955 ; colchicum in, 959 ; bodies found in urine in a case of, 108 Scirrhus, 229 Scorbutus, cases of, 993 ; epidemic of, in Edin- burgh, 993 ; observations of Dr. Christison and Dr. Lonsdale on, 994 ; Dr. Garrod on, 995 Scrofula. See Tuberculosis Scrofulous pus-cells, 94, 166 Sectio cadaveris, method and order of, 30 ; object of, 31 ; external appearances, 31 ; head, 31 ; spinal column, 31 ; neck, 31 ; chest, 31 ; abdo- men, 32 ; blood, 32 ; hints fc».- canying out post-mortem examination, 32 ; knowledge re- quired for correct examination, 33 Sensation, definition of, 147 Sensibility, definition of, 148 Sibson, Dr., his “ Medical Anatomy,” 34 ; his chest-measurer, 46 Silver-, nitrate of, action and use of, in laryngitis, 639 Skin diseases, classification of, 828 ; definitions of, 828 ; diagnosis, 831 ; varieties of, 834 ; treatment of, 836 ; scaly diseases of, 211 ; treat- ment of, 839 ; treatment of syphilitic diseases of the, 841 Small-pox, cases of, 962 ; general treatment of, 963 ; cctrotic treatment of, 963 ; greater fre- quency of, 965 ; relation of, to varicella, 968 ; identical with cow-pox, 968 Socrates, his death by taking hemlock, 463 Softening, cerebral and spinal, pathology of, 353 ; exudative or inflammatoiy, 354 ; hemorrhagic, 355 ; fatty, 355 ; serous or dropsical, 356 ; mechanical, 356 ; putrefactive, 357 ; necessity for microscopic examination of, 359 ; cases of, 359 ; cerebral cases of, 380 ; spinal cases of, 434 Solanoma, 222 Sounds produced by percussion, 50 ; elicited over lungs, 53 ; produced by pulmonary organs, 66 ; cracked-pot, 56 ; alterations of natural, 67 ; abnoi-mal, 68 ; rubbing or friction, 68 ; relative value of in auscultation, 70 ; of the circulatory organs, 71 ; diagnostic of diseases of the cir- 1 culatory system, 557 ; of aneurisms, 631 ; diag- INDEX. 1021 nostic of diseases of the respiratory system, 637 Spasm, definition of, 353, 448 ; of the jaw, case of, 408 Spermatocele, appearance of spermatozoids in fluid of, 103 Spinal column, post-mortem examination of, 31 Spinal cord, structure and functions of, 144 Spinal softening, pathology of, 353 ; origins and varieties of, 354 ; necessity for microscopic examination of, 359 ; cases of, 434 Spinal irritation, definition of, 448 Spinal disorders, classification of functional, 448 Spirometer of Mr. Hutchinson, 48 Spleen, percussion of, 59 ; waxy degeneration of the, 249 ; hypertrophy of, in leucocythemia, 868, 881 ; morbid anatomy of, in fever, 934 Sputum, microscopic examination of, 94 ; value of microscopic examination of, 95; microscopic appearance of in acute pneumonia, 102 ; ap- pearance of in black phthisis of colliers, 97, 267 ; elastic tissue in, 96 Squamae, definition of, 829 ; diagnosis of, 823 ; treatment of, 839 Starvation, symptoms of, 154 Steatoma, 197, 203 Stetho-goniometer, of Dr. Scott Alison, 48 Stethometer of Dr. Quain, 45 Stethoscope, 63 ; hints for choice of, 64 ; Can- man’s, 64 ; diJfferential, of Dr. Scott Alison, 64; flexible, 64 Stomach, percussion of, 60 ; hairy concretions in the, 279 ; functional disorders of the, 472 ; or- ganic diseases of the, 481 ; ulceration of the, cases of, 481 ; perforation, cases of, 483 ; fre- quency of ulceration in, 488 ; symptoms and treatment of ulcers in, 489 ; cases of cancer of the, 489 ; structural changes in glands of, 493 ; remarkable cases of emphysema of the co^s of, 671 Stramonium, action of, 453 Stricture, 186 ; of intestine, 534, 535, 763 Strychnine, action of, 453 Succussion, examination of patient by, 44 Sugar in urine, detection of. 111 ; trial of in the treatment of diabetes, 913 Sulphuric acid, poisoning by, 496 Supra-renal capsules, Dr. Addison’s views of, 264 ; case of disease of, without bronzing of skin, 714 Sweating in phthisis, treatment of, 751 Syphilis, cases of, 971; observations on, 974 ; symptoms of, 974 ; diagnosis of, 975 ; propaga- tion of, 976 ; pathology of, 977 ; treatment of, 980 Syphilitic diseases of the skin, treatment of, 841; deposits in the liver, 503 System, nervous, general anatomy and physio- logy of, 138 ; general pathology of, 148 Taenia solium, origin and development of the, 539 ; cases of, 542 ; treatment of, 544 Tape-worm. See Taenia solium Temperature of fevers, 933 Tests, chemical, use of in examination of pa- tient, 110 Tetanus, definition of, 448 Therapeutics, general, 284 ; recent changes in, 12 ; as aft'ected by the influence of the mind, 284 ; by the natural progress of disease, 295 ; by an improved diagnosis and pathology, 297 ; by the diminished employment of bloodletting and antiphlogistics, 302 ; of the dietetica, 320 ; of the hygienica, 323 ; of the materia medica, 331 Thermometric observations in fevers, 933 Thoracentesis, 675 Thorax, inspection of, 36 ; mensuration of, 45 ; motions of during respiration, 36 ; post-mor- tem examination of, 31 ; view of viscera in, 34 Thrombosis, 399 Tissues, structural relations of, 119 ; formation and sustentatlon of, by the blood, 130 ; attrac- tive and selective property of the, 131 ; re- absorption of transformed tissues into the blood, 131 ; action of remedies on the ultimate, 336 Texture, morbid degenerations of, 245 ; morbid growths of, 185 Tonsillitis, 466 Toxic disorders of the nervous system, 452 ; treatment of, 455 Trance, definition of, 448 Tracheotomy, in laryngitis, 643 Treatment, an inquiry into our present means of, 320. See Therapeutics Tricuspid valve, cases of disease of, 587 Trismus, definition of, 448 Trommer’s test for sugar in urine, 111 Tubercle, definition of, 179 ; forms of, 179 ; mi- nute structure of, 179 ; corpuscles, 95, 179 ; chemical composition of, 181 ; pathology of, 181 Tubercula, definition of, 829 ; diagnosis of, 833 ; treatment of, 840 Tuberculosis, 179; general pathology of, 181, 741 ; natural progress of, 182 ; general treat- ment of, 183, 741. See Phthisis Tumeur h6teradenique of M. Robin, 208 Tumors, classification of, 187 ; fibrous, 188 ; sar- comatous or soft fibrous, 191 ; dermoid or hard fibrous, 193 ; neuromatous fibrous, 195 ; fatty, 196 ; fibro-lipomatous, 197 ; cystic, 1'99 ; simple cystic, 199 ; compound cystic, 200 ; osseo-cystic, 204 ; glandular, 206 ; epithelial, 210 ; horny, 216 ; aneurismal, 217 ; cases of, 601 ; erectile, 218; varicose, 218; enchondromatous, 220; osseous, 225 ; myeloid, 226 ; cancerous, 229 Typhus and typhcdd fevers. See Fever. Ulcer, cancerous, of skin, microscopic appear- ance of, 109 ; cutaneous, microscopic examina- tion of, 108 ; of tonsil, case of, 466 ; of oesopha- gus, 468 ; of stomach, 481 ; of duodenum, 789 ; of intestine, 535 ; typhoid, 935 Ulceration, 172 University (Scotland) Bill, 15 Uric acid, microscopic appearance of, 105 Urinary concretions, 275 Urine, microscopic examination of, 103 ; specific gravity of, 110; detection of albumen in, 110; detection of bile in, 110 ; detection of bile acids in. 111; of leucin andtyrozin in, 111; detection of sugar in. 111 ; detection of chlo- rides in, 112 ; diagnostic value of the absence of chlorides from the, in pneumonia, 686 ; exa- mination of in Bright’s disease, 823 ; various kinds of casts in, 824 Urticaria, diagnosis of, 832 ; treatment of, 837 Uterine discharges, microscopic examination of, 100 Uterus, appearance of cancerous juice from the, 101 ; fibrous structure of the, 189 ; fatty degen- eration of, after delivery, 256 Yaccination, mode of, 966 ; Dr. "Wier’s scarifica- tor for, 966 Yaginal discharges, microscopic examination 100 Valsalva’s treatment of aneurism, 626 Valves of the heart, diseases of, 575 Van der Kolk’s observations on phthisical spu- tum, 95 ; views as to the propagation of cancer, 241 Varicella identical with small-pox, 968 Varicose aneurism, between vena cava and aorta, 217 ; case of communicating with the pulmonary artery, 608 ; signs of, 610 ; patho- logy and treatment of, 511 Variola, cases of, 962 ; treatment of, 963 ; obser- vations upon, 965. See Small-pox Varix, 218 Vascular growths, 216 ; aneurismal, 217 ; erec- tile, 218 ; varicose, 218 ; of new vessels, 218 Vegetation, dendritic, 215 1022 INDEX. Velpeau on the propagation of cancer, 239, 242 ; his letter on the results ef excision of cancers, 245 V enesection. See hloo d-letting Ventilation, 326 Vermifuge remedies, 542 ; male shield fern, 544 ; kamala, 544 Verruca achrocordon, 107, 212 Vesical calculi, 276 V" esiculse, definition of, 828 ; diagnosis of, 832 ; treatment of, 837 Vessels, auscultation of the large, 74 ■V illi, formation of, in pericarditis, 175 V ocal resonance, 67 Voluntary motion, 148 Vomited matters, microscopic examination ol; 9 / Vomiting and nausea in phthisis, treatment oJ^ 750 > "Warts, 211 Waxy degeneration, 249 Weir’s vaccinating instrument, 966 Winterich’s percussion hammer, 49 Woorari, effects of, 453 Worms, intestinal, 539 ; varieties in man, 543 Zymosis, definition of the term, 953 . ;■■■ ' i;-, (■ r ; ? . i i ti. ■fe K % ( * ff. V ' ?■_ • 'O y: I /■ -'r- f