:'■ V i^* Ulxfcfi'*- « :T Aff nf? < it~ v •^,."- fek^. Ty ..-.:^*4 { *'-''*»«••• ' l ■ • • «- f 1 ;^°i is kr-4'- /■41-v.*, ^* rTjrj-.* ;,i*m * y ^. .-r* . ' ') MEMOIR OF JAMES JACKSON, Jr., M. D. WITH EXTRACTS FROM HIS LETTERS TO HIS FATHER; AND MEDICAL CASES, COLLECTED BY HIM. By JAMES JACKSON, M. D. Hi Professor of the Theory and Practice of Physic in Harvard Uriiversity; and Physician of the Massachusetts General Hospital. <% Jvl t\ '~>r BOSTON: PRINTED BY I. R. BUTTS. 1835. VJ-2L \ oo .18*35 TO P. CH. A. LOUIS, M. D., OF PARIS, Who was regarded by the subject of this Memoir as a second father, not with more admiration than filial respect and affec- tion ; — and TO FRANCIS BOOTT, M. D., OF LONDON, Whose bright mind and pure and elevated virtues inspired the most ardent and sincere love in his young friend; — The two men, to whom, among many, he felt most indebted whilst in Europe ; — With the respect and gratitude, which under such circum- stances, a father must feel, this Memoir is respectfully and affectionately dedicated by JAMES JACKSON. Boston, April 15, 1835. MEMOIR OF JAMES JACKSON, Jr., M. D. MEMOIR OF JAMES JACKSON, Jr. The following pages contain a memoir of the life oS my late son, James Jackson, Junior, M. D., with extracts Srom his letters and a selection from the medical cases collected by him, principally in Paris. I have been induced to print these cases by the solicitation of those, who knew how he had collected them. I have been induced to write the memoir in conse- quence of the suggestion oS those who knew something oS him and whose opinions I respect. In some points the task has been grateSul to me; sad, though it may seem, Sor a Sather. I thank God that I have been able to maintain my cheerSulness and to attend to the common occupations oS liSe since the de- plorable loss, which I suffered in his departure Srom this world. But every hour has he been in my mind. In every occupa- tion, in almost every conversation, however little others could see the connection, his image has been before me. It has been a beautiful image and has not checked any pleasure, nor even any gaiety, in which 1 thought that he could have joined. Under any circumstances I might seem an improper person to give his history, and my statements may be deemed scarcely worthy of credit. Who will believe that I shall be impartial ? 4 I can say however that I would not willingly be guilty of exaggeration, iS it were only from a respect to the love of truth, which formed the most distinguishing trait in his character. He loved me as few sons love their fathers. Of this I have had ample and constant proofs. But he loved truth better, and would not subscribe to any opinion because it was mine, though he was quite willing, in his conduct, to submit to my direction and control. But, if I draw a Sancy picture, while I design to paint the character oSmy son, if that presents a young man who devoted his time most assiduously to the acquisition of useful knowledge, who cultivated at the same time his best moral affections and acted from the highest love of virtue, and who thereby secured the friendship of the wise and good, the fiction at least may have some good influence on the young and inexperienced. At least it may lead them to reflect on the immutable connex- ion between virtue and happiness. The subject of this story was not indeed rewarded by long life. But in this age will it be maintained that long life is the greatest of blessings? This is a topic, on which I shall not enlarge; but I will only say for myself, which I -do most sin- cerely, that I would not have added a year to my son's life by an habitual and allowed indulgence in a single vice. The history of my son's life is very simple and it may be told very briefly. He was born on the 15th January, 1810, was graduated at the University in Cambridge in 1828, and then engaged in the study of medicine. This he did under my direction and as my pupil. He continued as such till the April of 1831, and during this time he attended the medical lectures of our University and saw the practice of the Massachusetts General Hospital. In the spring, 1831, he went to Paris, where 5 he arrived in May, and remained till July, 1833, except during a visit of six months to Great Britain and Ireland in the spring and summer of 1832. He reached home at the end of the summer, 1833, and was graduated as Doctor of Medicine in our University in February, 1834. He was now prepared to engage in practice, and took rooms for himself in Franklin-Place. He was thus brought to the starting place of active life, and under circumstances the most flattering and the most grateful, when he was arrested in his course. Exactly at this point he was arrested. His arrangements being made, he sent an ad- vertisement to the public papers, which appeared on the 5th of March, and on that day he was taken sick so as to lodge at my house instead oS occupying the rooms, which he had just announced as his residence. This sickness was his last, and he died on the 27th oS the same month, being in his 25th year. Thus cutoff before he had yet been tried in the serious busi- ness of life, and having passed his brieS course without encoun- tering any of the trials, to which many men are subjected, it would seem that his story could hardly afford any details of in- terest except to his own family. And yet he did excite an in- terest during his life in very many friends, abroad as well as at home, and that of the warmest kind; and his loss has been deeply mourned by those, whom I never saw, and to whom he was recommended only by his own conduct. There must then have been something in him to have excited this interest, which I shall call deep and ardent, disregarding the imputation to which I subject myself of a blind partiality. This something was in his character. If he is to be commemorated it should be by delineating that character ; and while doing this I shall be led to detail, though it may not be in exact order, the events of his life as illustrating it. Any friend in pursuing this course would be thought liable to run into eulogy instead of giving a 6 true description oS the subject oS his discourse • a fond Sather must certainly be subject to this suspicion. Those who know the truth in this case must decide whether this suspicion is jus- tified by what follows. I may however premise that I shall not attempt to write coldly, while I shall endeavor to keep in mind that my business is not to display my own feelings to- ward the beloved subject of my discourse, but to draw a picture of one whose features are more perfectly engraved on my mind than on that of any one else. From his earliest age my son always manifested great cheer- fulness of temper and gaiety of heart, so that he was never long depressed by trouble of any kind. He was always ready to sympathize with those about him, and he loved to engage their sympathy in return. He was not contented without constant action, except when engaged in study or other occupation. These characteristics are common enough in boyhood, and did not distinguish him among his fellows at that stage of life. It was by myselS only perhaps that his indomitable gaiety oS heart was then noticed; though I also remarked, very early, that his mind was capable oS being engaged in the most solemn subjects. From these characteristics he was often boisterous and annoying to those about him, but he was so good-humored they could not long be angry with him. He had very little ambition to gain distinction, or to be a leader among his com- rades, but delighted to join in their sports on terms of equality, as anxious that they should be pleased as to have his share of the sport. He was agreeable to his young friends without be- ing distinguished among them. His schoolmaster loved him ; but had to punish him continually for the sin of laughing, of which he could not break him however. He would strive at times to get a high rank in his class to please me, for he always loved me most ardently; but he seemed not otherwise to value 7 the distinction. Once, when a little boy, he had kept at the head of his class for two or three days, and then a younger boy got above him. I reproached him for permitting this. But he said, with great naivete, that the other boy " ought to be at the head sometimes." I hardly gave him credit at the moment for this generous wish for the gratification of his rival, but his com- panions in later life will agree with me in believing that it was the result of that interest in the happiness of others, which he manifested more and more strongly as long as he lived. In college his ready sympathy led him at first into the com- pany of those, who were most gay, and for a few months he joined in their pleasures. At the end of six months the ex- cellent president gave me warning that my son had become in- timate with those, whose company was the most dangerous. This would have caused me great distress but that, happily, my son had recently given me the same information and had told me that he had discovered his danger; in fact, as soon as he perceived the vices of his associates, he no longer sympa- thized with them; he had broken with them. It was so; and his connexion was never afterwards renewed with them, nor with those who were like them. He now happily formed an intimacy with one who encouraged all his virtuous aspirations, and he began to cultivate, upon principle, a purity of heart, of which the fruits were forming in all his subsequent life. He was not led into habits, nor into any feelings of austerity. Gaiety he could not dismiss; it was ever springing up in him. He was guilty of imprudences like others. But he constantly studied his duty, he cultivated more and more the best princi- ples of action, and from year to year his standard of excellence was placed higher and higher. He never attained a distin- guished rank in his class by an exact attention to his collegiate duties, a circumstance which I do not mention in commenda- 8 tion. Yet without my knowledge, until long afterwards, he established for himself certain rules of action and habits of in- dustrious study, from which he seldom deviated subsequently, and was really storing his mind with valuable knowledge. I was not aware of his industry, though I thought that I watched him closely, till he had left the college. He did not tell me of it, though he was very open and ingenuous in telling me his feelings and his errors. When he began the study of medicine under my eye, he gave himself to it with an energy and indus- try that surprised me. I thought at the moment that he was resolved to make up for past negligences, but that his zeal would probably soon abate. I did not yet understand him. Subsequently my only apprehension was Srom his too great de- votion to his studies, which constantly went on increasing. I presumed that the temptations to pleasure in Europe would draw him off Srom laborious study quite enough; but not so; there, even more than here, he spent his strength, without reserve, in his professional pursuits; though he meant to keep himself within the limits of safety. The only temptation, which he could not at all resist, was that furnished by the in- valuable opportunities, there offered to him, for the increase of useSul knowledge. When he went abroad his reading on professional subjects had been so extensive and his habits of observation so well formed, that I thought him fully prepared to avail himself of the advantages he might derive from the excellent schools of Paris, London and Edinburgh. I dared not then say so even in my own family, for I feared the evil consequences of too much praise; but I regarded his acquisitions as very extraor- dinary for a student of his standing, and therefore let him go at an earlier period than that at which I commonly advise young men to take the same step. Those who are acquainted 9 with medical literature will believe that I did not overrate his diligence aSter considering the Sollowing statement. Before the termination of the second year of his pupilage he went through the Epistles of Morgagni on the seats and causes of diseases, as translated by Alexander, in three thick quarto volumes. He took notes of what he read, and as he went on compared with it the invaluable work of Baillie on morbid anatomy, another quarto, with the plates accompanying it. This he did indeed in the quiet of the country, but he took proper time for exercise, and did not seem to me more indus- trious than at other periods. He however completed the whole in seven weeks. Nor did he read this work, as a task, without possessing himself of its contents. He read it with great interest; and he fixed in his mind so many of its details, that by the aid of his short notes he was able to refer to it afterwards. Thus I find in his early autopsies in Paris, which he entered in his common-place book, many references in the margin to cases in this great store-house of post-mortem researches. Indeed I have not been acquainted with any one, who was so intimate with the details of this work, as he was. Immedi- ately after this, and before his second year of medical studies was terminated, he wrote a long dissertation on pneumonia, in doing which he consulted all the writings on the subject which he could get at, both those expressly on it and those which embraced it with other subjects in systematic works. This dis- sertation gained him the Boylston medical prize Srom a com- mittee, among the members oS which was Dr. Ware. Dr. Ware spoke to me oS this work at the time in terms of great commendation, and I conSess that, wrhen I read it, I was SearSul that it would be supposed I had rendered assistance in the preparation oS it, which in such a case would have been im- proper. But in Sact I had only pointed out the sources oS in- 2 10 Sormation and had made some general remarks on the subject, as I should in conversation with any pupil. I was aware that he was writing on the subject, but thought at the time it was only an exercise as a member of the Boylston medical society, not a dissertation for a prize. I have stated these things as examples oS his industry. I may add, that in the period oS his medical studies, beSore he went to Europe, scarcely two years and a halS, iS I deduct the time employed on journeys, he had read a very large propor- tion of all the valuable English standard works on medicine, and very many oS the French, Srequently and careSully con- sulting older works in other languages when referred to, espe- cially when Sacts were concerned. At the same time he had engaged as Sully as most others in dissection in its proper sea- son ; he had attended the hospital most punctually except in the summer season; he had seen much oS disease elsewhere, particularly at the House oS Industry, where Dr. Fisher was then physician, and Srequently invited him when there was anything particularly interesting ; and he took notes oS lectures and oS everything which came under his observation, especially oS the autopsies which he attended, so that he had covered twelve hundred Solio pages oS his common-place books, when he leSt home. It was thus prepared he went to Paris, there to take care oS himselS when just past twenty-one years oS age. Thus Sar, except two or three journeys, he had lived in a limited circle under the eyes and care oS his Sriends. At college, even, he resided principally in a private Samily oS the first respectabil- ity, and oS the greatest moral worth, where he had been treat- ed as a child and a Sriend, and had been allured by kindness to submit to wholesome restraints and to the Sriendly warnings of wisdom and experience. I could not dismiss one so inexpress- II ibly dear to me without anxiety, though satisfied that it was wise that he should go. The Sollowing extracts will show something oS the state oS his mind, and oS my own. They will bring beSore the reader the true Seelings and principles which then reigned in his heart, and iS I may write about him at all, I see not why I may not produce them. extract from my letter to him, APRIL 9, 1831. " Hook Sorward with sanguine hopes of benefit from the op- portunities you will have. I feel satisfied that you will not omit to avail yourself of them. It is this hope of benefit to you which reconciles me to your absence, for I have already begun to look to you as my most interesting companion for the remainder of my days. As to the hazards to which you are exposed, I certainly do not disregard them; yet I shall not allow a regard to them to make me unhappy. At least, I think so now. There is a risk of life, — and it would indeed alter the aspect of my future days, if I did not hope to have you by my side and to leave you behind me in this world. But this is the smallest risk by far. Whether we pass a few short years together in this world is comparatively of little con- sequence. Whether we meet in a better world is of immea- surable importance. This depends on ourselves ; — on the strict regard to morality which we both maintain ; — a mo- rality in Dr. Holyoke's sense, which includes piety, — a regard to our Maker, as well as to ourselves and fellow-men. Now I am not insensible to the temptations, to which young and old are exposed in Paris and London. I can think of them till I tremble. But ray trembling is stilled by the confidence I place in you. This confidence is sincere and strong. It is not un- 12 limited, but it is as great as it can be in any young man. I know that your fondness Sor society, arising Srom the best Seel- ings, is very strong; but I Seel assured that you know how to control it, — and that your principles are strong and oS the best kind. I shall not thereSore allow myselS to be anxious ; and it is more to tell you this than to insinuate any cautions, that I have been led into this long statement oS my views and Seel- ings. In temptation, I think you will first think oS home, — and then cast your eyes higher, — to the home we all ulti- mately hope Sor, and to the Father who is better than any earth- ly parent. I reSerred to the dangers oS society ; — I wish to add that among men oS the world, and I may say such gentle- men as a traveller meets, there is a sort of presumption con- veyed in conversation, that no one Seels bound very strictly by the rules oS morality. Now one need not turn knight-errant, nor missionary, to beat down the obnoxious principles thus in- directly maintained. But, on the other hand, I have never Sound any society, in which I needed to remain, in which a gentleman was bound to assent to such principles, — or in which he might not declare his dissent Srom them, when he was compelled to speak oS them directly. In short, a man never loses, but almost always gains with the worst men, by pursuing an honorable and virtuous course. The share of reputation, which you have yourself gained, while leading a quiet and you may almost say, a secluded life, shows you that a man gains reputation fully in proportion to his merits. Some persons must see your course, — and by them, even while they do not think of doing so, it is published and fixes your charac- ter. Not that a regard to character is the highest motive to action, but I was led to speak of it in another view, viz.; that a regard to it in the eyes of those about you, need not lead you to make sacrifices to their vices and follies.'3 13 The letter from which the foregoing extract is made, reach- ed my son in New-York, on his arrival there, after sailing upon the Hudson, and visiting the Trenton Falls. In his reply, of which the greater part follows, he refers to the scenes, in which his mind had been delightfully engaged. "New-York, April 15, 1831. " my dear father, -- " My heart beats, and my eyes fill, and my hopes are bright- ened, and my resolutions are strengthened, as I advance in reading your kind letter of affection and advice. Be assured I will nat neglect the opportunities which I am about to enjoy. My constant prayer is to God, that he will give me strength, moral and mental, to improve them to the utmost. I have already, sometime since, said to you that, were it not that I may with every reason expect to be in your society and under your guidance again on my return, I would on no account visit Europe. I feel and know that my oppor- tunities for improvement during any two years, which 1 shall be absent, would be much greater at home than any I can ob- tain abroad ;—but both have their peculiar advantages, and trusting in the mercy and providence oS God, who has already poured upon me so many blessings, I Seel a confident hope that I may enjoy both without Soregoing either. You next speak, my dear Sather, oS the temptations abroad to young men. I, too, can and do think, and have oStentimes thought oSthem, till I tremble. I Seel myselS to be weak, weaker than I should be. I am not phlegmatic ; — I have not yet learned to be master oS myselS;— I am yet, too oSten, much too often, the slave oS circumstances. I Seel that this is to be the toil and study oS my liSe, to become master oS 14 myself. I am learning each day, more and more, that it is the education of the immortal part, which should and must de- mand man's most serious and untiring attention. I begin to Seel too that it is his highest happiness to cultivate it. I see the difficulties with which I must contend, and I Seel deeply conscious oS my moral weakness ; — but again I Seel a sort of confidence in remembering that the Creator has given to man strength to resist all moral evil, and in hoping and praying that he will enable me to exert it. The Suture, with all, especially with a young man, is uncertain; — but Sor all that is important it is in our hands ; — an awSul responsibility, indeed, but yet ennobling and encouraging. One thought is most cheering, — we may depend upon it with security, — in the right conduct oSthe Suture, we have the certain aid and assistance oS our all- powerful and benevolent Father, who will point us to the right path and safely conduct us over it, however rugged, if we will but open our eyes to see, and our hearts to accept, instead of blindly refusing his kind offers. My dear Sather, this is no affectation; — it is no unmeaning rhapsody; — my mind Sor some time has been becoming more and more convinced of the essential importance of these subjects, and I promise you the last week has not been spent in vain ; — not only has my mind been improving; — my heart, too, is better for what I have seen ; — it is good for me to have been the spectator of these majestic works of the Deity in the natural world around us. My heart has been warmed with a sense of his benevo- lence, and my mind opened anew and more strongly, to a con- viction oS his power and greatness. In anticipating my Suture career in liSe, my mind is filled with what ? I can tell you, Sor I have spent much time during the last three months, in a serious consideration oS the subject, and Seel that I have arrived at somewhat more definite views than 15 I had previously entertained. I would divide all the objects oS my aim and efforts into two classes, — the essentials and the desireables ; — and in a Sew words they are these. Among the first, are a moral character, in the Sullest acceptation oS the term; or in other words a liSe oS virtue, so spent as shall be acceptable to God, and render me fit to enjoy the blessings oS the virtuous ; an honorable and useSul exercise oS my profes- sion; — these two will perhaps include the only remaining essential, viz. such a situation in society, as to property, re- spectability, and so Sorth, as every young man brought up, as I have been, Seels it his duty to expect and provide Sor. Among the second, I would reckon the pleasures oS social life, a handsome and independent property, and a high profess- ion a reputation. The time has been, and that not very long since, when I looked upon this last as the most important of all. But I am now wiser. I have not ceased to value this ab- stractedly as much as before ; but its relative place among the objects of my desire is changed,— I trust irrevocably changed. One word more on this subject, and 1 have done. You say it is rather to express your confidence in my principles, than to insinuate any cautions, that you have written me so fully on this subject. Trust not too much in my principles. At this moment they are as firm and as virtuous as I could wish; but I have told you that I am weak, and have yet to learn the severe lesson of self-denial. For your own comfort and happiness believe me strong if you will ; but for my good, believe me weak. It is my sincere wish and desire, I may almost say command, (for in such matters the child may com- mand the parent,) that you will often remind me in your letters of the temptations to which I am exposed, and the incentives to avoid them. Do not think that I am writing words which mean nothing. It had been my intention for some weeks past 16 to write you, before I left the country, on this very subject; to request your direct and constant aid in the preservation and improvement of my moral character. I hope that you will read and understand this request literally; as much so as any I ever made for a book to improve my mind, or a dollar to clothe my body. One duty yet remains, — a cheerful and a pleasant one, and yet one which I can perSorm but too inade- quately ; —it is to express my gratitude to you ; to express to you all that I feel would be impossible ; — perhaps also it would be unnecessary, as you must know it already. Jt might have been expressed more Sully, and most becomingly in the actions oS my past life ; but it has not been. No mode is now left me, but by words and my future conduct. No words that I can use, can ever exhibit to you my real feelings ; and for my future conduct 1 fear, yet hope. The duties of a parent to his child, which your approving conscience must tell you in more audible tones than I can utter, have been by you most strictly exercised, call for a correspondent gratitude Srom the child, none the less because they are the duties oS his parent. But in my ca^e, there is something more than this. Though I love to dwell upon the relation, which exists between us, and the circumstances and scenes and events, which have arisen Srom that relation ; yet I have sometimes taken another view oS the subject. I have considered the relation oS parent and child as adventitious or accidental; — I have looked upon you and myselS as two beings whom God had placed upon this earth, and whom accident had brought together ; I have then thought oS how much I was indebted to you Sor all the princi- ples and knowledge and powers that I possess ;—but, my dear Sather, I will stop. You see what is in my mind, — I have been writing you, till I am getting too much excited ; — but it is a holy excitement, and will do me good. My prayer is to 17 God, that we may meet again in this world, —but I know it is uncertain, — my prayer and efforts too are and shall be, that my life may be so spent as to meet you in another world, if not in this, which may God in his infinite mercy grant." It is easy for a young man to make promises in any situa- tion. We all know how uncertain must be the strength of his resolution when brought to trial. I certainly should not have given these extracts, if I did not believe that my son's conduct abroad was in full accordance with the promises implied in them. That he was always wise and discreet is not to be presumed. But, if all who knew him did not combine to de- ceive me, and if, also, evidences of every kind, which I could examine, were not fallacious, bis life was such, when out of my sight, as it had been at home; — marked by moral purity, as well as by incessant industry. The abundant testimonials of his industry which I now possess, specimens of which are in the following pages, show that he had not time to engage in those pernicious indulgences which too often engross young men in the cities oS Europe. Indeed, I would not intimate that he was singular in this respect. I gladly avail myselS oS the occasion to state that the medical students Srom this coun- try, with very rare exceptions, are too much occupied with their proSessional studies, when in Paris or London, to allow much time to the ruinous pleasures of those great cities. This may perhaps be Sairly attributed to the very interesting character oS those studies. In Paris my son attended principally in three hospitals, viz.; La Pitie, St. Louis, and that Sor sick children, (Hopital des 3 18 Enfans Malades.) In the first of these he saw the practice of M. Louis and M. Andral, and heard their clinical lectures. It was here he spent most oS his time. In the second, (St. Louis,) he attended to diseases oS the skin and to the lectures of M. Biett. It was not possible for him to give time Sor a Sre- quent attendance at the Hopital des Enfans Malades, at the regular hours, without omitting his visits at La Pitie. He was, however, so fortunate as to obtain permission to go with the internal, or house-pupil of that hospital in his evening visit. He was thus able, no other pupil being present, to examine more minutely the numerous cases there collected, than he could have done in any other way. The liberality oS the French government, Sor it is by the national government that the hospitals are maintained, permits Soreigners to join their own pupils in attendance on their hos- pitals without any See. The liberal feelings oS the physicians and surgeons oS those hospitals lead them in like manner to give instruction to all, who will attend to it, without any pecu- niary reward. OS the privileges thus granted my son partook with others. He had not any special introduction to the med- ical gentlemen on whom he attended. But he received Srom them not merely favors, but such substantial services, that I am bound to acknowledge them in giving this account oS his life. I mean, however, also to adduce the services thus rendered him, as the evidence oS impartial witnesses in prooS oS his merit as their pupil. 1 reSer particularly to M. Louis and M. Andral. By the latter he was treated not only with civilities, to which a common stranger could have no claim, but he was indulged in the Savor oS Sree intercourse at once most natterinc and most useSul Srom such a source. I can scarcely describe with how much reverence Sor the genius oS this eloquent pro- Sessor, and with how much gratitude these Savors were received. 19 By the former, M. Louis, he was distinguished so peculiarly, that I shall take the liberty to print two oS M. Louis's letters to me, least I be suspected oS exaggeration. There grew up between them a Sriendship of no common kind. M. Louis treated him with as much kindness and confidence as he could have shown to a son; and James felt toward him an affection second only to that which he experienced toward myself. The acquaintance commenced by very flattering attentions from M. Louis, to his young pupil, at a period, when even his name was probably unknown to his master. This gave my son confidence in addressing him. Subsequently with two excel- lent friends from Philadelphia, he requested from M. Louis, private instructions on auscultation and percussion. They offered compensation for the time and trouble, which he would bestow on them. The compensation was not such as could have been an inducement to M. Louis, yet he complied in- stantly with their request. They had not dared to promise themselves this success, and had almost feared that he would regard them as too presumptuous. They were transported with the prospect before them, and still more with the excel- lent instruction which they obtained in consequence of it. Soon after this, the epidemic cholera appeared in Paris. The part which my son took at this time, I shall state more dis- tinctly by itself; but at present I refer to this period as the time, in which the acquaintance of my son with both his great masters, became more intimate. When he left Paris, aSter having studied this disease, at the end oS April, 1832, M. Louis maniSested a regard Sor him in terms the most grateSul and most flattering. Venerating him, as my son now did, his aS- Sectionate heart knew not how to respond to so much kindness. On his return to Paris, in the Sollowing autumn, he at once was admitted to the Sull Sriendship oS his master, and, while he 20 remained with him, their intercourse was of the most confiden- tial character; and to the pupil was most instructive. I must now be permitted to give the letters beSore men- tioned, to show that I have not exaggerated the Savorable opinion of M. Louis toward my son. TRANSLATION OF LETTERS FROM M. LOUIS TO DR. JACKSON. " SIR, MY RESPECTED BROTHER,-- " I have received with gratitude the letter you did me the honor to write me in regard to your son and his memoir upon cholera. I give you special and hearty thanks for having af- Sorded me so good an occasion to speak of one, toward whom I entertain sentiments of real friendship as well as of esteem. It did not require much time for me Jo appreciate fully the sagacity and talent, which your son possesses, in the observa- tion of nature. I had remarked these characteristics in him, beSore I knew who he was. Soon afterwards, learning that he would ere long return to Boston, I pointed out to him the ad- vantage it would be for science and Sor himself, if he would devote several years exclusively to the observation of diseases. I now retain the same opinion and am strengthened in it; for the more I become acquainted with, and the more I notice him applying himselS to observation, the more am I persuaded that he is fitted to render real service to science, — to promote its progress. I find that he would be well pleased to follow for a certain period the vocation, Sor which nature has fitted him; but he has stated to me that there are many difficulties, which would prevent his devoting himselS exclusively to observation Sor several years. But can these difficulties be insurmountable ? 21 Must we compel ourselves to believe that a man, whom nature has peculiarly qualified for observation, cannot be permitted to exercise the peculiar talents bestowed on him. For my own part I cannot admit the belief; I hope and trust that the diffi- culties, of which Mr. Jackson has spoken, will disappear. Let us suppose that he should pass four more years without engaging in the practice of medicine, what a mass of positive knowledge will he have acquired ! How many important re- sults will he have been able to publish to the world during that period ! After that he must necessarily become one of the bright lights of his country ; others will resort to him for instruction, and he will be able to impart it with distinguished honor to himself. If all things be duly weighed, it will ap- pear that he will soon redeem the four years, which men of superficial views will believe him to have lost. It is with the utmost seriousness, sir, that I write to you thus. It would not be without the deepest conviction of the advan- tages of the plan I propose, that I should offer my advice on a subject, on which I have not been consulted. It is not for the sake of making to a parent some grateful remarks about his son, that 1 have pointed out to you how much may, in my opinion, be hoped Srom the talents Sor observation, which belong to Mr. Jackson ; but simply to render homage to truth. Excuse me then Sor the step I have ventured to take, and believe that, iS I had not felt that I had in this case a duty to fulfil, I should not have offered to you my advice, nor address- ed to you my petition ; for it is rather a petition I have ad- dressed to you, than advice that I have given you. How could I venture to do the latter ? Nevertheless in reading over my letter, it seems to me to betray the tone of an advocate who is pleading a cause ; and I would willingly begin it anew, were I not afraid that Srom 22 my deep conviction of the truth of what I have stated, I should relapse into the same fault. Accept it then, sir, such as it is, with indulgence, and believe that no one here is more sincerely attached to your son, or entertains for him a higher esteem than myself. Above all, listen to the suggestions, which I have ventured to make ; and may my wishes that your son may devote himselS exclusively to observation be ul- timately realized; Sor it is to that point I constantly return. I conclude by renewing to you my thanks, and beg you to be assured oS the sentiments, &tc. (Signed,) Louis." Paris, October 28, 1832." " SIR, MY RESPECTED BROTHER,-- " I thank you most sincerely Sor your last letter and particu- larly Sor the details into which you were kind enough to enter with regard to your son. Nothing certainly could be more grateSul to my feelings ; Sor it is almost a mark oS affection for myselS, and I Seel almost worthy oS it Srom the strength oS that, which I bear to your excellent son. He will soon leave us ; but his name will long be mentioned among us, and I hope that the ocean, which is to separate us, will not be a complete barrier to our intercourse. I Seel more than any one else how much you must long to see as soon as possible a son, whose proSession is the same as your own, and with whom it will be so delightSul to you to converse respecting it. Indeed, I never thought oS inducing you to leave him with us in Europe Sor Sour or five years. I love in Mr. Jackson the man and the physician ; but he is a son, and you are a Sather ; and though I have never known the delights oS paternal affection, I should not have regarded 23 as possible the sacrifice which you understood me to propose to you. My only wish was that you should allow your son to devote himself exclusively to observation, for several years in Boston. I recommended this to you, because no one is more capable than he is of cultivating science and consequently of promoting the progress of practice. For what is practice but science brought into daily use ? Think for a moment, sir, of the situation in which we phy- sicians are placed. We have no legislative chambers to enact laws for us. We are our own lawgivers ; or rather we must discover the laws, on which our profession rests. We must discover them and not invent them ; for the laws of nature are not to be invented. And who is to discover these laws ? Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who knows how few minds are fitted for it, and how few have at once the talents and inclination requisite for the task ? The inclination espe- cially ; for this requires that the observer should possess a thorough regard for truth, and a certain elevation of mind, or rather of character, which we rarely meet with. All this is united in your son. You ought, for in my opinion it is a duty, you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours also. I know very well that every one will not be of the same opinion ; but what matters it, if it be yours ; if you look upon a physician, as I do, as holding a sacred office, which demands greater sac- rifices than are to be made in any other profession. Believe me that I do not forget in all this the force of es- tablished usages. I think of all this ; but I am none the less convinced that Mr. Jackson, entering into practice after three or four years, with the esteem of all his professional brethren, 24 and surrounded as it were with their respect, will very rapidly regain all which he may have sacrificed and much more* At all events my best wishes and those of all his friends here, will follow him, whatever may be his course ; and I shall always esteem myself happy in having known him. Permit me, sir, to assure you of this, and of the sentiments of respect and af- fection, with which I am, he. (Signed,) Louis." Paris, March 22, 1833." To the foregoing letters, I might add others, not only from M. Louis, but from other gentlemen in Europe, addressed to me aSter my son's death. But, while 1 am extremely grateSul Sor the kind sympathy they manifest toward me, and have felt assured by them, that my partiality has not led me to a very extravagant estimate of the loss I have suffered, I cannot think it necessary to add any further testimony to that which I have given above. The period of the epidemic cholera in Paris was one of the greatest interest and oS the greatest anxiety to the subject oS this memoir. Until the end oS the winter 1831-2, the ac- counts which we had received in this country oS the cholera in Europe, were oS the most alarming character. We knew that, arising many years previously in the hot climates oS Asia, this deadly malady had passed in a north-west direction into the coldest regions oS Europe, and was thence extending itself over that quarter oS the globe. Why it thus spread, and whether it was propagated by contagion, many persons were ready to decide upon general principles; but precise Sacts, on * See note A. 25 which to form a decision, were not yet Surnished. One thing was certain, that it affected great numbers, wherever it went, and proved fatal to a large proportion of those affected. Re- garding my son as comparatively without friends in a foreign country, not then knowing the kind feelings already entertained for him by those most capable of taking care of him, I wrote to him urgently to fly before this plague, and even to leave Europe, should the disease invade at once France and Great Britain. Such letters, and such only had he received on this subject, when the disease appeared in Paris, on the last days of March. It had already been introduced into England, but had there been comparatively limited in its extension. In Paris, it extended at once to very large numbers, and assumed within one week the most terrific aspect; such as to excite within that short period the most outrageous mobs, under a belief that the poorer classes had been designedly poisoned. On the sudden outbreak of this most alarming disease, my son's mind was exercised in a distressing manner. The following extract from his letter of April 8th, which will be given in full among his letters, will describe his feelings, and give the re- sult to which he was brought in this dilemma. " I almost weep to write you again from Paris. It is now the first moment of my life, that 1 have been placed between two duties, each strong, each binding, and where my difficulty is to decide which is the most so. But I have decided, — as I know, against your wishes. God grant that circumstances may be such that you shall soon accord with me, when the time is passed. A medical man has his duties; — I am a boy in medicine ; — granted. But I am like the other Americans here about me. An opportunity is offered us of studying a disease, which will probably visit our hitherto untouched coun- try. Were the disease about you, would you fly ? You 4 26 could not, for the public would look to you. You would not, for your sense oS duty would prevent you. I am, in a mea- sure, in the same condition." The moment was a SearSul one, most assuredly. The mor- tality in Paris rose to eight hundred a day within three weeks from the first appearance oS the disease. It was in the Hotel Dieu my son first saw the victims oS it in any number, and the emphatic words in which he described it were nearly the same, as were oSten used by others. " The disease is death ;" he said, " truly, at Hotel Dieu, where I have seen SiSty and more in a ward, it is almost like walking through an autopsy room ; in many, nothing but the act oS respiration shows that liSe still exists. It is truly awSul." At a meeting oS the Academy of Medicine, on the evening of 3d of April, cholera was the subject of discussion, and va- rious suggestions and opinions were offered by men of sanguine characters. My son followed M. Andral on his leaving this meeting, and asked permission to visit the hospital (la Pitie,) at that hour, with the view of seeing any new cases which might have been admitted. M. Andral kindly took him into his cabriolet and gave him every facility. " Our conversa- tion," says my son, " turned naturally upon the cholera, and turning to me with a certain nod of his head, which is pecu- liar to him, and to me very significant, for I know that it is a thinking head which nods, —' I am deeply interested,' said he, ' my mind is totally occupied by this subject; but as yet I see nothing which is not vague ; — but I shall go to work upon it, and I indulge the hope oS arriving at some valuable results.' This is not his exact language, but it is the idea ; — and that idea inspired me; it seemed as iS he had imparted to me a new Seeling; I may call it a new besoin, so essential have I since Sound and still find it to satisSy and to yield to it." 27 James's resolution was fixed and he Selt only an ardor to study this plague under his excellent masters at la Pitie, hop- ing he might make his knowledge useSul in his own country, iS that also should be invaded by the universal epidemic. Accordingly he devoted his whole heart and mind to this study during the month oS April, only taking the precaution to lodge in a healthy part of the city, to be cautious in his diet, and to take regular exercise in the open air. He pursued the plan of his master Louis in taking down with minuteness and fidelity the cases, which came under his observation, and the results ascertained by dissection in the fatal cases. This labor occu- pied his whole time ; he almost lived in the hospital. At the end of a month he took his papers to London and there ar- ranged them. He made a copy of sixty of the most perfect of them, of which thirty were favorable and thirty fatal in their termination. From these he made the deductions which they afforded; and this required an exact analysis of each case. To this analysis he added the few reflections, which he thought to be fully authorized by the facts, but restrained himselS Srom engaging in any speculations on the subject. This was a re- straint, to which at his age he would not have submitted, had he not been Sully imbued with the rigid, philosophical princi- ples oS his master Louis. At the end oS May and first oS June he sent to me the papers thus prepared, in two parcels. Coming by private hands I did not get them all till the first of August. ASter obtaining the advice oS a judicious Sriend I de- termined to publish them, Sor my son had leSt it to me to do so or not. I am willing now to reSer to them in support oS the praise, which I have ventured to give to my own son. The only object oS the book was to throw light on the pathology, or strictly to give the natural history oS the disease and to draw such inferences as the Sacts afforded. On the treatment he 28 would not venture to offer any thing, except indeed that the disease had not thus far been influenced by remedies. The book was published here, when the public had begun to be tired of reading the numerous pamphlets upon it, with which the press teemed for three months. On this account it did not attract so much attention as it would have done otherwise. Besides, it promised no aid as to the treatment, in which the public were naturally and properly most interested. But, for its purpose, I might beg that it should now be compared with any other work on the same subject, which has been published any where. This is strong language and I should not be thus bold perhaps, if I claimed for my son all the merit of the work. I did and do give to him great credit, but the materials were gathered under the guidance of, and in part directly from his masters at la Pitie, to whom I have so often referred. While he was engaged on this work in London he made some acquaintances there, and acquaintances of the most valu- able character. Though he went from this country without letters to medical men in Paris, the friendship of distinguished physicians there had furnished him with a flattering introduc- tion to medical men in London and Edinburgh. In London also he was received, almost at once, by my friend Dr. Boott, on whose character, and kindness to my son I shall refrain from making the remarks, which my heart dictates. Thus was my son enabled to gain access to whatever was valuable in that city both then and in his subsequent visit in the autumn. But it was not only by an intercourse with professional men that he was benefited. Far greater was the advantage, which was afforded to his mind and his heart, from an introduction to a select circle by the gentleman whom I have just named. In France he had studied the external world only, under the best of masters indeed, and men whose whole conduct evinced the 29 excellence oS their hearts as well as the depth oS their science, and their holy devotion to truth. But in London he was re- Sreshed by being brought into domestic society and among peo- ple oS the greatest refinement, whose minds were engaged in the study and the elevation of the human character; — persons who were filled with philanthropy, and who took delight in Sostering all the best propensities oS his heart.* The hospital- ity oS England delighted him; and Sor a time he became ele- vated almost beyond himselS in the little paradise, in which he was placed. All his good and holy resolutions were strength- ened, and he learnt to view his proSession only as the means oS being useSul to his Sellow-men. The plan however, which he had laid out Sor himselS, was to spend a Sew weeks during the summer in Edinburgh, to make a brieS visit to Ireland, and to get back to London early in the autumn. Accordingly he tore himselS Srom the delightSul cir- cle, in which it had been his privilege to be admitted as a Sriend, and made a circuitous journey to Edinburgh, visiting many interesting places on his way. I am tempted to give here some extracts Srom his letters at this period, to show, not only his readiness to avail himselS oS opportunities Sor inSorma- tion, but also the excellent spirit oS those whom it was his hap- piness to meet. But enough will be Sound on this score in the letters which Sollow, under dates oS June, July and August, 1832. The letter oS June 30th especially, contains evidence oS the substantial hospitality, not that oS the table merely, which is shown by men oS science in Great Britain. In Edinburgh, as elsewhere, he was admitted to Sree inter- course by the most distinguished men, and had opened to him every source oS inSormation, oS which he could avail himselS in so short a visit. At Glasgow he stopped only to examine the * See note B. 30 famous museum of Dr. William Hunter. He walked over the highlands with a Sriend and Sellow-student Srom our own city; and read, with vastly increased delight, the Lady oS the Lake on the borders oS the lake itself. The cholera was in Edinburgh while he was there, and the treatment by saline injections was at that moment under trial. He had spent halS a day at London in conversation with Dr. Stevens on his peculiar opinions, physiological and pathologi- cal, those especially which had a bearing on the saline reme- dies ; and he was much indebted to that gentleman Sor his polite attentions. On his journey through England he had an opportunity oS learning something oS the trial oS these remedies. Although not sanguine in his expectations, he attended to the effects oS the saline injections in Edinburgh with the most ar- dent desire that they might be found useSul. But the result in his mind was the same, as I believe it has been in the minds of most of those, who made trial of this treatment of cholera in Europe and America. His letter of August 10th goes into some details on this subject, and in that and others there were many statements very interesting at the moment, but which I do not think worthy of publication at this time. In his visit to Dublin he was confirmed in the high opinion which he had formed oS the excellent spirit and high scientific attainments oS its physicians. There has arisen in that city within the present century a number oS talented and learned men, who have labored much to advance the science of medicine. Their labors have not been in vain, and their merit is acknowl- edged in all parts of the world; at least in all where the English language is spoken. My son derived great advantage from the museum oSthe College of Surgeons at Dublin, the value of which he thought greatly increased by a proper catalogue. He also praised very highly the excellent lying in hospital of that city. 31 Returning to London at the end oS August, he first indulged in the luxury oS visiting the Sriends, Srom whose society he had already derived so much pleasure and so much benefit; in which he Sound his Seelings and affections constantly purified and elevated. He then looked around for the means oS pur- suing his proSessional studies. He was in truth too Sar advanc- ed to find any adequate advantage in devoting his hours to regular courses oS elementary lectures, even though Srom most distinguished men. Surgery he did not meddle with; and the mode oS pursuing pathological researches in the London hos- pitals did not seem to him at all equal to those, which he had ; witnessed at la Pitie. It happened that the arrangements Sor the winter would not permit him to hear the clinical lec- tures oS those physicians, whom he would have been most pleased to attend. He Sound then those monuments oS indus- try and science, the anatomical museums oS London, to be the only objects, which in the actual state oS his mind and at his stage oS study, could repay him Sor delaying his return to Paris. He had beSore designed to revisit this city in the spring Sor a Sew weeks, aSter passing the winter in London. But he now decided that his winter could be spent most profitably in Paris. At once then he engaged in the study oS the excellent museum oS morbid anatomy at Guy's hospital, which owes its existence to Dr. Hodgkin. This most pure and philanthropic physician afforded him every possible assistance. My son examined each preparation careSully, inquiring minutely into the history of the subject Srom whom it was derived, and taking notes as he pro- ceeded, especially in cases where the whole history could be obtained. This study occupied him a Sortnight. He next visited the museum oS John Hunter, now belonging to the Royal College oS Surgeons oS London. Having learnt in the first year oS his medical studies to venerate the name of 32 the great author of this stupendous work, he went to it with the highest anticipations. His delight in seeing it was even greater than he had expected, and he thought that he derived great advantage as well as pleasure from his visits to it. But he saw that the advantage might have been much greater un- der more favorable circumstances. His remarks on this subject, or some of them, are given in his letters oS September, 1832. The want oS a catalogue, a want which is about to be supplied, made it impossible for him to study the preparations in a useSul manner, notwithstanding the excellence oS their scientific arrangement. I ought not perhaps to omit an acknowledgment oS, what he felt very strongly, the pleasure and profit he derived from an intercourse, in which he was indulged, with some eminent medical men in London; and I cannot omit to say that Sir Astley Cooper, one of the teachws on whom I myself attended more than thirty years before, was among them. But my son was so short a time in London that he could not acquire a very accurate knowledge of individuals there; and I do not deem it proper to quote his transient remarks on them, although these remarks were, Sor the most part, both respectSul and accom- panied by strong expressions of gratitude. On his return to Paris, about the 20th of October, my son engaged at once under the greatest advantages in his attend- ance at the Hospital la Pitie. He was now well prepared for observation of the phenomena of disease in the living and the dead. In addition to what he had previously gained, he now had had the advantage of having learnt many of the views and opinions of the greatest living masters on the leading questions in pathology. He knew that his whole life, of such a length as he then had reason to anticipate, would be too short for the full solution of these questions, even to his own satisfaction. 33 He knew also the inestimable value oS the opportunities afford- ed him in Paris Sor this purpose, such as he could not look Sor again; a value increased tenfold by the aid and guidance of his beloved and revered master. It was at this time that M. Louis almost adopted him as a son, admitting him to the most unre- served intercourse, and affording him every possible facility in the wards under his care. There James devoted himself en- tirely to careful observation and the collection of facts. Not to a selection of the facts, which favored particular doctrines; but really and truly to an exact inquisition into all the facts apper- taining to the cases before him. These, as far as time would permit, were all carefully noted on the spot in his daily visits; and these visits were not limited to the regular hours of the physician. By the orders of M. Louis he was admitted at all hours, and permitted to pass most of his day in the collection of his cases. Fully aware how much is lost to us in hospitals, in comparison with private practice, from not being acquainted with the families and with the personal constitutions and mor- bid dispositions of the patients, he endeavored to get a com- pensation by the most exact inquiries on these points. From the patient, or his Sri ends who visited him, he constantly sought an answer to the Sollowing and similar questions, viz: Where was the patient born and when? Was he nursed at the breast of his mother, or of a stranger? What have been his oc- cupation and his habits of life ? What have been his previous diseases ? Do his parents live ; iS not, at what age did they die; to what diseases were they and their relatives subject; and oS what diseases did they die ? Were they affected by palsy, asthma, or any disease oS the thorax ? IS so, what par- ticular symptoms did they manifest? Has the patient any children? IS so, do they live and with what diseases have they been affected ? 5 34 The observations thus collected were all of them such as he could himselS have employed usefully, in connexion with others of a similar kind, in seeking answers to many general questions. For instance, he noticed, and, so far as I know, he first noticed the frequency with which asthma and either apoplexy, or palsy occur in the same family. To ascertain the accuracy oS this observation, he inquired of all those he examined, whether asthmatic or not, if these diseases of the nervous system had occurred in their families. But, valuable as the cases he collected would have been to himself, the larger part oS them were not such as could repay a perusal by others. Those, in which the event was Satal, and where the details were Sull and precise, are the most instructive to others. It is Srom among those principally that the cases in this book have been selected. These are not sufficiently numerous to Surnish positive answers to many interesting ques- tions. They are to be regarded as contributions to medical science; and, when they shall be taken in connexion with many similar observations, the whole being careSully analysed, they will give results oS permanent value. They are printed with this view ; and a peculiar encouragement to expect ben- efit Srom them is derived Srom circumstances, which I shall proceed to mention. In the year 1832 there was Sormed in Paris a Society enti- tled " The Society oS Medical Observation." It had Sor its I first President M. Louis, and Sor its Vice Presidents MM. ( Chomel and Andral. Its active members were young men, who were proud to call M. Louis their master. Their object was to accumulate observations, made with the accuracy which their President had inculcated both by precept and example,* and to draw Srom them the inSerences, which a * See note C. 35 careSul comparison oS them should permit. OS this society, originally very small, its members being Srom different coun- tries, my son was a member at its Sormation. It was one oS his first desires to contribute his proportion oS materials to its stores; stores which must become ample iS its plan is not abandoned, and which will be opened Sreely to all the world. During his residence in Europe my son had a strong desire to visit Germany, Sully aware oS the means there to be Sound Sor increasing medical knowledge, as well as oS the benefit oS personal communication with those, whose lives have been devoted to science and whose minds are stored with it. Each has his own mode of viewing objects and oS presenting them to the minds oS others. From every one something is to be gained. But, on the other hand, iS one is limited by time, his mind may suffer from the kind of dissipation which arises from visiting even rich mines oS learning, into which he does not enter as a laborer. From considerations oS this kind, very judiciously urged by M. Louis, my son resisted the temptation and gave himselS up to observation oS disease at la Pitie, as has been stated. He had fixed on the end oS June, 1833, as the period when he should relinquish this employment, which grew more interesting every day. When July arrived he scarcely knew how to tear himselS away, though he Selt at the same time an eager desire to revisit his own Samily. Especially the idea of leaving M. Louis Sorever was afflicting to him in the highest degree. Never was attachment more just on the part oS a pupil to a master, and never could it have been warmer, or more sincere. M. Louis gave him some beautiSul articles as testimonials oS his affection, and the de- light, with which he subsequently regarded them, frequently made his eyes swim with tears. I cannot resist the gratifica- 36 tion of inserting the note by which these articles were accom- panied, as also my son's last letter to me Srom Paris. Translation of a note from M. Louis to J. Jackson, Jr. on his leaving Paris, accompanied with a bronzed inkstand and two pieces of marble, of which one was surmounted by the famous dog of St. Bernard, bearing a child on its back; to which reference is made in the note. " There is a satisSaction, though I conSess it is accompanied by Seelings which render it a very slight one, in leaving some token oS remembrance with Sriends from whom we are about to part; yet a satisfaction it certainly is, and for that reason, my dear friend, I beg you to permit me to enjoy it. Your thoughts would very naturally dwell at times upon your good friends in Paris ; but, for my part, I choose you should have something to recall them more particularly to your recollec- tion. I must thereSore beg you to accept this inkstand, which I hope you will keep upon your study table, and these two little pieces of marble, which will serve to keep in their places the leaves upon which you will be writing the results of your researches. From these researches let nothing divert you ; be constant in your pursuit three or four years, and do not let the poor child whom the faithSul dog is bearing to his home, speak too feelingly to your heart. Do not forget that you are to be one of the lawgivers in our art; and that, if it is our duty upon earth to use our faculties in the best possible manner and for the advantage oSthe greatest number, you owe yourselS to ob- servation. Your Suture Sortune will be none the less, and the satisSaction you will derive Srom four years' labor will be in- comparably greater. Be assured that my best wishes follow you wherever you go, that no one can more sincerely desire your happiness, that I Sully appreciate the value oS your 37 friendship and of your esteem, and that I should be most happy to be able to give you proofs of it. Farewell, my dear Sriend. (Signed,) Louis." July 10, 1833." "Paris, July 13, 1833. " mt dear father,-- " In two hours I am out of Paris. I will not attempt to describe to you the agony it gives me to quit Louis. He is my second father, and God knows that is a name I of all men cannot use lightly. I may not persuade you to look upon him with my eyes exactly as a scientific man; but in your heart he must have the share of a brother; Sor he almost shares my affection with you. From one, upon whom I had no claimSj but those which my life and mind and habits gave me, I have experienced a care, an affec- tion which I never could dare expect from any but my dear Sather, and which I shall ever Seel to be the most honorable and truly worthy prize of my liSe. To meet with satisSaction in the eyes oS such a man, and to hold a place in his heart as I do, I allow I am proud of. But, my dear father, I can- not write; I am sitting here, expecting to see Louis for the last time in my liSe, and it is only upon the occasion oS quitting yourselS, whom I have ever Selt to be a part of me, that 1 have suffered as I do at the present. The ties of relationship are strong, the strongest when that relationship is close and dependant; especially iS it be mingled with the strongest and warmest sympathies. But one's mind's Sriends, the hearts that not nature, but our own characters have given us, the Sriend, who not Sather to our bodies, has yet been and is ever to be the source, Sountain and direction oS the dearest thoughts 38 of our minds, that friend and that relationship is also dear. It is that friendship I must now quit, probably forever; it is that relationship that in the person I must now break, though in the mind and in the heart it can never be broken. Till now, I knew not how I loved my French master. I know well I shall rarely be called to such trials; they can occur but few times in life. Thank God, that with me, grieS is as short as it is poignant, and that in a few days nought will occupy my mind but the anticipation of the joys of home. Once more in the arms of my beloved family, and under the wing of my dear father, and I can imagine no higher joy." In addition to the testimonials oS M. Louis's affection above referred to, my son obtained shortly before he left Paris another memorial of him, which he valued as above all price. This was a picture, and an excellent likeness of his master, executed by Champmartin, which M. Louis very kindly consented to sit for. The emotions which my son experienced on the arrival of this picture, which was during his convalescence from his fever in December, 1833, were too strong and too deep to admit of description. From his younger friends also, James could not part without the greatest sensibility; from those especially whose home was in Europe. To one of these, M. Maunoir, of Geneva, he felt the attachment oS a brother. Some, or all oS these Sriends, per- haps, were surprised not to hear more from him after his return to this country. I therefore avail myself of this opportunity to say to them that he survived his return to us scarcely seven months ; that half of that time was passed in the chamber of sickness ; that, in the residue, he could not find time to respond fully to the kind expressions of affection and most friendly 39 attentions on his return and during his first sickness, which were abundantly poured out upon him; while he had also professional objects constantly calling for his observation. The friends, to whom I allude, will well understand how much interested he was in the inquiry as to certain points in typhus fever in this country, in regard to tuberculous cases and many similar subjects, which had interested him and them in Paris. Under any circumstances my son's gloomy Seelings on leaving Paris would soon have subsided, although without any SorgetSulness of what he had left behind. His natural cheerful- ness was sufficient. But he had also the pleasures of home in view, and he had more immediately the joy of seeing his friends in London, and the prospect of crossing the Atlantic with a rare company of friends, as fellow-passengers. It may seem like romance to speak thus of his happiness in finding rare and excellent friends at every turn. Yet, if it were well to bring out the evidence, many who will read this would know that the language is quite as cool as the subject will permit. I shall not however dwell on the high gratification he re- ceived during a few days passed in London and Liverpool, nor that which attended his voyage to this country. The ship which brought him arrived at New-York on the 23d of August, 1833, with a precious freight, which rejoiced many hearts beside those of my family. For my household how little then seemed there occasion to apprehend the sad suffer- ings, to which they were soon to be called. The dangers of the sea and the risks oS a long absence were over, the SearSul cholera had leSt my son untouched, and now we embraced him as iS we had a security oS the happiness he was so capa- ble and so anxious to afford us. He could indulge his heart at this moment in expressing his love for his friends with an ardor, which the cold manners oS our country scarcely per- 40 mit on ordinary occasions, and he was almost in a delirium oS joy. But after an indulgence oS this kind Sor two or three weeks, he felt that the serious business oS liSe called him, and sought to renew his observations on disease. The opportunities offered him Sor this purpose were ample, though not so great as those he had leSt in Paris. My con- nexion with the Massachusetts General Hospital afforded him every Sacility at that institution. Besides, here as every where, he met the kindest attentions, and he soon found that the most busy among the medical men oS our city were ready to show him their important cases and to invite him to their post-mortem examinations. In this way his time was abun- dantly occupied ; and in accepting the kind hospitalities of numerous friends it was more than occupied. He was con- stantly under too great a pressure and I was seeking how to prevent it. The temptations came day by day, and in so many instances were the results of the most friendly kind- ness, that to resist at once was impossible. Our autumnal fever was prevalent much more than usual, and with some uncommon severity. The opportunity to study this and to compare it with the fever oS Paris, on which Louis had written so admirably, was one which he could not forego. And when he Sound that this disease exhibited in the living and in the dead the same characters, which his master had so accurately delineated, his ardor was increased more and more, and he put all his powers to their greatest trial. It is not surprising, in the retrospect, that he became affected with the prevailing disease. He was attacked just two months after his arrival in New York, and underwent this Sever in a very severe Sorm. Some oS my sanguine brethren will ask why we did not crush the disease at once ? It is in accordance with my experience certainly, that, in most instances, the 41 early use oS active remedies, of which antimonials are the most important, will diminish the violence of this fever, and in many cases will arrest it. But in some instances a pecu- liarly irritable state of the alimentary canal will not permit the use of these remedies; or, evil only will follow their use. Such was my son's case ; owing in part to a stomach naturally irritable, but in part also to an intestinal disease which he had suffered abroad. Notwithstanding some active treatment at the beginning the fever took its course, and during the second and third week its result was very uncertain. It then became more mild, yet for six weeks he was unable to assume the erect position. His convalescence was not rapid, but in three months from its commencement he seemed to be in perfect health, having then been three weeks riding and walking abroad. His convalescence was not destitute of pleasure to him; on the contrary he spoke of it as a happy period ; he thought it good for him to have been sick, that he should better know how to minister to others, and that his own heart would be the better. His sensibility to the kindness oS his Sriends and the pleasure he derived Srom them were also increased; and we all meanwhile promised ourselves thathis health would become more firm. The time now arrived when he should apply Sor admission as a Doctor oS Medicine in our University. If he had been at home he might have taken this step in August, 1831. He had now been five years and a half engaged in the study of medicine. It could not be a question whether he could pass the requisite examination. Yet he felt some anxiety, because he thought it wTould be shameful for him to be found deficient in any point. This examination was about the middle of Februray. He had seemed quite well at the end of January 6 42 and beginning of February. But he now appeared less firm, and had some recurrence of a diarrhoea, which had afflicted him in France. I attributed this to the momentary anxiety he felt as to the examination, and to the deeper anxiety as to the more weighty duties which were before him; as he was soon to enter on the responsible duties of his profession. The examination being passed and the degree conferred, I felt de- sirous that he should make his arrangements at once to en- gage in business, hoping that he would feel a tranquillity when this was done. But I was in an error as to the cause of his dif- ficulty. It was a physical and not a moral one. He thought his diarrhoea was no more than he had often had before. But suddenly the disease grew worse, it assumed the character of severe dysentery and he was entirely prostrated at once. Under this disease he suffered much and struggled hard, re- taining his firmness oS mind and Sully aware of the uncertainty of its issue. He was severely sick about three weeks, but after the first Sortnight, I regarded him as safe. The dysen- teric affection was clearly subsiding, and he recovered some appetite, though still very weak. Suddenly a change occur- red, of which the cause was latent; the prostration was ex- treme ; his mind gave way, and in less than two days and a half he ceased to breathe.* In his last hours, his mind, amidst many wandering thoughts, appeared to get momentary glimp- ses of his real situation. He did not seem to shrink from the view, but was unable to keep it before him from failure in his physical strength. In one of these moments he said very dis- tinctly and solemnly, " God, pardon me." That he had sins which called for this petition at all times there is no doubt. That he was deeply sensible of his own frailties and imperfec- tions I well knew, for no son was ever more frank than he was * See note D. 43 in communications to a father. That the prayer Srom a heart like his, not now uttered Sor the first time, was Sreely granted, it was impossible Sor me to doubt. His own humble penitence was highly proper. But Sor me, there was no Sear that he would find anything but bliss in the new state oS existence, into which my mind seemed almost capable oS Sollowing him ; almost, oS seeing his admission. It was Sor my own loss, Sor that of my household, I had to grieve. And thatgrieS, sincere as it was, Sound solace Srom the first in the delightSul recollec- tions his liSe had leSt on my mind. These recollections have constantly hung about it, and how grateSul they have been may be seen by what I have transcribed in the preceding pages. As 1 have not very strictly Sollowed the plan which I laid down, there remain to be traced more distinctly some oS the Seatures of my son's character. His cheerSulness and gaiety oS heart have been beSore mentioned. The influence oS these on the society around him was oSten recognised by his Sriends. It was heightened among those, who had become acquainted with his purity and the sincerity oS his interest in others. He was described very appropriately by one, who knew him well and loved him much, as having a " morning Sreshness," which shed gladness where he went.* He never took the lead among his Sriends, and his influence was not maniSest; oS course, it was not offensive, nor annoying. It was nevertheless great and extensive, so that each one was surprised at last to find that there were so many besides himself whose happiness was pro- moted by him. The number of Sriends, by whom he was ad- mitted to intimacy, was large. The reason was that he loved men Sor different good qualities, and showed his interest in those he loved. He did not shut his eyes to their faults; he examined them critically, but not for the purpose of reproach ; * See note E. 44 he regarded those Saults as misSortunes, which he should assist his Sriends to overcome. I suspect that he oSten perSormed the hardest duty oS Sriendship : he told their Saults to many. If he had not done it gently and in love they would have been offended. They were not offended. His most intimate friend has told me that be exercised a salutary influence in certain cases, where friends of a sterner character were not listened to. In the society oS the young he would give himselS up to sport, so that it might have been doubted whether he could think soberly ; and Srom the warmth oS his Seelings it might have been argued that he could not exercise his judgment coolly. Yet he was exact and discriminating in the investiga- tion oS Sacts, which related to science, and rigid in his deduc- tions from them. This union oS coolness of the head with warmth of the heart is rare, and this partly explains the cir- cumstance of his finding favor with persons of very different character. There was something agreeable in his manners certainly, which recommended him to good men ; for be quickly gained the favor of good men wherever he went. Though he had acquired sufficient polish of manner while abroad, there was not enough of it to be a peculiar recommendation. So far as his manners were agreeable then it was not from any polish ; it was from their manifestation of the good feelings already described. I cannot omit remarking here the sincere reverence Sor age, which he imbibed very early in liSe and always maintain- ed ; which, far Srom checking his intercourse with the aged, made him seek it, both that he might minister to their comSort and that he might gain by their wisdom. The principle oS gratitude was very strong in him. He did not easily Sorget the slightest Savor, and his heart was burn- 45 ing with affection toward those, who had rendered him impor- tant services. He deemed no services so great as those, by which his heart, was made better ; and hence arose his strong Seelings toward his English Sriends, among whom he was placed at a moment, when his heart, was truly hungering Sor the things which could elevate and puriSy it. What shall I say oS his ambition ? The word is an equiv- ocal one. Or, perhaps, the question should be oS what was he ambitious. I think his young Sriends and associates will agree that he was not anxious Sor honorary distinctions. He had not such a spirit oS emulation as leads one to study hard, so that he may get the highest rank among his Sellows. He could rejoice most sincerely in seeing his Sriends gain honors, while he remained unnoticed. Envy, I think, scarcely sprouted in his breast; I, who knew him well, could never see the slightest evidences oS that baneSul Seeling. But he had the strongest ambition to be worthy the esteem and love oS the wise and good. He rejoiced openly when he made any acquisition in knowledge; he thanked God reverently when he thought he had made any advance in virtue. But so far from wishing that others might be less that he might be great, he would labor to communicate to his fellows, in a mode not offensive to their self-love, every acquisition he had made. He even took pains to manage this in some cases, so as not to seem to be bestowing what he was very anxious to give. He made it his aim to go as far in the branch of his profession, to which he particularly devoted him- self, as any other man; and he said to me, after his return from abroad, that he had at some periods indulged hopes of such honors as our profession could afford ; but that he had then totally renounced all such hopes and wishes for that, which he deemed of much more importance, the being truly useful 46 to his fellow-men. As to wealth, he loved the good uses of it, but he indulged no anxiety for it; and he was not prone to such extravagance in his expenses, as made it necessary Sor him. During his college liSe he had made some attainments in general literature ; not such as to give him claims to any dis- tinction on that score, yet enough to give him a taste for more. He hoped to have a period in which he could do more in this way. But, in the few years he devoted to professional studies, he did not feel at liberty to spare many hours to other subjects. To politics he gave very little attention, and this only to what he could learn in conversation. During mo- ments oS political excitement in France and England, in 1832 and 1833, he could not avoid taking some notice of passing events; and, like all young men of ardent tempers, he sided with those who thought more of the attainment of liberty, than of the security which it requires to render it a real blessing. 1 may seem to have said enough of his industry in the ear- lier pages of this memoir, yet I must state some of the evi- dences that in Europe, when left to himself, it was even great- er than when under my roof. While he was abroad, with three necessary exceptions, he wrote to me by every regular packet to New-York, from Havre or from Liverpool. The letters were not ordinarily short; some of the extracts which follow will prove that they were not always so. They were fre- quently Sour Sull sheets. These letters, with some to other persons, were so voluminous, that I have thought it right to enumerate them among the prooSs oS his industry. But they amount to nothing in comparison with the papers oS other kinds, which occupied his pen while abroad. These were, 1st. his cases, taken at the bedside in brieS notes, many of them in French, and which amount I believe to fiSteen hundred pages 47 at least, and some oS these were copied and stated in Sull in the French language; 2d. many notes Srom books and Srom conversation with distinguished persons, accompanied oSten by his own reflections, making not less than eight hundred pages in his common-place book; and 3d. the translation oS a large portion oS Andral's Clinique medicale. During the same period he made himselS Samiliar with the French medical literature oS the present day, studying a large number oS volumes with great care. It would thus seem that no small portion oS his time must have been devoted to books and writing. He however attended lectures on different sub- jects, but particularly and careSully two long courses by M. Andral. Yet his attendance on hospitals would seem alone to have afforded him sufficient occupation ; while, except his notes oS cases, the occupations above-mentioned could not have been carried on except at his lodgings. The time spent by him in hospitals while in Paris, a period of eighteen months, was not less than five hours a day, and Sor many months it amounted to six and seven hours a day. This time too was not spent in a holiday service ; a large part oS it was oc- cupied in examining cases Sor himselS, strictly scrutinizing their history by the interrogation of patients and by examining for the physical signs of disease; and a portion oS it almost every day in the autopsy room, where, on the cold and wet floors, he usually tested by his personal examination all the minute changes oS structure to which disease had given rise, so as to have become perSectly Samiliar with the common changes oS this sort, to which the human body is liable. In thus re- viewing his labors it seems strange that he could find, as he did, any time Sor society, Sor exercise and for relaxation. I am almost tempted to blot out the lines I have written on this topic. My heart bleeds almost in thinking how arduous were 48 his labors and how much more my happiness might now be, had they been much less so. I believe the statement to be quite within the truth, and it makes a part oS his history ; but I cannot recommend to any young man to follow his example, to its Sull extent, in this respect. In the enumeration oS his labors, while abroad, I have omit- ted to notice that he had first to acquire the art oS speaking the French language, which he could not do, when he first en- tered Paris, and Sor which he devoted two hours a day for some weeks, though he at once went into the hospitals and learned to talk among the sick ; — that he gave a portion of time to the study oS practical anatomy under a private teach- er ; that he attended to instruction on obstetrics, and connect- ed himself with three private institutions at the same time, so as to increase his opportunities Sor practice in this branch ; and that he devoted one whole month industriously in London to the copying and arranging his cases oS cholera, which formed a book in octavo of two hundred pages ; and lastly, that his whole summer in Great Britain was spent in travelling, con- versing with medical men, not idle conversation, and in a critical study oS their collections of preparations of comparative and morbid anatomy. Of the professional acquirements, which were the fruits of his industry at home and abroad, I have perhaps said enough; but 1 am tempted to point out more particularly what those acquirements were ; the more, as I think his attention wras directed to the points which a medical student should princi- pally regard. Every thinking physician finds more and more, as he gains experience, that his greatest difficulty is in what we term the diagnosis and the prognosis. He wishes to ascertain by exam- ining his patient precisely what is his present difficulty, and 49 what course his disease is likely to pursue. He wishes in short, to be acquainted with every thing, which goes into the natural history oS diseases. For this purpose he finds the speculations of the closet as useless, as such speculations would be to a gardener, who should desire to know one plant Srom another and the manner oS growth oS each. Further, to understand the natural history oS diseases, he must have a knowledge oS what appertains to the living body in health ; in other words, oS physiology. Facts and Sacts only are useSul to him. Close observation alone will serve his purpose. It is some- times not until aSter the experience and disappointment oS years, that the physician Sully realizes all this; but iS he is an honest and intelligent seeker Sor truth, he discovers it more or less clearly at last. Impressed as I have long been with these principles, it will be supposed that 1 endeavored to fix them in my son's mind. He was willing to receive them and soon came under their Sull influence. But it was away Srom me that he learned how to apply them more rigorously and with the greatest benefit. This he did Srom M. Louis; who, I hesitate not to say, has been the most successSul, as well as the most rigorous, in pursuing this mode of studying disease, of any physician in ancient or modern times.* The result was, as respects my son, that he returned to this country already possessed of uncommon skill for his age, in the examination oS cases oS disease and in distinguishing in each case the actual morbid affection ; and also well taught in the best mode oS pursuing his investigations, so as to promote the cause oS true science. In the examination oS the thorax by percussion and auscultation he was peculiarly well versed, as * See note F. 7 50 likewise with the diseases oS this region of the body. He was also familiar with the various morbid changes, to which the several organs and textures are liable. When he went to France, I urged upon him the importance of getting a knowl- edge of the morbid changes, to which the various membranes, and particularly those of the alimentary canal, are subject. In no other place could this knowledge be obtained so perfectly. The occurrence oS the cholera in that country furnished at once occasion and inducements to pursue these inquiries, as to the alimentary canal; and he did so with success. He did not overlook the morbid changes which occur in the brain, and in other parts. But he seemed early to fix upon the thorax as the subject of his particular study. He was led to this, perhaps, by my frequent remarks on the obscurity of the diseases of this great cavity in many instances, and on the large proportion of cases in which they were fatal. He was not ignorant of the common methods of treating diseases both in this country and in Europe, though less in- formed as to the reputed virtues oS some medicines than many others. But he considered therapeutics as a branch oS medical science which he had yet to study. He was very sceptical as to the utility oS many practices commonly adopted, believing that they rested on insufficient authority, and he wished to bring them to the test oS experiment. He did not Seel a reli- ance, in respect to the influence of medicine, on the experience of men, who could not tell what would be the result of a dis- ease without the use of remedies. He was nevertheless ready to follow to a certain extent the course adopted by physicians of sound judgment, until he should have opportunities to decide by his own experience. For his scepticism there certainly is some ground in the actual state of our science; and, if either extreme must be chosen, I would advise a young physician to 51 adopt the expectant mode of treatment, recommended by some physicians of France, rather than to employ on every occasion the heroic remedies of some of our countrymen. The profuse use of these remedies, and the abundant use of even mild articles in endless combinations, too often witnessed among us, cannot be too openly, nor too loudly reprobated. These errors are disgraceful to our profession. But, if that were all, one might be silent. They cause needless and often great suf- fering to those, who are already afflicted enough. At the suggestion and request of one of my most judicious brethren I shall add, that my son's influence on the profession here, in the short time he was with us, was of a very salutary description. This gentleman states that my son not only caused others, who had not yet read the works of M. Louis, to study them with care; but that he induced among the rising members of the profession in our own city the habits of thorough observation of the phenomena oS disease in the living and in the dead, which he had learned from the same great pathologist. He also taught us much in respect to the physical signs of disease in the thorax, with which we were imperfectly ac- quainted before; at least I may say, this was true as to my- self. Indeed I ought to say more; for he aided me very much in regard to the diagnosis of the more obscure diseases of that region, derived from the combination of the physical and rational signs. On emphysema of the lungs he threw, for me, quite a new light. These good impressions will not be lost. Already we have with us one of his fellow-students under M. Louis, who is abundantly able and will not fail to keep them alive. And others are soon to follow, who will, I am sure, carry forward the good work with the same disinterested love for science. 52 I have mentioned the sensibility of my son to the kindness he had experienced from his Sriends during his Sever. I cannot close this memoir without some notice oS the extent oS that kindness. It was in truth so great that I never stated to him the Sull amount oS it; waiting till he should recover more strength and be better prepared to acknowledge it. While his liSe was thought to be in danger, not only Sriends and neigh- bors, but those who were personally strangers to me, manifested a great interest in his welfare and the utmost readiness to afford to him and to me any assistance in their power. Every aid was proffered from the most respectable sources; and my son had for his night-watchers, during all the critical period of his disease, the most busy and most experienced physicians of our city. So great indeed was the public sympathy on this occasion, that I could not consent to have it roused again in his last illness; and hence I represented his case to all, except my most intimate Sriends, in the brightest possible colors. I cannot omit to make this acknowledgment oS Savors, which I can never repay, though its statement involves so much oS egotism. I would say something oS the religious principles oS my son. He began early to look at religion with real solemnity, yet without Sear. At the very outset he acquired a conviction oS and a confidence in the unbounded goodness oS his Maker. It is Srom the views adopted on this Sundamental point, whence issues so much light, that the religious principles of most per- sons take their color. He could love and did love supremely the Father of all things. He loved with fear, a fear that he himself should do wrong; but he loved also with confidence. He listened with delight to those instructions from the pulpit, which called on him to think worthily of his own nature, that 53 he might act in accordance with it. The sublime character of our Saviour and oS his teachings was regarded by his heart, as well as his mind, with the greatest possible respect. He viewed that character and those teachings as strong evidence oS his mission Srom God. In regard to the external evidence he saw that it required long and careSul study, which every man could not undergo. He was willing to believe that it was sufficient, on good authority, until he should be able to examine it Sor himselS. He would not however proSess to believe, as iS he had already examined it. Meanwhile he entertained no Sears of death; satisfied perSectly that that event would be decided by wisdom beyond his comprehension. Such, almost literally, were the sentiments, which he expressed to me, shortly beSore the first sickness, oS which I have given an account. With such characteristics as I have attributed to my son, he seemed calculated to be highly useSul in the world. I never anticipated that he would have a commanding influence in society, but I did think that he would have an agreeable and useSul influence. Why he should have been permitted to go so Sar, to give blossoms oS so Sail' a promise and oS so sweet a flavor, and just then be cut down, it is not Sor us to say. It is one oS those events, which show us that we know very little of the designs oS our own being, at least while we regard this world only. I do not consider it as singular, because to me it was so afflictive; because I was disappointed oS the most cherished hopes, just when I was almost ready to think my liSe well spent in having learned how to educate one, who could be much more useSul than I had ever been. I need not look Sar Srom home to find those, who suffered in like manner, almost at the same moment. The instance is not singular; and because it is not, we must inSer that the end oSour existence is not merely 54 to be useful in this world ; and we must be comSorted by the assurance that a good liSe, however short, is the great blessing which alone should satisfy all our desires, as respects our children. Almost unnatural, it may seem, at least against the ordinary course oS nature, Sor a Sather thus to erect a monument Sor his son. But surely he should be solaced, if the liSe oS his son has Surnished at once the solid materials Sor its erection and flowers Sor its ornament. 55 NOTES TO THE MEMOIR. Note A. —Pa g e 24. It is due perhaps to M. Louis to state why his urgent ad- vice in respect to my son's course oS liSe was not adopted by us. I will first mention that I leSt my son to decide Sor himself, only placing beSore him the objections which I saw to the plan proposed by his excellent and wise Sriend. This I communi- cated to him, while abroad, desiring only that he would not decide, until aSter his return. It was not long aSter his return that he decided, that he could not adopt M. Louis's plan in its Sull extent, but he determined to conform to it as far as he should find practicable, and I was very ready to aid him in so doing. He decided to engage in business, but to take no pains to be fully engaged in it, and thought that for several years he could be occupied principally in the course of observation, on which he had already entered. But why could he not adopt the plan Sully? Because \ in this country his course would have been so singular, as in a measure to separate him Srom other men. We are a business doing people. We are new. We have, as it were, but just landed on these uncultivated shores ; there is a vast deal to be done ; and he who will not be doing, must be set down as a drone. If he is a drone in appearance only and 56 not in fact, it will require a long time to prove it so, when his character has once been fixed in the public mind. This view of the subject is too vague, at least for those, who belong to other and older countries. Let me then state the matter more definitely. Among us, where the hands are yet few in proportion to the work to be done, every young man engages as soon as he can in the business of life. The public estimation oS his character is decided early in his liSe ; earlier than in Europe. In our learned proSessions men cer- tainly come forward too young in most instances. They do not ordinarily keep at work so long, nor do their work so well, as iS they had made more thorough preparation for it. But, if an in- dividual were to go very far in the other extreme, his reputa- tion would be fixed, as one, who perhaps loved knowledge and knew how to acquire it; but who was not disposed to use it, and who perhaps did not know how to apply it. Most of our physicians go into business aSter three years of study ; some, by visiting foreign schools, protract the period of study to five or six years. If now, after this longer period, one should at the present day, spend four or five years longer in the acquisition of professional knowledge, before he should begin to engage in professional business, and this in the society where he meant ultimately to be so engaged, he would be re- garded as a singular being, governed by a peculiar taste ; and it would probably be thought that he would never be fit for the active business oS liSe. He might become a teacher and attract pupils, but he might find it difficult to get patients. In Europe it would not be so; but at present my fears would be that such would be the result in this country. It should be added, that my son, like most other proSessional men among us, necessarily looked to his own labors for his support. I should with great pleasure have supported him, 57 while going through his Sour or five years oS medical observa- tions. But I could not give him the means oS support Sor liSe, because I had not them to give. He must then, at the end oS those years, have come Sorward as a candidate Sor practice, with young men who had started in liSe many years after him ; while his former companions would be already immersed in business, and could hardly, sympathize with him in any re- spect. He would be regarded as in a Salse position, because he was in a singular one; and because so regarded, he would be kept there. He would come Sorward with the habits and Seelings oS a student, while his early companions would have acquired the habits oS men of business. In this way he would both fail to obtain a support for himself, and Sail to be useSul to others. He would have acquired the habit oS de- pendence on others, instead oS that habit oS dependence on one's selS Sor support, which in this country seems almost necessary Sor every man. Such at least were my Sears. It was Srom considerations of this sort that I hesitated to en- courage the plan proposed by M. Louis to my son. He him- selS saw the subject in the same light, and, though with reluc- tance, relinquished the plan. Perhaps we were both too timid. I now advert to the subject to show, that we did not reSuse to Sollow the advice oS his excellent Sriend, without a considera- tion oS it. Note B. —Page 2 9. I am not willing to mention the names oS private individ- uals, to whom my son had the honor oS being introduced; nor to adduce evidence of the claims to much more praise than I 8 58 have given, on the part of the select circle, among whom he was admitted as a Sriend in London. One circumstance only I shall state which may be regarded by many as such evidence, and I state this partly for the sake oS a quotation Srom my son's letter of June 12th, which relates to this circle. It is that in this same circle the Rajah, Ram Mohun Roy, was in the habit oS visiting familiarly and unceremoniously, like an old Sriend. My son speaks oS his introduction to this most excel- lent Hindoo as among the benefits, which were conferred on him by one of his Sriends ; and subsequently adds substantially as Sollows: "When I reflect upon the character and regard the lofty front and nobly intelligent and benevolent countenance, which, could it but be in the station, would almost exercise the influence of a moral sun, and read the works of Ram Mohun Roy, and then remember that I was born in an enlightened and he in an unenlightened country, I blush for my own imperfec- tions and make resolutions for the future. A new Seeling, a new passion has been awakened in me. * * * * It will be the object of my life, not singly, but much more than it would have been had I not seen this circle, to aid in the work to spread knowledge and happiness." Note C—Page 3 4. P. Ch. A. Louis, physician oS the Hospital de la Pitie, is a man, whose labors and whose writings must become more and more known Sor ages. I should deem it service enough to my brethren in this country, iS 1 could induce them, one and all, to read and to study the works oS this great pathologist. M. Louis is the Sounder oS the numerical system, as it has been denominated, in respect to the science oS medicine. It 59 is the object of this note to state what that system is, and briefly to advert to the successSul application oS it by its Sounder. How many will be ready to turn aside, when they hear oS a new system. Has not system Sollowed system, it will be asked, ever since the days oS the Sour humors. Facts, it will be added, observations, exact observations are wanting, not sys- tems, in order to carry Sorward the science of medicine. Be it so; it is the last point, on which I would disagree with my reader. If however that reader has not had much experience on the subject, he may not be aware of the difficulty of mak- ing good observations, as regards both pathology and therapeu- tics, and of the caution which is requisite in making deductions. These difficulties should not deter us from adopting the right course; they should only make us study to find out what this course is. M. Louis certainly will not direct us to turn from observation to speculation. But to remove the objection, let me say at once that M. Louis has not brought forward a new system of medicine ; he has only proposed and pursued a new method in prose- cuting the study of medicine. This is nothing else than the method of induction, the method of Bacon, so much vaunted and yet so little regarded. But, if so, where is the novelty ? If any one, after patiently studying and prac- tising the method proposed by M. Louis, denies the novelty of it, I will not dispute with him a moment. Perhaps he will then agree with me that it is a novelty to pursue the method of Bacon thoroughly and truly in the study of medicine; though it is not new to talk oS it and to laud it. A little history oS one part oS M. Louis's liSe will throw some light on this subject. This gentleman went abroad, and I believe had some appointment in Russia, aSter he had gone 60 through the usual course of professional education. Return- ing to France at the age of thirty-two, he was about to engage in private practice. He was then led to examine anew the state oS the science of medicine, and was dissatisfied with it. He now decided to abandon the thoughts of practice for a time, and to devote himselS to observation; that is, to the study oS disease as it actually presents itself. With this view he went into the hospital la Charite in Paris, and followed the practice of M. Chomel, now a physician at the Hotel Dieu and Professor of Clinical medicine, and highly esteemed as an author. M. Louis passed nearly seven years in studying medicine in this way. The first part of this time he was learning how to make observations. When he thought he had attained this art, he threw away, as I have understood, the notes he had already collected, and began anew to accu- mulate exact observations of the phenomena presented by the sick and of those derived from an examination aSter death in the fatal cases. In this course of observations he did not make a selection oS cases, but took them as they were pre- sented, indiscriminately. He was not in a hurry to make deductions from his cases, satisfied that he was gathering the materials, from which truth must ultimately be elicited. He was only careSul that his observations should be correct, and had not any general principles, or doctrines, Sor which he sought support, or confirmation. To estimate the value oShis observations, it is necessary to understand the plan, on which he collected them. First, then, he ascertained when the patient under his examination began to be diseased. Not satisfied with vague answers, he went back to the period, when the patient enjoyed his usual health; and he also endeavored to learn whether that usual health had been firm, or in any respect infirm. He noted also the age, 61 occupation, residence, and manner of living of the patient; like- wise any accidents which had occurred, and which might have influenced the disease then affecting him. He ascertained also, as much as possible, the diseases which had occurred in the Samily oS his patient. Secondly, he inquired into the present disease, ascertaining not only what symptoms had marked its commencement, but those which had been subsequently developed and the order oS their occurrence; and recording those, which might not seem to be connected with the principal disease, as well as those which were so connected; also, meas- uring the degree or violence of each symptom, with as much accuracy as the case would admit. Thirdly, he noted the actual phenomena present at his examination, depending Sor this not only on the statement oS the patient, but on his own senses, his eyes, his ears and his hands. Under this and the preced- ing head he was not satisfied with noting the functions, in which the patient complained oS disorder, but examined care- Sully as to all the Sunctions, recording their state as being healthy or otherwise, and even noticing the absence of symp- toms, which might bear on the diagnosis. Thus all secondary diseases, and those, which accidentally co-existed with the principal malady, were brought under his view. Fourthly, he continued to watch his patient Srom day to day, careSully recording all the changes, wThich occurred in him till his resto- ration to health, or his decease. Fifthly, in the fatal cases he exercised the same scrupulous care in examining the dead, as he had in regard to the living subject. Prepared by a minute acquaintance with anatomy, and Samiliar with the changes wrought by disease, he looked not only at the parts where the principal disorder was maniSested, but at all the organs. His notes did not state opinions, but Sacts. He re- corded in regard to each part, which was not quite healthy in 62 its appearance, the changes in color, consistence, firmness, thickness, &c.; not contenting himself with saying that a part was inflamed, or was cancerous, or with the use of any gene- ral, but indefinite terms. Without presuming that I have described in the most exact manner the course pursued by M. Louis, I have said enough to make his plan intelligible to men of sagacity. Others have taken down cases in like manner. In the first volume of the " Transactions of a Society Sor the improvement of Medical and Chirurgical knowledge," published 1793, there is a paper by Dr. George Fordyce, entitled, " an attempt to improve the evidence of medicine." In this paper Dr. Fordyce recom- mends the careful collection of cases, as the only foundation Sor the improvement which he wished to see. Dr. Fordyce goes into many details, and gives two cases in a tabular Sorm by way oS illustration, and states that he has many cases collected upon this plan. In his plan some matters are insisted upon more than by M. Louis perhaps; others less. But Dr. Fordyce does not insist upon the examination after death, a most im- portant part oS the plan adopted by M. Louis. IS however the attempt proposed had been followed by vigorous efforts, most important benefits would have resulted from it. Many no doubt thought of doing it. I myselS thought seriously of it more than thirty years ago, and had blanks printed Sor my cases accord- ing to the plan oS Fordyce. But the difficulties attending the plan in private practice discouraged me too soon. So far as I have known, M. Louis is the only physician who has devoted himself for years together, at a mature age and after a sufficient education, to simple observation, without the distraction of medical practice, and without having any share in the treatment of the cases under his observation. 63 It was only when he had accumulated a great mass of cases, that M. Louis began to deduce from them any general principles. He then arranged the facts he had collected in a tabular Sorm, so as to Sacilitate a comparison oS them. How much labor this required will be in some measure conceived, when 1 state that, while going through one class oS his obser- vations, those, I believe, which relate to acute diseases, he retired to a distance Srom Paris and occupied ten months in making out his tables. This statement is, I believe, substan- tially, iS not precisely correct. Let the reader conceive of these tables drawn out with accuracy, having columns devoted, with proper discrimina- tion, to each function and to its various derangements, as manifested during life, and to each organ and its lesions as ascertained after death; let him then go to these tables and inquire, under what circumstances certain signs of disease arise, and with what pathological changes in the dead body they are found to correspond; let him ask under what circumstances certain morbid changes of structure occur, and with what symptoms they are Sound to be connected ; he may find the answers and he may obtain them numerically. That is, he may learn in how many cases out oS a hundred of any particular disease he will find a certain derangement of a particular function, or a certain change in structure of a par- ticular organ; and he may also learn how often the same things may be noticed in other diseases, with which that undei consideration may be compared. For instance, does he ask how often does it happen that dysphagia occurs in typhus fever? M. Louis replies from his tables that in the fatal cases of typhus, which he had examined when his work on this sub- ject was written, rather more than one in five had this symp- tom. Is it then asked whether this symptom was found to be 64 connected with any particular organic lesion, M. Louis says that in four out of five of these cases there were ulcers in the pharynx or oesophagus, or other change of structure in the or- gans concerned in deglutition. Thus it was shown, that it has been for want of examination that we have so often attributed this symptom to weakness. IS the same questions are asked in respect to other acute diseases, the answer Surnished by M. Louis is, that in the acute diseases, of which he had accurate notes, exclusive of typhus, severe dysphagia did not exist; and that ulcers were also wanting in the pharynx, &c.; though slight organic affections were Sound in a very small proportion oS those cases. Or, again, is it asked, how often the epiglottis, larynx and trachea are ulcerated in pulmonary consumption ? M. Louis replies that the trachea exhibits ulcerations in nearly one third of the subjects of this disease; the larynx in a little more, and the epiglottis in a little less than a fifth of those subjects. Meanwhile, in other chronic diseases, M. Louis had found only one case, in which these parts were ulcerated, while the lungs were not tuberculous. The symptoms, by which the ulceration of the epiglottis was marked, were a fixed pain in the upper part of the thyroid cartilage, or just above it, and a difficulty of deglutition, such that the drinks are sometimes thrown out by the nose. The symptoms attending the other lesions are much less distinct, and the state- ment of them would lead to details not necessary in this place. The instances here taken are the first which came to hand, on opening M. Louis's publications ; but in like manner we may find an answer to most of the questions, which would arise in reference to the subjects discussed. The experience of one man is necessarily limited, and more extensive researches may give results different from those at 65 which M. Louis has arrived. But I am disposed to think that the difference will not be material in many instances. His observations were made only in the hospitals of Paris. Other observations, made in different climates and among persons of different habits, will probably discover differences of some kind, and perhaps some which are material. But in most respects, since the works of M. Louis have been known to me, I have found his observations confirmed by my expe- rience here ; and indeed in many respects they accord with my own previous observations, being, however, more precise than mine had been. But there are various points in pathology, on which M. Louis has taught us what we did not know before. For instance, he has given us certain signs, by which we may recognise pericarditis, in a large proportion of the cases in which it occurs. He has shown that tubercles are always found in the lungs, if they are found in any other part of the body ; or that the exceptions are so rare as not to be practi- cally important. He has shown that chronic peritonitis is found only in tuberculous subjects. Others had suspected that the fever, now commonly called typhus, was dependent on inflammation of the mucous membrane of the stomach and bowels ; and it had been shown that in certain seasons the elliptical patches, called Peyer's glands, were the seat of in- flammation, and commonly of ulceration, &c. M. Louis has shown that a morbid alteration of these glands is constant in typhus ; constituting, as he terms it, the anatomical character of that disease. He has likewise pointed out the other ana- tomical changes, which belong to, and those which often attend the same disease ; as well as some symptoms which had been overlooked, or not duly regarded by others. At present I can 9 66 say that his observations, in regard to typhus, have been con- firmed by all that I have been able to learn respecting it in this country, since his observations have been known to me. I am not, however, engaged in reviewing the works of M. Louis. I have not guarded myself in all points in stating his observations. I wish to induce others to read his books, and they will then see the prudent caution, with which he offers all general remarks, and the scrupulous care which he exercises in making his deductions. He studies nature with a full faith in the uniformity of her laws, and in the certainty that truth may be ascertained by diligent labor. It is truth only he loves; not anxious to build up a system, nor pretending to explain every thing, he says to his pupils, such and such have been- my observations; you can observe as well as I, if you will study the art of observation, and if you will come to it with an honest mind, and be faithful in noting all which you discover, and not merely the things which are interesting at the moment, or those which support a favorite dogma; I state to you the laws of nature as they appear to me ; if true, your observations will confirm them ; if not true, they will re- fute them ; I shall be content iS only the truth be ascertained. I wish to add that M. Louis has inspired a gallant band with his spirit. They have combined to Sorm the Society oS Medical Observation at Paris; M. Louis is their President and MM. Chomel and Andral are the Vice-Presidents. They meet to report their observations and to be corrected by each other and by their president, when their observations are inaccurate or deficient, or when their inferences are broader than their premises. The members are selected without ref- erence to their country; they are from different nations; they are scattered, and will in succession be scattered over the world ; and all, who carry with them the true spirit, must con- • 67 tribute to the advancement oSreal science. Men who devote themselves thoroughly to labor, in whatever department, must be Selt and known in society. Let the members oS this soci- ety go on and throw the Sruits oS their labor into a common stock, and they must all oS them be enriched, and all around them be enriched at the same time. To the remarks, perhaps too desultory, which I have given in this article, I am desirous to add two more. The two great works oS M. Louis, which have yet been published, are that on phthisis and that on typhus. My first remark is, that the inSormation given in these works is much less limited, than their titles would indicate. In the first, other chronic diseases are compared with phthisis in re- spect to its symptoms and to organic lesions ; and thus it may be regarded as treating, to a certain extent, oS chronic diseases, and embraces a vast deal oS inSormation in respect to them. In the second, acute diseases are compared with typhus, with the like advantages. My second remark is, that the general results, to which M. Louis has attained by his mode oS studying diseases, have been greater, that is, more numerous and more important, than might have been anticipated in so short a time. I think he could hardly have hoped Sor such abundant Sruits oS his la- bors, great as they were; diligently and SaithSully as they were pursued. In this there is much encouragement. Already in his hands medicine, at least what regards the signs of dis- eases and the pathological states on which they depend, begins to assume the Sorm of an exact science. In moulding his materials indeed, he has availed himself of the useful in- structions which have been furnished by others, on whom he could depend. This is especially true in respect to the discoveries oS the illustrious Laennec, to whose merits 68 he renders ample justice. His own merit however is peculiar. While all were ready to acknowledge, that it is only by a careSul observation oS nature we can ascertain her laws, he only has had the boldness and the vigor to undertake and carry through a series oS Sull and exact observations, without prejudice, and with a determination to report his discoveries Sairiy and exactly, not magnifying, nor diminishing the evidence in any case to make it quadrate with principles previously imagined. My son bore this testimony of him, that he would not be tempted to entertain an hypothesis in any case, saying that it had almost uniformly happened that rigorous observa- tion had reSuted the hypotheses he had formed. I venerate M. Louis greatly. As the heir of my son I love him most sincerely. But it is not with the vain hope, nor even with the desire to promote his fame by my feeble commendations, that I have written this note. I regard it as certain that his fame, and what he will regard much more, the truths which he has discovered, will be extended and will live Sor ages. My sole expectation is to lead some, who might otherwise be ignorant oS them, among my brethren oS the present day, to study works which I esteem as among the most valuable certainly, iS not the most valuable, which any age has Surnished us in regard to medicine. Unlike the sys- tems, which are always spoken oS in the history oS medicine, as successively rising with splendor and Sailing into oblivion, the principles published by the Sounder oS the numerical sys- tem are not an artificial network, where the cutting oS one thread may cause the whole to drop away; these principles may be added to, they may be enlarged, limited and modified, and yet the system may be maintained ; and it will still derive its support Srom the first labors devoted to its erection as much as Srom the last. If, Sor instance, M. Louis has observed a 69 certain symptom, such as the enlargement in the region of the spleen, to be present in Sorty-five out oS fifty cases oS typhus ; the exceptions will be ten per cent. Should subsequent ob- servers find, that in a hundred and fifty cases there have been twenty exceptions, it will then appear that these in the two hundred amount to twelve and a half per cent. As far as I know, there are very Sew oS M. Louis's numerical inSerences, which have hitherto required to be modified so much as in the instance here supposed, since the publication oS his great works; although ten years have now elapsed since that on phthisis and six years since that on typhus was published; and although he himselS has continued, during this period, to devote a great portion oS his time to the collection oSnew observations. Were it otherwise, however, it would be glory enough Sor one man to have led the way into the true path, and to have in- spired others with the courage to Sollow him. I repeat the idea;—it is the spirit oS bold and hardy enterprise, which is (he glory oSM. Louis. I must add a Sew remarks on another point. It is objected by some to the labors oS M. Louis, and of others oS the French pathologists, that they labor indeed with ardor on the subject oS diagnosis, that they study with the zeal oS ente- mologists to discriminate minute changes oS structure in the va- rious textures of the human body, but that they do nothing to advance the proper business of the physician, the art oS heal- ing. Their therapeutics are decried, as showing an ignorance oS what has been thought certain in England and in this coun- try ; and they themselves are regarded even as indifferent to this branch of science. Can this objection need a reply ? I have long been satisfied, Sor thirty years I have been satisfied, that the physicians oS Paris were laying the firmest Soundation Sor the science of therapeutics, by studying the natural history 70 of diseases; and by thus giving us rules Sor diagnosis and prognosis. The course they have pursued has not always been the most satisSactory, and one at least among them has gone over to the dogmatic philosophers, though he has tried to disguise his desertion oS the true cause. But the course they have pur- sued has led honest spirits to be more and more exact in their observations,until now, when one has arisen, who has vigorously undertaken all the toils, to which the method previously adopted would rightly lead them. Let them proceed in the same spirit, aided, but without any spirit oS rivalry, by the pathologists oS other countries ; let us all learn what may be looked Sor, when art does not interSere in the diseases oS the human body ; that is, let us study the rules oS prognosis, which are only in- ferences Srom the natural history of diseases; then we shall be prepared to study therapeutics. Let M. Louis, or men like him, test the effect oS remedies in the same spirit, with which he has pursued his pathological researches. Having deter- mined the average duration, fatality, &c, of typhus, for exam- ple, by an observation of a sufficient number of cases through a series of years, such cases not having been actively treated, let him then employ in the same disease the different reme- dies which have been thought useful. One physician extols the advantages of bleeding; another commends antimonials employed on the first days of the disease, in emetic doses, and for a few days afterwards in doses just short of nauseating; another contends that cinchona is the best antidote to the deadly tendencies of this malady. Let each mode of treat- ment have its fair trial; and let the results be compared with each other, and with similar cases, treated at the same time upon the expectant method. This is substantially the mode, in which questions in the- rapeutics are beginning to be treated in Paris. So, no doubt, 71 they have been treated elsewhere. But it is in proportion as we arrive at precision, in respect to the natural history of dis- eases, that this mode will be pursued with the greatest advan- tage. It is because we are approaching to that precision that I think it scarcely rash to predict, that in fifty years the art of healing will be grounded on many exact rules, which we and our predecessors have not known. These rules will not be brought forward as derived from grand principles of physi- ology, or pathology; they must be deduced from the ag- gregate of careful, faithful observations of individual facts, made by men of enlightened minds. A love of truth, an unflinching love of truth is the first requisite in those, who engage in this holy calling. I shall conclude this note by expressing my regret, that the writings of M. Louis have not yet appeared in an English translation. I trust that this will not long continue to be the case. Dr. Gerhard, of Philadelphia, determined to translate the work on phthisis two years ago, while in Paris. He en- gaged my son to assist him, who commenced the work after his return, and Sound time to go through a hundred and fifty pages, in the intervals oS other occupations, during the short period oS health which he had. Dr. Gerhard has since finished the translation ; but he inSorms me that, owing to the great depression in the book-trade Sor the last year, no book- seller has been willing to undertake the work. It shall not be the reproach oS another year, iS I can prevent it, that this work shall be kept Srom the hands oS our proSession in this country. And more; it must be Sollowed by a translation oS the work on typhus and oSthe volume oS memoirs by the same author. IS I am not greatly in error, it will hereaSter be the subject oS much wonder that these works have lain so long, comparatively disregarded by those who speak the Eng- 72 lish language. I am not ignorant that they have been praised in the British and American medical reviews. I have in another article reSerred to a review in the Edinburgh Medical and Surgical Journal oS the work on typhus, in which that work is treated with great respect. I may be told, that the re- viewer says that the Sacts observed in London and Edinburgh, are, some of them, in contradiction to the observations oS M. Louis. On this assertion of the reviewer I must remark that it is made in general terms; but neither he, nor any other writer, whom I know, has brought forward any series oS ob- servations careSully made, which go in the least to controvert the statements oS the great French pathologist. Note D.-Pa ge 42. The following is a note of the autopsy in the case of James Jackson, Jr., Surnished me by my Sriend Dr. Bigelow, under whose charge it was made. Mucous coat oS the rectum very dark and thickened ; up- per part more mottled; solitary glands slightly enlarged, — Colon eighteen inches Srom end oS rectum exhibits small ul- cers ; — in the transverse colon the mucous coat is thickened and large patches of it apparently destroyed. Coecum, — mucous coat thickened, injected and ulcerated;—contains dark, thick fluid, ropy mucus, and a little Soecal matter. Ileum contains the same dark fluid, its mucous coat but slightly changed; Peyer's glands uncommonly Sew and small, only one, near the coecum, being of the usual size, and containing doubtful cicatrices. Jejunum natural,— stomach contains a pint of dark thin fluid ; — its mucous coat uneven, perhaps by glandular enlargement. Spleen firm, natural. Liver natural. Gall bladder contains dark bile. 73 Thorax. Pleura mostly natural. Lower edge oS left lung slightly adherent to diaphragm. Apex of right lung also ad- heres slightly to pleura, and contains about a dozen tuber- cles ; — air vessels visible to the naked eye in the lower part of this lung, with some interlobular emphysema. Pericardium has reddish patches and a slight effusion of coagulating lymph, one detached mass of which is equal to a small pea ; it also contains semi-opaque purulent fluid. Heart pale, softish. Examined forty-eight hours post-mortem by Dr. McKean. Present Drs. Warren, Channing, Ware, Stevenson and Bige- low. — March 29th, 1834. Note E .—Pa ge 43. The quotation, to which this note is appended, was Srom an obituary notice, published in the Boston Daily Advertiser and Patriot, of March 29th, 1835. It was understood to be writ- ten by a class-mate oS my son's, one of his most intimate and dearest Sriends, and a man oS whose Sriendship any one may be proud. My quotation from this article was made Srom memory, and was not literally correct, but I leave it as it is. On submitting the memoir in manuscript to the supervision of a Sriend, just when it was going to the press, he begged me to insert this article in a note. I wanted no persuasion to add a testimonial, and an offering of pure friendship, so grateSul to my own Seelings. FROM THE DAILY ADVERTISER AND PATRIOT. Died, in this city, on Thursday, Dr. James Jackson, Jr., aged 24. There are circumstances which give this event prominence, even among the severest afflictions with which it is the plan 10 74 of God's Providence to try us in the world. A few months ago Dr. Jackson returned from Europe, where he had been engaged more than two years in the diligent study of his profession. The praise oS his uncommon attainments, and his ardent devotion to medical science, had already reached us from across the sea. He was welcomed home by the wide circle of his kindred and friends, whose warmest expectations he satisfied. There was nothing in him which they wished to alter; and they had everything to anticipate from his suc- cess in that benevolent province of duty, to which from childhood he had wished to dedicate his life, and to which he now brought with him such rich accomplishments and re- sources. He had scarcely ceased receiving congratulations on his re- turn to his native land, or had time to take the steps prepara- tory to commencing practice as a physician, before he was called off from his pursuits, and laid prostrate by disease. The hearts oS those, in whom he had excited just pride and eager hope, were now agitated with all the alternations of feel- ing, with which we wait the issue of a malignant and insidious disorder. At length they were relieved from the load of fear, by his apparently complete restoration to health. He came back to us as one recalled from the gates of the grave, and we Selt grateSul that our prayers in his behalf had been answered. We little thought for how short a space he was spared to us ; how soon the treasure, we had taken anew into our keeping, was to be required at our hands. He applied himself after his recovery, with unabated ear- nestness, to the science and art to which his whole soul was wedded ; and it did not fail to strike some of us, who visited him during his convalescence, with astonishment, to see how quickly and tenaciously his mind resumed its grasp of its dar- ling subject. The degree of Doctor ol Medicine was con- 75 ferred on him in the month of February, and it was but a day or two after he had publicly entered on the practice of his profession, that he was seized with the disorder which proved rapidly fatal to him. In the death of this young man, a thousand expectations are shattered. We have no right to use the language of a pri- vate and exclusive sorrow. He belonged to the public, to whom he had already given pledges of rare eminence in his profession ; and to the troops of friends whom he had bound to him by the charm of his pure and enthusiastic character. Indeed, he was so well known to this community, where he had a sort of hereditary claim to men's affections, that we feel restrained from any attempt to draw the character of our friend. He does not need our inadequate eulogy. Short as was his life, it has left imprinted on our memories, with per- fect distinctness, the beautiSul traits oS mind and temper, which made him the Savorite of all who saw him. To his near and intimate acquaintance, his death seems like withdrawing part oS the general light which Sell on their daily walk. For, not only was he one among those whom they chiefly loved and trusted ; the ornament oS their social circle ; one whose idea never came to them, but they Selt more respect Sor them- selves that they enjoyed his confidence ; — but he had in him so large a soul; a spirit oS such morning Sreshness ; an inter- est so unexhausted in whatsoever was good and true, in man- ners, opinions, persons, that, in losing him, our whole con- nexion with society, our whole delight in living, seems to be loosened and impaired. We hardly dare intrude, even in our thoughts, on the sa- credness oS the bereaved home. What sorrow is like their sorrow, who mourn the separation Srom such a son, and such a brother ? 76 " Where is Timarchus gone ? His father's arms were round him, And when he breathed his life away, The joy of Youth had crowned him. Old man, thou wilt not forget Thy lost one, when thine eye Gazes on the glowing cheek Of Hope and Piety." Thus early has the shadow of the dark valley settled down over the human prospects of him, who seemed to be the child of a prosperous fortune. Thus hastily has he gone away to converse with what is spiritual and eternal. It is well with him. But we who had promised ourselves many years to re- joice in his friendship, and to witness the harvest of true honor he should reap in the large field of his usefulness, we, who stand sadly looking into his sepulchre, what is to console and cheer us ? God forbid we should distrust His infinite love ! No: we lay in the earth the dust of our friend, full of gratitude Sor all that he was in himselS, and Sor all the happi- ness and virtue to which he ministered, like a good angel, in others. He has gone while the dew of his youth was on him • we shall no more see his Sace, nor hear the sincere eloquence of his voice. But the beauty of his liSe, and the sweetness oS his memory are ours. And ours too is the Saith in the immortality oS the soul; the assurance that the parting is not Sorever ; that we shall again greet our brother in the blessed employments and inseparable union of Heaven. Note F.-Paci 49. In this work I have endeavored to avoid introducing my- self, except where it was inevitable Srom my connexion 77 with its object. But I wish in this note to deviate from my course, so far as to explain my own tardiness in acquiring a knowledge oS M. Louis's writings. Among those who know me it may be asked, why I did not earlier become acquainted with these writings, and commend them as I have done the last two winters in my lectures. And it may now be supposed that the personal Savors bestowed on my son by M. Louis have biassed my judgment. Greatly as I value those Savors, I am not willing that it should be believed, that my opinions on matters oS science could be influenced by them. The holy cause oS scientific truth rejects all aid Srom even the best emotions of the heart, as much as Srom considerations oS policy and expediency. My first knowledge of M. Louis's writings was from the re- view of his work on typhus in the Edinburgh Medical and Surgical Journal, in 1830. I was much impressed with the statements there made; but I felt of course great hesitation in believing, in regard to a stranger, that his labors and his success had both been so ex- traordinary as they were there represented. Much depends in such a case on the character of the man, and it should be noted that the review could not, like the works themselves, present internal evidence of the author's devotion to truth. I made a note of the titles of M. Louis's works, determining to send for them. It happened by a succession of little acci- dents, that I did not act under this determination the ensuing season ; and though the matter was not Sorgotten by me, the impression made on my mind by the review became less lively, and at last I decided to leave these and other French works till my son should go to Paris. Little could I then anticipate that M. Louis, or any other distinguished man in Paris, could Sorm so intimate a connexion with that son as actually took 78 place. Notwithstanding what James wrote me on the subject, until his return home, I had not read any of Louis's works. One of them had been in my possession for two or three months, but circumstances prevented me from doing more than to look into its first pages. The discoveries made by Louis in respect to typhus were in contradiction to opinions, which I had maintained and taught for many years. But, within six weeks after my son's return, the evidence derived from post- mortem examinations in our hospital, and in private practice, went very strongly in support of the observations made by M. Louis in Paris. Then I was no longer willing to hear oS that gentleman's works only Srom the lips of my son ; I took hold oS them immediately and derived Srom the perusal oS them the greatest satisSaction. Finding the facts stated in them to be confirmed by my recollections of the past in many instan- ces, and by my subsequent observations in others, and that the whole results were of the valuable character, which I have en- deavored to describe in another article, I have been led to urge upon my pupils the study of those works with all the earnest- ness, which I wish always to feel in aiding their progress in the search for sound knowledge. If it be discreditable, I must sub- mit to the disreputation of yielding old opinions to new evidence; though I might show that M. Louis's accurate observations and nice analysis have confirmed my previous opinions in ten in- stances to one, in which they have reversed them. But the purpose of this note will be answered, if it serves to show, that my efforts to induce my pupils to attend to the instructions oS the Sounder of the numerical system, have been grounded on deliberate conviction and not on personal feelings. EXTRACTS FROM LETTERS FROM JAMES JACKSON, Jr. TO HIS FATHER. EXTRACTS FROM LETTERS. It will readily be understood that in letters written in such entire confidence, as the Sollowing maniSestly were, there must have been many things improper Sor the public eye, and many oS temporary and personal interest only. Hence, there is scarcely one entire letter in the Sollowing collection ; and hence, I have omitted to print many, which might be inter- esting to some minds. Wherever individuals are mentioned, unless such as may be called public men, I have suppressed the passages ; and, Srom the connexion, the whole letters have in some instances been suppressed. This has not been because such individuals have not been mentioned Savorably ; on the contrary, in most cases I remarked that my son avoided speak- ing oS those, whom he could not praise, unless from peculiar and rare circumstances. It may be thought more necessary, perhaps, Sor me to apol- ogise Sor printing so many, than Sor not printing more oS these letters. I can only say that I have admitted none, which I did not believe would interest some oS my son's Sriends. It cannot be supposed that each one of them will be interested in all the letters. 11 82 The ardor, the impetuosity and the freshness of youth, will be sufficiently obvious to the cool and dispassionate, in these letters. They were written by a young man, principally in his twenty-second and twenty-third year. It will not, I think, be by persons of experience and reflection, that these qualities will be regarded with the least charity; or, if by any such, they will be those who are not fathers. If I am wrong on this point, I fear not but that I shall be readily excused. I wish to add that these letters are published as they were written, obviously not for the press; with the exception of the few verbal corrections, which such compositions must always require. I have avoided these even, when not abso- lutely necessary. Paris, October 28, 1831. my dear father, -- I feel almost disposed to cover a sheet or two in enu- merating the difficulties of auscultation. If Laennec has added an important aid to our insufficient means of exploring diseases oS the chest, he has, at the same time, rendered the study oS those diseases more difficult, more laborious I would say, to the learner. Perhaps we may better say, in other words, that this great observer has so Sar extended our knowl- edge upon this subject, by his accurate distinctions, that the labor, requisite to obtain all that is known, is much greater than it has hitherto been. I have just returned Srom the Hopital des EnSans, where I have been experiencing the difficulties and the uncertainties oS auscultation. I have been employed for nearly an hour in examining two children, in both of whom there is some reason to suspect the existence of tubercles. In both, the chest resounds well on percussion on each side ; in 83 both, there is one side where the respiration is natural, strong, vesicular; in both, upon the other side, is an absence, or at least a great deficiency of the vesicular respiration; while, to- gether with a mucous and perhaps a crepitous rale in some points, there is also what seemed to me and my friend, the interne, the bronchial respiration. But iS this last supposition be true, the diseased lung must be in each case, in a great measure, either hepatized, or very Sull oS tubercles. IS this were the case, we should certainly expect to find a great dif- ference in the sound of the two sides by percussion, whereas the difference, if there be any, is very slight. I have not mentioned all the circumstances of these cases ; I shall keep notes of them after future examinations, and should I ever know their end, you shall hear of it. You see there is no doubt which is the diseased side in either case; the difficulty is to pronounce upon the exact seat and nature of the disease. By the by, one of the cases is complicated with a contraction of the side to a very considerable degree, though the child dates his disease to six weeks only, has not had the ordinary symptoms of pleurisy, and says he has been well from his in- fancy. This last, I should doubt. I have mentioned these cases in order to introduce the subject of bronchial respiration. I was not at all aware, or rather I was not fully aware, of the very important distinction between this and vesicular respira- tion, before I left home. I knew the distinction from descrip- tion; I had once, or twice recognised it; I knew generally what was indicated by it; but I was not by any means aware in how many cases it was to be heard, and under what circum- stances it was to be sought. It has been pointed out to me here much oftener than I expected. First, I heard it last summer in several cases in Andral's ward, during the second stage of pneumonia; and from him I learned to distinguish it 84 from vesicular respiration. I remember well one case, in which he said you will hear upon the right side the bronchial respi- ration at the same time with the vesicular, and on the other the bronchial alone. I listened, and could make this distinc- tion ; was confident of it. The difference consisted in a slow expansion oS the vesicles by the air in the one, and an absence of this in the other. From that moment I thought myselS master oS it. Unhappily, I was deceived; and I have often had melancholy occasion to find that my knowledge is not yet perSect on this point. I have since had Srequent occasion to hear this bronchial respiration, and to distinguish it with great confidence Srom the vesicular. At this moment there are two patients in Louis's ward at la Pitie, where I feel confident of making the Sull distinction. There is also a child at the Hopi- tal des EnSans, in whom the difference between the two, in the whole extent oS each chest, is most decided. Another has just left, in whom I thought the distinction also sure; but, unhappily, besides these there are other cases, like the two which I have related, which are very doubtful. Next to the bed in which is placed the child, where the distinction is so marked, lies another, in whom I feel almost sure of a bron- chial respiration on one side, and yet I am distrustful of myselS. Let me remark, en passant, one important point oS difference between the two cases ; the first is chronic, breathes slowly in comparison, although the whole right lung is hors de combat; while the other is acute, its respiration is immensely rapid, seventy while awake and ninety while asleep. This rapid respiration greatly increases the difficulty of auscultation, especially on this one point, with children; because, where the respiration is thus rapid, the air hardly reaches the vesi- cles, or rather their expansion is so momentaneous, as hardly to be distinguishable from the sound oS the air passing through 85 the bronchia ; so that the respiration in the healthy lung comes greatly to resemble that in the hepatized. I speak on this subject, because it is one which has interested me much. Andral in his lecture-room and by his book, has turned my attention very strongly to it. As I tell you, I have occa- sionally found very great satisSaction Srom it; at other times, I have been almost in despair; but I say to myself daily, " listen for that slow, full expansion of the vesicles, which ought to exist in a sound lung, and strive to distinguish it Srom the mere passage of the air into the bronchia." 1 am con- vinced that this is one of the most important distinctions that can be made by the stethoscope. The knowledge to be gained by the auscultation of inSants is much greater than I had supposed. There are certain points oS great difficulty, like that I have mentioned ; but as to others, on the contrary, there is a great Sacility. The crepitous rale, 1 think, is more easily distinguishable in them, than in adults; they are examined with greater ease and more profit upon the dorsal region ; and the immediate is much more easily prac- tised, than the mediate auscultation with them. For my part, I can never henceSorth examine a child under disease without bringing to my aid this means. By the by, you would be much surprised, my dear Sather, to see how much more the imme- diate auscultation is used here, than the mediate. There is one other point, we are too apt to neglect at the Massachusetts General Hospital; it is the examination oS the dorsal region. The French examine the back more than the Sront; we do the contrary; both err, but they the least. 86 Paris, November 6, 1831. I still Sollow Louis, and still find the visit an instructive one. We have a great proportion of uninteresting cases, it is true ; but we have likewise a fair share of the rare and interesting. One of our greatest benefits is derived from the examination oS new cases. He always proceeds by the method oS exclu- sion in his diagnosis; suggesting all possible causes oS the symptoms, aSter having elicited these in a masterly manner; stating the objections to all objectionable suppositions ; and at last arriving, when it is possible, at a satisSactory decision. This mode oS examination is exceedingly useful to the student. It habituates his mind to the consideration of the individual symptoms belonging to each disease; it teaches him what affections are liable to be conSounded with each other, and by what means he is to distinguish them. We have a case oS pleurisy, which has been very interest- ing and instructive; — but here again I have been instructed by committing an error, which, I am very happy to have been convinced is an error, by the change of circumstances in the case. You remember that Laennec says aegophony often re- sembles pectoriloquy so much, as often to be taken for it, et vice versa. Louis had pronounced this case to be pleurisy, saying that there was an effusion into the left pleura. Several oS us, students, on examining this side about the scapula, be- came assured that there was a pectoriloquy at this part, and did not hesitate to declare to each other that we distrusted the diagnosis oS our master. But the gradual absorption of the water has proved him to be right, and taught us to be cautious in Suture to distinguish aegophony Srom pectoriloquy. The case has been very interesting in other respects. During the time of the pressure oS the lung by the fluid in the pleura 87 there was a very distinct bronchial rale, contrasting finely with the vesicular expansion of the opposite side ; and at the latter part oS the disease a very fine aegophony toward the base oS the lung ; as also a peculiar craquement, similar to a crepitous rale somewhat, which Louis attributed to the rubbing oS the false membranes together after the fluid was absorbed. 1 shall never Sorget the case, and am very glad I made the mis- take ; — it reminded me oS a very important Sact in the science of auscultation. We have also a case oS pericarditis oS great interest. Woman, aged Sorty, had not menstruated Sor Sour months, and thought herselS pregnant. FiSteen days since, very copious flow oS menses commenced, lasting eight days, accompanied with violent palpitations oS heart, and difficulty oS breathing, especially on motion ; — at first syncope; no febrile affection Sor Sew first days, no cough, no pain in chest; for last few days some Sebrile action. Now, great palpitation, dyspnoea, almost orthopnoea, cannot assume horizontal pos- ture ; no cough nor pain ; but in space oS size of a man's hand over praecordial and epigastric regions, she says the part " seems dead ;" — no sensibility there except to the most se- vere pinching, and this hardly perceptible to patient; pulse regular, no great febrile affection ; — by percussion, flat sound over region of heart, much more extensive than natural; — no other local symptom. Diagnosis; pericarditis advanced to effusion. Prognosis, almost certain cure. The diagnosis did not surprise me ; — I had come to the same opinion. The want of sensibility in this circumscribed region is a very ex- traordinary circumstance. By the prognosis I was a little sur- prised and perhaps looked a little incredulous ; — but Louis went on to state that, at the least favorable estimate, the cases of recovery were five out of six; and that, of seven or eight which he had treated at la Pitie, he had not lost one. 88 The chance, he considered about as good as in pleurisy. But these remarks applied only to cases which were not com- plicated with any other disease. He added, that the circum- stance of our meeting so often with adhesions oS the pericar- dium, in subjects dead from some other cause, proves that these individuals had survived a pericarditis, and thus confirms his view as to the prognosis. * The woman is now much better, — the dulness on per- cussion has almost disappeared; the sensibility has returned in that spot; less dyspnoea, etc. Paris, November 28, 1831. I am still following at la Pitie. I have made two, or three efforts to follow Chomel at Hotel Dieu; — but it is impossible to do so with advantage. One may hear the clinique to be sure, and a very good one too; but he cannot see the patients. This, especially in my present situation, is the most important by far. My great object is to accustom my ear to stethoscopic sounds; in order to this I must see the patients. The visit at Hotel Dieu is commenced an hour and a halS beSore clear daylight, by candle-light, indeed; — there are from two to three hundred pupils in the wards at the same time, and one is for- tunate iS he sees Sour patients, and examines one in the course of the visit. Whereas, the visit is made at la Pitie by day- light, there are not more than fifteen students, and I call it a black day, in which I have not examined as many as six patients at least, who present stethoscopic phenomena; — ordinarily I examine as many as ten. Besides, as I have * This was a marginal note on the letter, added at a later day evidently, but not dated. 89 told you before, Louis gives a little clinique at each bed. You see that I do right in giving the preSerence to la Pitie. 1 think I am becoming daily more able to distinguish the signs which indicate commencing phthisis. They are not one but many. I find that both Louis and Andral depend more upon the respiration, its Sorce, or its modification, the rales, craquement, gargouillement, and the sound when the patient coughs, than upon the voice. This craquement, or, when more marked, gargouillement is, with them, a very important sign. When slight, it indicates the commencing ramollissement. Frequently it is not heard during the common respiration, but only when the patient takes a Sull inspiration, or coughs. This, if attended with obscurity, or feebleness in the respiratory murmur, is very decisive. Andral says, in as many words, in an article on auscultation, which he has lately written in the new Dictionary of Medicine, that he depends much more upon the respiration, the rales, and the sound of the cough, as affording evidence of tubercles, than upon the voice. In this same article he makes some very important and very interesting distinctions, especially on the subject oS bronchial respiration. I think he has facili- tated Sor me the study oS auscultation with children, particular- ly by his description oS one variety oS bronchial respiration. I fancy that one or two oS those mistakes in diagnosis, oS which I lately wrote you, were owing to a want oS attention on my part to this distinction. IS so, I may hope to profit by them. Since reading the article I have not yet had an opportunity to settle this important question. 12 90 Paris, December 1, 1831. I have to-day seen three very interesting cases of pleurisy. 1. A woman, sick fifteen days; chills; no heat; no pain, unless a little on coughing low on right side ; no loss of appe- tite ; at present pulse very little excited; slight cough; no other complaint; no apparent dyspnoea. The case seemed very slight, and as the French say " pas beaucoup de choses," until Louis, with his almost magic hand, percussed the chest. It was then evident that the lower half of the left chest was perfectly flat, beSore and behind ; — respiration there, while sitting, inaudible; aegophony, not very pronounced, behind. Here then was a case oS complete latent pleurisy, which had gone on to considerable effusion, without pain, or dyspnoea, or any great constitutional disturbance. But, is this new; — have I never seen latent pleurisy before ? Surely it is not new, yet it is interesting. Surely I have seen such cases beSore; —but I have never (or rarely, Sor I remember one, an old man in our Sever ward, in whom I discovered aegophony, when there was no reason to suspect an affection oS the pleura) seen a case, on which light was so quickly and completely thrown by the use oS percussion and auscultation. But Surfher; I made this woman lay upon her belly and I could then perceive the respiratory murmur slightly upon the back, which was entirely inaudible while she was in the sitting posture. This is important, as distinguishing a pleuritic effu- sion Srom hepatization oS the lungs. 2. A woman lies upon the opposite side of the same ward, who has had an acute pleurisy, for four or five days; great pain and dyspnoea; — the side still sounds well on percussion; thereSore, as yet no effusion. Yesterday, about half an hour before the visit, I examined this patient and heard the respira- tion plainly upon both sides oS the chest. Louis, an hour aS- 91 terwards, could hear no respiration upon the affected side. I mentioned to him that it was very clear there an hour before. He said it was highly possible; for no effusion existed; that it was the pain only that prevented the Sull expansion of the lung, and as the pain varied, this must vary. This morning the disease still continued, but the respiration at the time of Louis's examination happened to be Sully audible. This case is valuable in two points oS view. First, in its contrast with the one just related; — great pain and dyspnoea in the one, absence oS both in the other; — total want of effusion, unless it be oSmere lymph, in the one, and very great effusion in the other, so as to enlarge the side even. In the one, nothing but negative and uncertain evidence derived from auscultation and percussion; in the other perSect and entire evidence, by these means, oS a disease which would have been unknown without them. Second, it is useSul as showing that the respiration may be obstructed over a great portion oS a whole lung, without any mechanical cause; — that we must not decide in such a case without comparing the results oS percussion with those of auscultation; — that we must not be satisfied with a single auscultation, but repeat our observations in every case, in which absence oS sound is not accompanied by dulness on percussion. A want oS attention to these two last points would have led to a Salse diagnosis in the present case. Louis regards this last case as rare. He says pleurisy occurs more often without pain than with it. Is he not supported by the records of morbid anatomy ? He would say yes; and by his own diagnosis too; — and by his wonderSul ability at percussion, he can distinguish many a case, which would escape almost any other man. To practice percussion well is no easy thing, and no ordinary ac- complishment. How oSten do men, or women pay five hundred 92 dollars to learn to touch the piano; I would willingly give five hundred to any one who would teach me to percuss like Louis. 3. My next case of pleurisy is at the EnSans Malades. I will spare you a detailed history,—sick a week; pleuritic pain in left side;—respiration very rapid; — great dyspnoea; — constitution much and actively affected; — no cough till night beSore last. When I first saw him, Sour days since, it was as pure a case of simple pleurisy as I ever saw; — he began to cough, night beSore last; — I thought to-day the lung might be affected; — still no expectoration. I observed to-day the Sollowing physical signs, to which I am desirous to draw your attention, because they are each and all interesting. 1. Flat, left side behind, — perhaps also, but less certainly, in Sront. 2. Want oS vesicular respiration Sront and back on left thorax; behind, respiration bronchial; aegophony; certainly alteration of voice. 3. Puerile respiration, whole extent of right side and full sound on percussion. 4. When the boy laid on his belly crepitous rale very distinct, behind, on left side. I forgot to examine him by percussion in this posture. 5. Pressing up of the diaphragm on the right side greatly increased the dyspnoea ; — the same pressure oS the left produced no such effect. 6. Natural vibration on speaking, perceived by appli- cation of hand to right thorax; — entirely imperceptible on left. Diagnosis; pleuritic effusion; pneumonia to first degree on posterior part oS leSt lung. This is only my own examination. 1 was alone. It is to be trusted by no one but myselS; — but to myselS, as I must have a certain degree oS confidence in it, it is very interesting. You will observe that in this case and the first, I have ex- amined the patients while lying on their bellies. This is a mode advised by M. Reynard to determine whether the effu- sion be simple, or accompanied with pneumonia. You see that 93 in No. 1, I heard a slight, but natural respiration, while the patient was in this position; whereas in No. 3, I Sound a crep- itous rale ; leading to the conclusion that in the first the lung was not affected ; in the third it was inflamed. Again, the want oS vibration on the affected side, is a mode oS distinction, pointed out by Reynard and approved by Andral, between a pleuritic effusion and hepatization. I ought not to have omitted to mention that, in two oS these three patients, (and I am not sure with regard to the other on this point), percussion upon the diseased side was painful. Are not these cases replete with interest ? Will you not forgive your pupil Sor daring to write his master such a letter ? It is only Srom the Sullness oS the heart, that the mouth speaketh. But good by, my dear Sather, Sor the present. I am daily, hourly expecting to hear Srom you; it is fifteen or sixteen days since I have had any letters. I hope Sor a clinique; — but as Sar as I see, you get more cliniques than I, Srom our correspondence. UnSortunately such is the Sashion at the present day. Our talkers and writers are those who want experience, the unlearned; whereas, those who are able to speak wisely, are silent. Paris, December 14, 1831. I have been lately much interested in diseases oS the brain. Cruveilhier excited me upon the subject. I have since read an excellent work by Rostan, on the ramollissement oS the brain; and am now reading, with very great pleasure, a most learned and talented work by Lallemand oS Montpellier, upon diseases oS the same organ. This last is truly a master-work. The author differs Srom Rostan as to ramollissement. I have read the arguments oS both and am inclined to agree with Rostan. 94 I find that Andral, in his Anatomical Pathology, does the same. There is still another standard author upon diseases oS the brain, — Bouillaud, whom I intend to read next. That, with Andral's promised volume upon the brain, which will probably appear shortly, and which I look Sor impatiently, will give me a pretty good knowledge oS what the French have learned upon the subject. But, happily, I am not left solely to books. We have now some very interesting cases of cerebral disease in Louis's wards ; — one has particularly engaged my attention within a day or two. A young man, headache for some days ; considerable febrile excitement; eyes quite sensible to light, and ears to sound; Sace flushed, countenance very serious, almost melancholy ; — intelligence perfect, but answers short, as though disturbed by the effort to speak ; no trouble in chest, none, or but very slight, in alimentary canal; — no local symptoms then, but those of cerebral affection, and those slight; — still, hot skin and ex- cited pulse, which must be accounted for. On the whole, the probabilities were in favor of an inflammation of the brain, or membranes. He was twice bled and is much better ; but the sensibility to light still continues. This does not seem to be an extraordinary case upon paper, — and yet to a mere hos- pital observer it is so ; — because it shows him the disease in its very forming stage, which is in every disease by far the most interesting, the most important, and the most worthy of close attention and study. It is Srom this circumstance that I have been much interested in it. Is it not deplorable, my dear Sather, that our science is yet so impotent, as to the means it affords us to discover theirs* morbid changes, be they oS Sunction, or structure; which last is indeed but a continued change oS Sunction, or rather a result of that change ? Is it not deplorable that we are obliged to rest satisfied 95 with the discovery oS the existence oSan aneurism, or a schirrous pylorus, or oS tubercles in the lungs, or some tumor in the brain, only at a time, when they are so Sar advanced as to be beyond our aid ? Have not the public a right to demand something more of us than this ? But there are limits set to the advancement of our knowledge by nature herself. She will not always indi- cate by appreciable signs her commencing disordered actions. Have we yet reached these limits ; and is there not a portion of cases, in which appreciable signs do really exist, did we but know how to seize them ? Has not this subject been too much neglected, my dear father ? Have we not too many books devoted to the nice diagnosis of advanced disease, inevitably fatal; and too Sew upon that oS commencing disease, which may be stopped in its progress ? It is the most difficult, and yet surely the most important oS all the subjects, to which the medical observer can turn his attention. I do not Sorget that the diagnosis oS an advanced disease, a cancerous pylorus, Sor example, is useSul; that we are better able to give proper ad- vice to our patient, than iS we did not know that such a disease existed ; — but, surely, it would be Sar better iS we could be apprised oS the first disorder oS the vessels engaged in this morbid process. I know well we can never become perSect in this respect; — yet I cannot but hope that the time will come, when we shall be Sar in advance oS our present knowledge. At present, the discovery oS even far-advanced disease, which is soon to destroy life, is often beyond our power. My mind has been turned to this subject for a day or two from reflecting upon two cases, now in our wards ; — one, that I have just related, oS commencing cephalitis discovered at its debut, in which liSe was saved by active treatment; and a second, oS aneurism oS the thoracic aorta, which is but lately discovered and will shortly prove Satal; — an exceedingly interesting case. 96 Dec. 17. — I believe I have already written you that my attention has been much turned, since I have been in Paris, to the distinction between vesicular and bronchial respiration. It is the most essential distinction with regard to respiration. Andral, by his book and in his ward, first turned my attention to it; indeed, he has insisted very much more upon it than did Laennec, and in my opinion he has rendered a very great ser- vice to the science of auscultation. He has lately written an article on the subject in a new dictionary oS medicine, which is short, but contains some most excellent remarks, some distinc- tions which I have been able to see verified. During the last week cases, in which this bronchial respiration exists, have multi- plied most surprisingly in our wards:—I was this morning count- ing them, and the number at present under my eye is eight;— seven at la Pitie, and one at the EnSans Malades. They are mostly Srom pleuritic effusion,—one Srom hepatization and perhaps two, — one Srom dilatation of one of the bronchia. This last is doubtful, but quite probable. I suspect, by-the-by, that that form of phthisis which you have called fistulous phthisis, in which there is one small cavity, is in fact a disease depending on a dilatation oS the bronchia ; — in these cases, all the symptoms oS phthisis sometimes occur. In them one cir- cumstance oS healthy anatomy, undiscoverable in a healthy state oS the lung, is maniSested in this unhealthy state, viz.; the existence oS a muscular coat in the bronchia, which in this disease is hypertrophied. My authority is Andral. I wrote you in my first sheet that I have been lately inter- ested in diseases oS the brain. I have had the good Sortune, this evening, to see a very beautiSul morbid specimen of dis- eased brain. A child oS Sour years oS age entered last eve- ning at the Hopital des Enfans. For the last month it had had occasionally slight convulsions, but its health was perSect- 97 ly good, it was playing about till yesterday-noon, when it was suddenly taken with severe convulsions and brought to the hospital. Last evening when I saw it, every part, face, arms and legs were in continual convulsive motion ; it was insensi- ble to the hardest pinching of the skin, and blind. I laid my finger upon the cornea without disturbing it; pale ; died at nine and a halS P. M. Autopsy. Tumor (tuberculous ?) nearly the size oS a hen's egg in the right hemisphere, near, behind and external to the corpus striatum; the white substance surrounding it was in a state oS the most complete ramollissement, absolutely fluid, though tenacious. In one oS the lobes oS the cerebellum there was a similar, but smaller tumor. The case is extraordinary Srom the absence oS symptoms, and the continuance oS the health oS the child, and also the rapid termination Srom the first development oS symptoms. These diseases of the brain are more than sufficiently obscure; — here is a case of most extensive disease unattended, as we may say, by any symp- toms ; Sor a long time, at least, it was so. It is not a week since a woman died at la Pitie, with paralysis oS the right side, almost complete, with great Seebleness oS the left; — loss of speech and consciousness; in fact many of the symptoms of apoplexy, which had come on within three or four days before her death, and on examination we found nothing, or next to nothing, to explain the symptoms. — What a contrast between the two cases. In one, most striking symptoms and no appre- ciable disease; in the other, no symptoms and very extensive disease. Much depends, I know, upon the rapidity with which each progressed ; — but with all allowances oS this sort, there is yet much unaccounted Sor. I find it very useSul thus to bring cases oS the same sort together, to study their resem- blance, and their distinctions, and endeavor to draw Srom the 13 98 whole something, which shall make a durable impression upon my mind. It is thus that I have done in those cases of pleu- risy and four or five others, of which I lately wrote you. It 's thus too, that I have enumerated and brought together all the cases, in which I hear the bronchial respiration. I find it useSul, though you may complain, that I too oSten make you read my boyish studies; that I read loud and disturb my bet- ters, when I ought to read to myself. But after all, perhaps, you may like as well to receive letters which shall show you what is the bent of my mind from time to time, although rapidly and poorly sketched, — as on any other subject upon which I can employ my pen. Paris, December 27, 1831. I intend giving you a short list of the cases of stethescopic interest, which have been under my eye and ear since I last wrote you, in order that you may realize that I have, not only nominally, but actually an opportunity to acquire a certain de- gree of facility in the exercise oS auscultation and percussion. To any but my Sather, to send such a list might seem to betoken either a degree oS vanity, or a desire to impress the reader with an idea that I possessed more proficiency than I really do ; but you will understand my object, viz ; to present you with a picture of that which actually engages my attention, that you may realize it. 1. Woman, — acute case, palpitation of heart ; pain in left side of chest, especially on percussion ; dyspnoea ; flatness over greater extent than common in praecordial region ; nothing peculiar by auscultation ; — pericarditis ? The case is uncer- tain ; the legs are cedematous. Louis depends very much on 99 percussion in the diagnosis of this disease ; he has written an able memoir upon it, which I shall send you in the spring. 2. Phthisis ; cavernous respiration, gargouillement, pectoril- oquy under right clavicle, but all much more distinct in supe- rior spinous region behind; voice for last few days almost extinct; excessive difficulty in deglutition ; pain in larynx. Diagnosis. — Cavity in summit of right lung, whose parietes are thinner behind than in front ; laryngitis ; ulcers of epiglottis ; death ; diagnosis fully confirmed. 3. Sibilant and sonorous rales over both lungs, varying in degree, with paroxysms of asthma. Louis says, emphysema. I believe it is a congestion of the mucous membrane, perhaps complicated with emphysema. 4. Gargouillement, and dulness on percussion under left clavicle; voice modified, though not perfect pectoriloquy; right clavicle dull on percussion ; bronchial respiration there ; com- mencing cavity in summit of left lung and tuberculous indura- tion in summit of right. 5. Double pleuritic effusion ; flat on percussion over lower halS of each chest, behind ; aegophony and bronchial respiration left side ; of the other I am not sure what we discover in the voice or respiration,— it has been a very latent case. — Decem- ber 30th, perSect aegophony on the right. 6. Latent pleurisy oS left side ; effusion, now mostly ab- sorbed ; aegophony has disappeared; respiration returned; almost as sonorous as opposite side on percussion. 7. Woman, who had pneumonia some months since at Hotel Dieu; no symptom of diseased chest at present, full flesh, etc.; under treatment for leucorrhea; crepitous rale over two thirds of left lung. Is it oedema, the remains of pneumonia of six months' standing? 100 Dec. 30. —8. Woman, past forty years of age ; symptoms of diseased heart since age of nineteen ; now extreme ascites and oedema; percussion over praecordial region natural; by auscultation also natural; nothing positive then from stethe- scope, yet important to note that there is nothing ; Sor the other local and the general symptoms prove an affection of the heart. Louis says all these symptoms may be produced by an ancient inflammation of the pericardium, especially if this membrane has become ossified. Laennec has related a similar case, and I think Andral likewise. There is no proof of hypertrophy, or dilatation. 9. Near the last is a young woman, who has the local symp- toms of a hypertrophy of the left ventricle, dating two years back, without any general symptoms; palpitation; under stethescope, great impulse in front and behind. 10. A fine case of aneurism of the thoracic aorta, of which I have before written you; slight projection of right side of chest; Sremissement cataire sensible to hand, bruit de soufflet to ear, and complete dulness on percussion over some space ; excessive dyspnoea on the slighest motion. 11. Woman, phthisis; very distinct cavernous respiration in both supra-spinous regions; pectoriloquy very distinct at left, less so at right; no gargouillement; cavern in summits of both lungs. 12. Sibilant and sonorous rales over both chests ; resounds well on percussion ; asthmatic paroxysms at times, and constant dyspnoea in some degree; congestion of mucous membrane. 13. Commencing phthisis in a man with scrofulous abscesses in neck ; flatness and diminution oS respiratory murmur under right clavicle. 14. Flat sound over two-thirds oS right chest, want of ve- sicular respiration, but fine bronchial. Louis says pleuritic effusion ; I doubt between this and hepatization of lung. 101 15. Young boy, very interesting case ; sound entirely flat over whole leSt chest; entire absence of respiratory murmur ; six weeks since, on entrance, the chest on this side was con- tracted ; now enlarged, intercostal spaces obliterated, heart Selt to beat on right oS sternum. Louis says tubercles throughout whole lung; but I say an effusion, probably purulent, into left pleura; — we shall see. 16. Phthisis : — perfect pectoriloquy, loud cavernous respi- ration and great gargouillement over space of five inches diam- eter, from right clavicle downwards; enormous tubercular excavation. 17. Gargouillement, pectoriloquy and cavernous respiration, in both supra-spinous regions ; loss oS voice; cavern in summit oS each lung, ulceration oS larynx. 18. General symptoms oS organic disease oSthe heart, bruit de soufflet especially on right side oS heart, Sor some months ; latterly more dyspnoea; flatness Over very extensive portion of chest, about praecordial region; sub-crepitous rale right side oS chest; disease oS right side oS heart; effusion into pericar- dium ; oedema oS right lung. 19. Cavernous respiration, or rather a loud soufflet under right clavicle, with pectoriloquy, in an old man who has had catarrh for a long time, and not attended with any symptoms of phthisis. Probably dilatation oS bronchia. 20. Very interesting case, in ward about two months ; dysp- noea and other symptoms oS disease oS heart or great vessels ; impulse oS heart natural; an inch or two below left clavicle battement simple, (See Bertin) stronger than pulsation in car- diac region; same battement in corresponding point behind; no projection or tumor whatever; aneurism of the aorta. Died yesterday,—diagnosis fully confirmed; large aneurism commencing just aSter arch, also Salse membrane and serous 102 fluid in pericardium. The pericarditis had been overlooked. I shall never Sorget this case. 21. Man, aged, enormous pulsation of both ventricles, especially left ; other general symptoms of the disease I have not mentioned ; autopsy ; general enlargement oS heart; hy- pertrophy oS both ventricles especially left. 22. Flatness, more extensive than common, o ver praecordial region ; strong impulse oS left ventricle ; pulsations of jugular veins; pulse at radial artery very small; general symptoms of diseased heart. Death ; hypertrophy of left ventricle with diminution oS its cavity; dilatation oS right ventricle ; orifices Sree ; remarkably small pulse with diminution oS cavity oS left ventricle ; Abernethy's pathognomonic sign oS contraction of mitral orifice disproved. 23. Old woman, great impulse oS heart; pulse exceedingly small, especially in left wrist; flatness and aegophony right side of chest; organic disease oS heart; effusion into right pleura. Will probably die to-day. 24. Old woman, oedema, ascites, very small irregular pulse, enormous, enormous impulse of heart; flatness extensive over praecordial region ; flatness and bronchial respiration right side of chest in two lower thirds; tumor below right hypochon- drium Selt through a fluid. Death; great general enlarge- ment oS heart ; ossification of mitral valve; piece of bone nearly an inch long, a quarter oS an inch thick and broad ; hypertrophy oS left ventricle, dilatation of right ; fluid in right pleura ; liver descended nearly to crest of ilium. 25. Very interesting, — woman Sorty years oS age, — en- tered six weeks since, — said she had pain in praecordial region, palpitation, and swelling of lower extremities, five months since; had been convalescent; now dyspnoea ; flatness over praecordial region more extensive than natural; one or two 103 pneumonic sputa; cough; crepitous rale in two or three points behind. Was bled, etc., — went on pretty well Sor Sour or five weeks, — exposed to cold and Satigue; increased dysp- noea, cough, more pneumonic sputa, crepitous rale in two lower thirds oS right lung; next day bronchial respiration on side about opposite sixth rib; bruit de cuir, or rather a sound precisely like that produced by chewing India-rubber, over region oS heart; would not permit percussion, and would not allow any examination during Sour last days oS liSe. Diagno- sis. Pneumonia oS right lung. I added on the authority oS Collin and Meriadec Laennec, pericarditis, with Salse mem- brane but not adhesions. (Andral was not there ; it was in his ward ; we were all young men who saw the case.) Au- topsy. Sero-purulent effusion in right side oS chest, — hepati- zation oS two lower lobes; hepatization oS part oS leSt lung; small quantity oS sero-purulent fluid in pericardium,—heart and pericardium covered with Salse membranes. 26. Old woman, orthopnoea; swelling oS lower extremities, etc.; double bruit de soufflet or rather de scie, Sor it is very loud and just like the sawing oS timber, especially on right side oS heart. Diagnosis. Disease oS heart, impossible to say oS what nature. 27. Man, flat behind, right side chest, aegophony, absence oS respiratory sound ; pleuritic effusion. 28, 29, 30. Man and two women, each an enormous cav- ity in summit right, or left lung, indicated by a frightfully perfect pectoriloquy in two, and by gargouillement and loud cavernous respiration in all. These are all at la Pitie, — at the Enfans Malades, just now, there are very few cases of interest. 31. Boy of four years of age. Pneumonia for three or four weeks, in which we have formerly heard crepitous rale in 104 both sides; now constantly emaciating ; pulmonary expansion very feeble in lower half oS both lungs, scarcely any; hepati- zation oS lower lobes, — pretty certainly of right, left more doubtful. 32. Pleurisy of right side in boy of twelve, followed by very great effusion, indicated by complete flatness over whole right chest; absence oS vesicular respiration ; Sull bronchial respira- tion ; now considerably lessened; perSect aegophony. 33. Boy, aged ten, fever, latent pneumonia; flatness oS right chest; absence oS vesicular respiration and presence of bronchial in lower halS of chest. It is somewhat astonishing to me that during the last half of the month of October, I saw at least twelve or fifteen cases of acute pneumonia in this hospital; during the last two months, on the contrary, there have been very few. Indeed there is scarcely any acute disease in Paris, at this season. I have not seen ten cases of fever for the last three months. You will find my catalogue of cases dull enough, but they will tell you how my ears are employed. I have enumerated them only from recollection, as I sit in my room, by going round the wards in imagination. OS course I have forgotten some, but have mentioned the most interesting. I begin to think peri- carditis a pretty common disease, Sor I have seen seven cases within three months, and three oS these have been proved by dissection. As Sor organic diseases oS the heart, you see I have had lately a fine assemblage of them ; and the two cases of aneurism of aorta have been very useful tome. As for advanced phthisis I have given you an abundance of cases. It so happens that at this moment we have but very few cases of commencing phthisis in the wards. You see, too, that pleurisy, more or less latent in many cases, is quite common among us; but not 105 of an acute or dangerous form. We have also many and quite interesting cases of cerebral disease. There are some points, some modes of examining patients with these diseases, employ- ed by the French, which are neglected by us. I told you I was reading Lallemand ; I have finished his work and am now engaged with Bouillaud. Lallemand is a man of talents; his work, besides many valuable details, contains some most important general considerations as to symptoms and pathol- ogy. It contains also some errors, as I think; but is on the whole a most excellent work, and I am very glad to have read it. Note by Editor. — To medical students, who wish to know what they may find in a Paris hospital, the foregoing may be interesting, as helping them to realize the scene. It may not be without interest to some others, perhaps. For those who regard the diagnosis, I wish to add, that they should attend to the date of the letter; at a later period the writer would have been more ready to recognise emphysema of the lungs in the third and twelfth cases. Yet, in the present state of my knowledge, I should hold to the opinion I have long entertained, that a congestive state of the vessels in the mucous membrane of the lungs exists during the asthmatic paroxysm. Paris, January 15, 1832. * * * * This bronchial respiration, especially, which is of vast importance, I have got to distinguish of late with much more ease ; — from it I made a correct diagnosis an evening or two since at the Enfans Malades ; and with children (as I have found from experience, and on talking with Andral about 14 106 it, a few days since, I found he had made the same observation as myself,) it is vastly more difficult than with adults to dis- tinguish it from vesicular respiration. When I am examining children I adopt the following rule, which may or may not be a true one; it is at any rate my own. Between the moment, at which I first hear the entrance of the air into, and that of its exit from the lungs, I listen for an intermediate moment, in which there is an expansion, which lasts a longer or shorter time be- fore the expiration commences. Ifl find any such expansion, I presume the vesicles to be still free; if not, I call the res- piration bronchial. You may not understand me ; — in other words then, — the air in passing through the bronchia during inspiration makes a certain sound; on passing through the same tubes on expiration it again makes a sound somewhat similar; — if between these two sounds there is a third, which resembles the expansion of a number of little membranes by this air, I call the respiration vesicular ; — if there be no such intermediate sound, I call the respiration bronchial. But is such a distinction always necessary in order to assure your- self of bronchial respiration ? By no means. As I have told you, Andral divides this respiration into three species, all of which I have more than once tested; — one oS them is that, in which the bronchial seems at first to be only an exag- geration oS the puerile ; — it is this which I have oSten found in children, and which Andral tells me he has found more in them, than in other subjects ; during pneumonia. My rule is Sor this case ; I think a close application oS it, while my ear was on the chest, has enabled me in more than one instance, to make a correct diagnosis. I suspect you will hardly believe it, at least I should not, when I was last with you, that it re- quires a vast deal oS attention and habit in many cases, to say 107 which lung is hepatized in an inSant; so much is the respira- tion upon the diseased side, like that upon the sound. I do not speak Srom one instance but Srom a great many, which I saw two months since, and such as I now see again in abundance. On the whole, pneumonitis, in its first stage, is easy to dis- tinguish in children; but not by expectoration; there is none; not always by cough, Sor it is sometimes very slight, and be- longs also to bronchitis; not by oppression, Sor it is not always present, and occurs sometimes to a great degree in bronchitis; not by Sebrile excitement, Sor this too accompanies bronchitis. As to the remissions in the morning I have not been able to attend to it; my visits are made necessarily always in the eve- ning. Not certainly, but more certainly than by any other means, by crepitous rale ; this in the child is almost constant and very marked; but unhappily it does sometimes occur in cases, which we cannot believe to be anything more than bron- chitis ; — iS not the crepitous, at least the sub-crepitous. I shall make some remarks to you on this subject, in my next. I believe, I have learned here some limits to Laennec's pathognomonic signs, which, though I am sorry to find them, as they are true, it must be useSul to know. But when you come to the second stage of pneumonia, contrary perhaps to your previous expectations, you will find the physical signs Sar less easy to seize, though to be sure, the general and other local symptoms will then generally aid you greatly. Percussion is here, oSten useless ; — in vain will you endeavor to make a difference in the sound oS the two sides ; I do not say always, but oSten, very oSten ; — and the bronchial respiration is very difficult to appreciate. I should blush to have written you such a letter, but that I know my experience in the auscultation oS children is Sar greater than your own. I will write you, by the next, an account oSmy difficulties and deficiencies in this branch. 108 Paris, January 16, 1832. I have written you several times oS pericarditis; can you believe me that I have seen eight cases within three months. Louis has rendered a great service to science by his memoir upon that disease. He has established an almost certain pathog- nomonic sign. I can now subscribe to the Sour Sollowing propo- sitions with regard to it, which I deduce Srom Louis's memoir, the cases I have seen in his wards and his clinical observations. 1. It is a common disease. 2. Like pleurisy it is often latent, being attended neither with pain, nor any of that assemblage of horrid symptoms, by which it is generally described. 3. It is simple in its diagnosis for one, who can exercise well the art of percussion; instead of being absolutely undis- coverable and only to be divined, as Laennec has said of it. 4. It is by no means so fatal as has been generally supposed. Of the eight cases I have seen here, three only ended in death, and in each oS these the disease was connected with other very extensive and severe thoracic disease. In the other five, it seems to have been uncomplicated, unless with a simple bronchitis. I would not have believed this when I left Ame- rica. I now believe each of these propositions, as firmly as I believe the same with regard to pleuritis, although not to the same degree. But you will ask, in how great a proportion of cases there is sufficient effusion of fluid to afford a flat sound. Louis answers in his memoir, that oS thirty-six cases collected Srom the best authors, in thirty-three the quantity oS fluid was sufficient. I have lately seen a case oS death during, and from exces- sive haemoptysis, in which the autopsy was against Laennec's apoplexy of the lungs, and against the theory of a ruptured vessel, and in favor of an effusion from the mucous membrane. 109 Jan. 22. — * * * * But I must not tell you the good side only of my auscultatory experience, neither must I allow you to believe me too great an enthusiast on the subject oS auscultation. Know then, that I still make mistakes in my diagnosis with children, conSounding the bronchial with the vesicular respiration, and vice versa. I have twice made a mistake upon this subject, lately. Again, the various modifi- cations oS the voice are exceedingly difficult to seize, and will still require a good deal oS practice with me. But in order to prove to you that I am not a blind enthusiast on the subject oS auscultation, how shall I proceed better, than by stating several oS the limitations, which I have here learned, to what I had considered truths and pathognomonic signs beSore I leSt America. Thus, though much more confident in the art generally than when I was less acquainted with it, you will see that in advanc- ing farther, if I have met with new truths, I have also met with new and unexpected doubts. 1. The crepitous rale is a sign oS pneumonia; — here are two main difficulties. First, the distinction between crepitous and sub-crepitous rales, is, to say the least, very difficult and probably impossible at times, so nearly do they approach each other. I say impossible, Sor both Andral and Louis conSess by their very words that they cannot decide, at times, to which class the rale they hear is to be reSerred. Here then are two rales indicating a different state oS the parts, which cannot at times be distinguished Srom each other. Secondly, crepitous rale, which at times approaches so near to sub-crepitous, does not always indicate pneumonia. Laennec had already pointed out its existence in oedema oS the lungs; but it occurs also, or at least a sound not to be distinguished Srom it, in two other cases; acute bronchitis, when the disease exists in very small bronchia; and in pleurisy, aSter the effused fluid is mostly absorbed and the Salse 110 membranes rub against each other. You may ask, if I only quote, or if I know these things. I answer, yes, to each ; I both quote and know them ; but my knowledge is as yet imperfect; I have seen two instances at least of each, which were tested by all the other symptoms of the diseases; but I have not yet had anatomical evidence of either. 2. Sub-crepitous rale. I have before said that it was at times difficult to draw the line between this and crepitous. Now, for the other extreme, — it is impossible to say when the sub-crepitous becomes mucous rale; — this, however, is not so perplexing as the Sormer. 3. Mucous rale. Here is a great difficulty. We hear the bursting oS a Sew bubbles under the clavicle. Is it a sub-crep- itous rale and is the part oedematous? Is it a mucous rale and is there an inflammation of the bronchia ? Is it a craquement, a species oS gargouillement, and have we the sign of some Sew soStened tubercles ? Or finally, is it pneumonia, in which there is also an inflammation of the mucous membrane, and is the sound produced by a mixture oS the two sounds proceeding Srom the two parts affected ? But again, — the difficulty of the accurate distinction oS this rale does not exist only, when it is slight and limited. When it is very Sull and extensive, the mucous rale approaches so near to the gargouillement in a large cavity, that not only the most practised ears cannot make the distinction, but have actually been deceived. I would, iS my paper would allow it, continue my remarks about some other rales and the various modifications oS the voice. I have spoken above, not oS imaginary difficulties, but oS those which I have myself often experienced, and to which I have seen other and better men than myself obliged to bow. I have some ideas upon the varieties of crepitous and sub-crepitous rale, which I will submit to your judgment in my next letter. Ill You see I still remember to limit the reports of the stethe- scope, to compare them with the rational symptoms, and from this comparison to form my judgment. I never write you of other modes of studying pulmonic diseases, but do not imagine that I neglect them; au contraire, I flatter myself I have made some advancement in this part oS the science also. Paris, January 23, 1832. my dear father,-- I have an hour to spare beSore going to bed, and as I wish to review a portion oS Andral's lecture oSthis afternoon, I will do it by giving you an abstract oS the same. I shall retain the paper however to send by my friend S —. The general subject was the symptoms oS phthisis, oS which disease he has given a most learned description. The part, which I am especially desirous oS reviewing and sending you, is that in which he treats oS the physical signs. Physical signs, to be derived Srom two sources, percussion and auscultation. I. Percussion. — The evidence afforded by this means of exploration varies according to circumstances. First* The sound may be every where normal; and this too, during all the stages oS the disease, even after the forma- tion oS cavities; as when these are deep-seated. Secondly. The sound, may be augmented partially, or gen- erally over the chest; this augmentation may be only apparent as regards the lungs, or it may be real. 1st. Apparent Srom the great emaciation oS the subject; the bony parietes will yield a clear sound which may be mistaken Sor the sound yielded by the lungs themselves. 2d.* Real Srom a modifica- * For explanation of * see page 116. 112 tion of the parenchyma of the lungs, which may arise from three causes. 1. A large cavern, which is at once superficial and empty and not surrounded by indurated lung; 2. Emphysema, which, as I have already told you when discoursing upon the anatomical signs of phthisis, often exists around the tubercles. *3. Rupture oS cavern into pleura, producing pneumo-thorax. Thirdly.* The sound may be diminished ; this over a whole lung or more limited in its extent. 1st. From an agglomeration oS crude tubercles; — this is not a very common cause by itself. 2d. And principally, Srom an induration of the paren- chyma about softened tubercles or caverns; — from this cause you will almost invariably find a flat sound over a cavern. Fourthly.* There may be neither increase nor decrease oS sound, but a change in its nature. The bruit de pot Sele; (the sound oS a cracked jar;) when there is a large cavern,this is sometimes observed, especially iS the patient's mouth be open during percussion. This is rare, but you will remember a case, which interested us in the Massachusetts General Hospital, in which it occurred; and there are now three such cases at la Pitie. Add to the Soregoing, that without percussion, on placing the fingers upon certain points oS the chest, while the patient speaks or coughs, you will Seel a peculiar sensation, a sort oS vibration, which continues up through the whole hand. This exists, not when the portion of lungs beneath the hand is com- pletely impermeable to air, nor when there is an effusion into the pleura in that spot; for in these cases no vibration is felt; but it occurs where there are a few disseminated tubercles. As yet we have obtained no signs, which indicate the exis- tence of tubercles; we have discovered only that there do ex- ist certain lesions of the lungs, without indicating their nature. II. Auscultation. Three points to be considered,—respi- ration, — rales, — voice. 113 First. Respiration. — 1st. In many cases, or at least in some, we must acknowledge that the respiration is natural throughout the whole course oS the disease. This may be while the tubercles are crude, or even after they are softened and caverns are formed, if these be deep-seated. 2d. It is sometimes more intense than natural; — this phe- nomenon is very frequent, and you should always fear from it, if there be other symptoms of phthisis. It is on the con- trary very rare in chronic bronchitis; whereas, when there are tubercles disseminated through the lung, the healthy parts seem to act more than common, as iS to supply the place oS those occupied by tuberculous matter. This intensity has very oSten excited my attention and is well worthy oS yours, in forming your diagnosis during the early stage of phthisis. 3d. It is sometimes more Seeble than natural; —either uni- versally, which is rare ; — or partially, as under the clavicles ; which is very common. 4th. It is entirely wanting in some cases, — in certain points, or over a considerable extent. 5th. The inequality oS the sound over a certain extent is sometimes very striking. Thus, you apply your ear, and as you pass along, at this point the respiration is natural, at the next it is wanting entirely, at the next it is unnaturally strong, and at the next unnaturally Seeble ; and thus at each point It varies. This inequality, which I have oSten observed, indi- cates almost certainly, indeed, I may say certainly, either the existence oS disseminated tubercles, or of indurated lobules. By other symptoms you must decide which oS the two. This inequality oS sound is oS very great assistance in the diagnosis. 6th. The respiration is heard, but it is modified. 1. In- stead oS being vesicular, it becomes bronchial, Srom the in- duration oS the surrounding parenchyma and the agglomera- 15 114 lion oS tubercles. OS this species oS respiration I have al- ready pointed out to you the important varieties in my lec- ture upon pneumonia. *2. Cavernous, — when the cavern is empty; thus, you may discover it at night, and it will have disappeared the next day. It will also sometimes disappear entirely after coughing and be replaced by a gargouillement. You will sometimes hear gargouillement at one spot and directly at its side the cavernous respiration. This may be explained by the existence of two near caverns ; or of one which was par- tially divided by a septum. If you have heard what has seemed to you a cavernous respiration for a long time, and it has never been accompanied by gargouillement, you should sus- pect that the respiration is truly bronchial and not cavernous. *3. Amphoric, this is rarely heard, — yet it occurs sometimes in very large caverns, when quite empty. If the gargouillement has ceased, and these two last modifications of respiration con- tinue, we may then hope Sor a cicatrization of the cavern. *4. Sometimes, though rarely, tintement metallique, in a large cavern. Second. Rales. — 1st. Sometimes none whatever. 2d. While the tubercles are yet crude, all those rales may be heard which I have described to occur in acute and chronic bronchi- tis. * 3d. During the ramollissement, there may be either sub- crepitous rale, or mucous rale. But, to be truly valuable in the diagnosis, these must be heard always at the same point and for a considerable length of time. —* 4th. ASter the Sormation oS caverns, —gargouillement; —this sound is in my opinion the best proof of the existence of a cavern in the lungs; I find it more certain than pectoriloquy. You will some- times hear it only after the patient has coughed; or rather on applying your ear it will not be audible, but will become so after a cough. Therefore, you should always ask the patient 115 to cough, before allowing yourselS to decide whether this sign exists or not. When the gargouillement is well marked and is always found at the same spot, it is the best proof of a cav- ern. Take care not to confound this sound with a mucous rale. *5th. You will sometimes hear under the clavicles a variety of rales succeeding each other; and passing into each other; — craquement, sub-crepitous, mucous, etc.— when these exist Sor a long time at one fixed point, they indicate pretty surely soStened tubercles, or small caverns. Third. Voice.—The modifications oS the voice are owing to two circumstances. — * 1st. A diminution oS the permeability oS the lung to the air. — * 2d. The existence oS caverns. In the first we have an extraordinary retentissement oS the voice ; bronchophony. * In the second, the word spoken seems to pass directly into the ear; pectoriloquy. But, in the first place, these two phenomena are liable to be conSounded with each other, and, in Sact, are so conSounded daily ; varying as they do with a thousand circumstances. 1. They are heard sometimes even in healthy persons. 2. They vary as the tone is grave or acute. 3. They may arise Srom the size oS the bronchia which open into the caverns. 4. They may arise Srom the greater or less induration oS the parenchyma surround- ing the cavern; 5. Or Srom the brides in the caverns; 6. Or Srom the quality and quantity oS fluids contained in them. From these and other causes is an endless variation. When I hear the peculiar retentissement oSthe voice, called pectoriloquy, without gargouillement, I am in great doubt whether a cavern really exists. Again, very often when there is indeed a cavern, no pecto- riloquy is found. Garguoillement is Sor me a much better sign. Result. OS the signs afforded by auscultation, 1. Some- times there are none. 2. Some are doubtSul. 3. Some are 116 certain. But Sor an accurate diagnosis you must depend upon a combination oS these various signs. The above is only an abstract; I cannot pretend to give Andral word Sor word. Those signs marked * on the margin I have observed my- selS, and can at this moment recall the cases in which 1 have observed them. Some of those not marked I am quite sure 1 ikewise to have tested, but as I cannot recall the individual cases, I do not choose to consider them as yet tested by my ear. Although I should like to write still more upon auscultation, and especially oS two or three anomalous cases of phthisis, yet, Sor Sear that you may imagine me totally regardless oS other diseases, and totally inobservant oS therapeutics, I shall say a word or two more on other subjects, which have lately at- tracted our attention at la Pitie. First, then, of cancer of the womb. We have had ten or twelve cases of this disease in Louis's wards during the last four months, and he has lately called our especial attention to them in his clinique. It is useless for me to write about the ordinary symptoms; I wish only to allude to two or three of the most important points to which he has turned our attention. 1st, and chiefly, M. Louis has established that, in a great majority of cases, the first symptom of this affection is uterine haemorrhage; not slight, but severe and long continued. Of twenty-one cases, which he formerly collected at La Charite, sixteen commenced in this manner ; — of six which we have now in the ward, five certainly, and perhaps, the sixth com- menced in this manner likewise. And I well remember two months since, that of five cases, then in the ward, all but one likewise commenced by haemorrhage. M. Louis asserts, then, 117 that iS a woman aSter the entire cessation oS the menses at the due period, has a severe haemorrhage Srom the womb, although there be no pain orother local symptoms, although on touching you find no evidence of disordered structure, still you should be very suspicious that a cancer will sooner or later Sollow in that part. 2d. Authors generally describe this disease, as attended with excessively severe pains, &c. This is sometimes true, but by no means so generally true as has been thought. OS the six cases now in our wards, in three there was no pain until a very advanced period; and then it was inconsiderable ; and in one, although the disease is quite advanced, there has as yet been no suffering. The case oS the old lady whom you saw frequently occurs to my mind; — iS you know the Sate oS that lady, please to write it on the margin oS this letter. There is one very important subject in general pathology, on which Louis insists very much and very often, and which is certainly too much neglected. It is important not only as a matter of science, but also practically. It is, that in all acute diseases we should acquaint ourselves with the state of all the important organs, prior to the occurrence of this acute disease. Thus, for example, you see your patient with all the signs of pleurisy, which is considerable in extent and intensity. Your subject may have been in perfect health be- fore that time, or he may for some months or years have had slight symptoms of pulmonic or other disease, which he will pass over in silence unless you question him particularly, most particularly, about them. It will too oSten happen, especially iS the acute disease be striking and serious in its character, that the attention, not oS the patient only but oS the physician, will be entirely occupied by that alone, and the chronic dis- ease, iS there exists any, will remain unnoticed, to the Suture regret and dismay oS both parties. 118 Of what vast importance is it in the case I have taken as an example, (pleurisy,) to know if your patient for some time past, has not had the commencing symptoms oS phthisis. And yet in many cases, where the symptoms oS the latter have been very slight, and the symptoms of the acute disease are so serious as to absorb the attention, how often has it hap- pened that the practitioner has thought that he was treating a simple pleurisy, when in fact it was a pleurisy complicated with tuberculous disease. And here, under this mistake, how erroneous may be his prognosis. For pleurisy, by itself, sim- ple pleurisy, is scarely ever fatal; Louis says not more than one in an hundred, for of sixty-eight cases which he has seen within six years, not one died. And, on the other hand, when the same disease occurs in a tuberculous subject, what have we after a month or two convalescence ? disappearance of all the symptoms ? no, but the appearance of new ones ; — signs oS soStened tubercles and commencing caverns ; — loss of strength and emaciation, etc. ; in fine, declared phthisis. I am describ- ing only what I am now seeing, and each day I feel more and more the necessity of acquainting myself with the previous state of the organs, before I allow myself to form an opinion of an acute disease. I trust that I shall never forget the uniform importance, which Louis gives to his two first questions, and the untiring patience, with which he repeats them, until he has settled, so far as possible, the exact truth. " Depuis quand etes vous malades ?" Perhaps the answer is three days or three weeks : whatever be this answer however, the first question is invaria- bly followed by a second; " Avant ce temps-la etiez-vous tout-a fait bien-portant, tout-a fait, tout-a fait ?" Then follows a most exact investigation of the symptoms from the very first departure from health to the present moment. 119 I want to say a few words upon a disease I have frequently seen here, but never in Boston; the colique de cuivre, or brass colic. This is marked by pains, as in lead colic; but in- stead of constipation, diarrhoea; and yielding to a purgative treatment; as I have often seen under Louis and Andral. I have seen the antimonium tartarizatum given in full doses in three cases of pneumonia successfully ; but in each there had been a previous venesection repeated two or three times. I once saw, last summer, a man killed by the same treatment. You see I am laconic on the subject of therapeutics. Paris, February 16,1832. " Laennec has rendered a great service to science by his description of emphysema of the lungs," said Louis, yesterday evening ; and I may add, Louis has rendered me a great, a very great service, by teaching me the characters of this disease, during life and after. His two last lessons upon this subject were invaluable. I did not know the disease when I left you, except in the pages of Laennec. I now know that it is com- mon, and that a knowledge of it is very important. Shall I give you the proof that it is common ? I have seen at least ten cases within six weeks ; and I speak of those only, which I have myself examined either before, or after death. Shall I prove to you that an acquaintance with this disease is practi- cally useful ? I can do it in more ways than one ; but I choose to illustrate its utility by telling you of a false diagnosis of my own. Yesterday morning I examined by auscultation a young man, with whose history I was not acquainted, without having first practised percussion in a careful manner. He is emaciated 120 and coughs ; that was all I knew of him, and, in truth, my examination was made very much en passant. I found the respiration much more feeble under the left clavicle than the right, and suspected at once the existence of tubercles. Having requested one of my friends to examine him, he came to the same result, and in the evening we mentioned to Louis our suspicions that the subject was tuberculous. He said he did not believe it. On careful examination we found that the percussion was more sonorous under the left clavicle than the right, but at the same time the murmur of respiration was much feebler under this left clavicle, as it was indeed over the whole extent in front, where the sound on percussion was still quite sonorous. We now saw our mistake and immediately recognised an emphysema. On inquiring into the history of the case, we found that it accorded with this last supposition, but not with that of a tuberculous affection. Here would have been a very grave error in the diagnosis, on my part ; and the lesson was a very useful one. I cannot doubt that many a case oS emphysema has and will be mistaken for phthisis by those, who are but partially acquainted with the science of auscultation; — unless they are so well acquainted with the natural history of phthisis, as to be able in a great measure to supply thereby their deficiencies in the " musical science." I asked Louis whether he had often seen emphy- sema mistaken for phthisis; — he answered, very frequently. Andral has some very interesting views upon this subject, differing from those of Laennec and in my mind more tenable, and better supported by actual anatomical investigation. You will see them in his chapter upon atrophy of the lungs, in the Anatomie Pathologique. I. walked to the hospital, this morning, with M. Andral, and asked him what you desired, with respect to the greater fre- 121 quency oS intestinal inflammation during Sever in France, than in England, or America, viz. whether it was not partly owing to the neglect oS purgatives by the French. His answer was a just one ; — " perhaps so, sir, but a series oS experiments with purgatives in Paris is necessary to prove it; — and, again, this disease of the intestines is observed very early in the disease, by the fifth or sixth day even." He added, that he had observed and was much struck with the observations of Mr. Alison, of Edinburgh, by which the intestinal affections seem to be more rare than in France. * * * * But I have almost Sorgotten to tell you oS a case, which shows me oS what use auscultation and percussion are to be to me in practice. I observed, a few days since, that one of my young Sriends here looked rather unwell, rather more so in fact than is com- mon Srom a slight catarrh, which was all he complained oS. I told him, I should come and see him at night, and went accordingly. We laughed and talked Sor some time, he ap- pearing pretty well. On my questioning him, I Sound he had a little pain on the right side on coughing and on Sull inspira- tion. He thought nothing oS it, however, and said he had nothing but a slight bronchitis. I examined his chest, not expecting to find anything, so slight were the local and gen- eral symptoms. On the right back, however, 1 Sound evidence, by percussion and auscultation, oS a considerable pleuritic effusion. I bled him Sully; he has recovered and the fluid absorbed. I mention the case to you, because it is the first time that I have been obliged to practice upon the evidence oS auscultation, in an acute case ; and because cases oS this sort cannot be too often cited, so frequent, so latent and so important are they. How many thousands of pleurisies pass 16 122 unnoticed. Not so, in Louis's wards, however; and thanks to him, not so many will escape me as would have, without his example and instructions. In the present case, perhaps, indeed almost certainly, this young man would have recovered without any treatment. But, iS the disease had not been discovered, it would probably have been aggravated, as he would have continued his dissections in a cold room, and in other ways have exposed himselS; and the inflammation might then have extended from the serous to the cellular tissue. Feb. 17. How unhappily imperfect are our histories of even the most common diseases! How often have excep- tional cases been mistaken for ordinary ones ! What false descriptions have authors given us of pleurisy and pericarditis, Sor example ; taking Sor the type of those diseases a few rare cases, which were attended with very positive and striking symptoms, and overlooking the vastly more common cases, in which those symptoms are far less marked and some- times entirely absent! I have been especially struck with this in pericarditis ; — and what have been the causes of this error ? Perhaps, chiefly two ; — first, owing to an insufficient examination, a large majority of cases are overlooked during life. This you know to be literally true in the case of pleu- risy, and I believe it to be so in pericarditis. 1 often think oS your recital oS the case of pericarditis in a certain cook, since I have attended to this subject; and when you have received one of my letters oS about a month since, I do not doubt you will remind me oS it. Second, because practitioners have not been in the habit oS counting their cases, preferring to trust to their memories and what is called general observation. Louis is the father of the numerical system, and will at some time publish to the world the tables containing the results of his practice. There can be none more valuable, for diseases 123 of the chest at least; for he is the most exact in his investiga- tions and diagnosis oS any living man. # # # * "But," says the practical physician, "this is all nonsense; why trouble yourselS about a disease, which nature will cure without your help, as she will all, or almost all those cases oS undiscovered pleurisy, and pericarditis too r" The practical man here forgets what should be the first principle oS every good practitioner in medicine, or morals ; — to treat disease successSully, we must attack it at the commencement; and many oS these cases, which begin with such latent symp- toms, and which are, in very truth, oS themselves compara- tively unimportant, become very severe and Satal Srom a neglect oS even hygienic rules. A man continues to expose himselS while affected with a latent attack oS pleurisy, and in a week he may have an extensive pneumonia, which shall destroy him. But, again, the man who enters into the field oS pathology with his eyes open, and does not love truth Sor truth's sake in his scientific researches, may possibly be a moral man, though I should almost doubt it; at any rate, he will make a very poor practitioner. I must indeed work Sor my bread, but, in working, if you take Srom me the interest which search after pathological truth inspires, I can no longer work well. Paris, February 27, 1832. * * * * The truth is Louis is a remarkable man, and his \ system of pursuing medical science a most excellent one. ] There are without doubt many questions that cannot be re- solved by counting; but to draw a description of the natural history of diseases, you cannot proceed without it. What is the chance that such a disease will prove fatal ? How often does such a symptom occur ? What part of an organ is most 124 often affected in a certain disease ? How often is such and such a lesion Sound after death, when such and such symptoms have preceded ? These are all questions oS immense impor- tance, and they can be decided in no other way than by an ac- curate observation of all the cases which occur, and a counting oS them with respect to each point. You state Sor instance, that pneumonia occurs oftener on the right than on the leSt, that it affects the lower oftener than the upper lobes ; suppose some one chooses to doubt it, and demand of you what is the proportion, in order that he may know whether your knowl- edge be exact. You have made no table ; you can only tell him such is your general experience. General experience has for this once told you the truth; but it would be much more satisfactory for your student, if you could give him the result in numbers deduced from exact observation. And, in fact, what is this general experience ; it is the result of an enumeration of the cases, seen by an individual, in his own memory. But how much better would this enumeration have been made on paper; for who can tell that from some peculiar circumstance or association, one class oS cases may not have excited his at- tention, and, thereSore, left a more permanent impression than another; — so that a greater number of these first would enter into the calculations of the memory, than of the last. Had medicine been studied for one hundred years, as Louis now studies it, our knowledge of the natural history of disease would be placed upon an infinitely more certain basis ; and diagnosis, and prognosis, and consequently therapeutics vastly more advanced. On my return I will prove to you the advan- tages of this system. Inspired with this belief, viz.; that the only way to place our knowledge oS disease upon a true basis, is to make rigorous observations, and to count them under their various bearings and relations,— a set oS young men, who have 125 Sor a long time Sollowed Louis, (and some oS whom I know, or believe to be the most intelligent of the French students, my collaborators, oS whom I wrote yesterday,) intend Sorming a so- ciety, whose main purpose is to make exact observations over the whole world, as Sar as may be ; and Srom these, properly arranged and submitted to the numerical method, to arrive in the course oS years at certain and fixed laws. Those, who have Sollowed Louis, the Sather oS this method, are alone to become members; and oS those I trust only a select corps ; Sor the majority are not fit to make accurate pathological inves- tigations. As yet, I am the only American who knows oS their plans, and I certainly shall with great pleasure become a member, promising in all honesty to elicit Srom our public in- stitutions whatever is in my power. I shall love to work Sor such a society, because it will be useSul not only to myselS, but all; and again, by so doing I shall keep up an acquaintance with those Europeans who will be the most distinguished in medicine during my day. Say nothing oS this as yet, Sor it is not made public,— I shall write you as soon as the society is organized and explain in Sull its objects, etc. It is to me, a new spur to study; — Sor I am now learning how to observe. Paris, March 1, 1832. Louis's wards. A new and striking case oS emphysema has just entered, and I will take occasion to say a few words on this subject. You remember that Laennec first pointed this out clearly; though Baillie had already noticed it. Laennec attributed very many cases oS asthma to this affection. Be- Sore I left home, not having seen a single case, and not being acquainted with its anatomical characters even, except Srom 126 books, I could not persuade myselS that it was so common a disease. I am now Sully persuaded it is a common disease; and that it is one oS the causes oS asthma; either being in some cases the sole cause, or as 1 strongly suspect coexisting, especially during the paroxysm, with a congestion oS the mucous membrane; — itselS being the constant lesion; and this congestion, at various periods and Srom various causes being superadded. This is my opinion Srom what I have ob- served of the symptoms. I have no post-mortem evidence oS it; — and Louis does not accord with me, but I think Andral does. * * * * But be that as it may, I will state to you the symptoms which characterize emphysema, and then the additional symptoms, during the severe paroxysms, wThich lead me to believe in a concomitant congestion of the mucous membrane. The distinctive characters of emphysema are 1. A more than natural sound on percussion. 2. An absence of the sound of pulmonary expansion in the same part, or at least a murmur which does not at all correspond with the full sound on per- cussion ; being, for instance, less full than on the sound side, where the percussion is less sonorous. These two are the most characteristic signs. But, 3. Very frequently (I have seen it in four cases, which I now call to mind, and doubtless in others, which for the moment have escaped me) a projection, saillie, or bombee of the chest over the part affected. This, when it exists with the other two signs, adds much to the certainty of the diagnosis; but alone it is not enough, for it often exists in pericarditis, as I have seen in three cases ; in pleurisy; in aneurism; and in some other more rare affections, as pneumothorax, and anomalous tumor, &tc. But in all these the other local, with the general, symptoms, and the march of the disease will easily enable us to make the distinction. 127 4. In one form of emphysema (interlobular) is heard a dry rale, crepitous, a grosses bulles. This Sorm oS the disease I have not yet seen during life;—though I have twice seen very beautiSul anatomical specimens of it. Thus far I have spoken oS the physical signs only; — there is much to be learned by. the history oS the case. 5. It generally, and as Sar as my experience goes, (which is Sounded upon about twelve cases,) always Sollows a chronic pulmonary catarrh; — and you will find a very ingenious explanation oS the mode in which it is created in Laennec's chapter on the subject. 6. Dyspnoea, constant to a certain degree and occurring in paroxysms, and obliging the patient Srequently to sit up in bed a good part oS the night. 7. Full expansion oS the chest, with inability to get air enough. 8. Expectoration aSter, or during a paroxysm, oS a great quantity oS serous, Srothy fluid, mixed with more or less mucus, clear, or opaque, according to circumstances. This I have observed in several cases, so that a peculiar- thin, Srothy appearance oS the surSace oS the fluid in the spit cup, at once creates in my mind a suspicion oS emphysema. Perhaps there are some other symptoms, which at the moment escape me ; for I am writing extemporaneously, (so to say,) and eliciting the symptoms, not from books, but from an analysis of the cases I have seen in my own memory. You see that the only two characteristic signs are the two first, and they must exist together. The truth of them I have seen tested by anatomical demonstration. Now Sor those signs, which do not exist constantly in this dis- ease, but which I have several times Sound during the paroxysm; or iSexisting at other times in some cases, only very limited in Sorce and extent. These signs are those various rales, which go under the name oS sonorous, sifflant, sibilant, etc.; all oS which indicate either a congested state oS the mucous membrane, or 128 the presence oS an unusual quantity of mucus upon that mem- brane, or both together. And it is precisely Srom the circum- stance oS these rales existing at the time of the paroxysm only, from the increase oS dyspnoea, at this time, (which cannot be owing to the state of the vesicles, for their lesion is permanent and not changeable,) and from the termination of these paroxysms in an expectoration of mucus and serum, that I have arrived at my opinion with respect to this occasional and transient con- comitant of emphysema; and this, though not the constant lesion, is perhaps Sor practical purposes the most important; as in the actual state oS our art we can in no way remedy the original lesion, and as each paroxysm, with this its cause or con- comitant, must have a tendency to increase the original lesion. There is another complication oS emphysema with tubercles, oS which Andral has spoken and which now interests my mind very much; because I and some oS my young fellow- students think that we have evidence of its existence in one case now at la Pitie. The case has taught me a great deal, and cost me much reflection, and, perhaps, in some Suture letter I will write upon the subject. You have surely by this time read enough oS my hasty lines on emphysema, in this. # # # # You write so warmly oS Hodgkin's museum and Hunter's, as to excite in me a strong desire to enjoy these promised pleasures. But I shall not hurry while Louis calls me to listen to his interesting clinique, in v/hich he gives us the thread, whereby to walk through the labyrinth oS pulmonic disease; and while he deigns to teach me in a more familiar manner in his wards. Neither do I feel inclined to tear myselS Srom the eloquent course oS Andral, oS which I have as yet taken most copious notes; nor to Sorego the delight of his clinique, which will commence in May. 129 Paris, March 20, 1832. * * * But there is another extremely important sign in pneumonia ; — it is the bronchial respiration after hepatization. I had no idea of its value in this disease, nor indeed in any- other, beSore I leSt America. ASter a vast deal oS practice and attention to and thought upon the subject, I hardly know a more important sign in relation to many diseases, (1 speak oS auscultatory signs,) than this bronchial respiration, either alone, with crepitous rale, or with a degree oS vesicular respi- ration; the last constituting the respiration rude oS Louis. It is the most difficult to attain, the most valuable when attain- ed, oS all the distinctions which the ear recognizes. It requires much time; — at least, such has been my experience. It was very long beSore I knew well the natural respiration, the sound of vesicular expansion; — i.e.it was long beSore I had my present ideas and understanding oS it, and could make such use oS them as I now can. When in England I will write oS something else than auscultation; Sor you must be pretty well wearied with my school-boy remarks upon it. March 24th. — One word more upon bronchial respiration. For as much as two months I have made the Sollowing remark, and Srom very frequent observation am quite convinced oS its correctness. In some commencing cases oS phthisis, when the respiration is not yet truly bronchial under the clavicle; when we still hear the vesicular expansion, and nought else on inspiration, I have discovered the bronchial sound on expira- tion. In other words, as the tuberculous deposit advances, the bronchial expiration may be heard before the bronchial inspiration;—it may be heard at an earlier period of the disease, and may thus become a very important sign as making known the disease yet sooner after its origin. This circum- stance is very explicable. As soon as tuberculous matter is 17 130 deposited, there exists a solid material around the bronchia, which will transmit the sound made by the passage oS the air through these tubes; — but thus early a great portion oS the lung, even in the part affected, (the summit,) is permeable to the air; and thereSore the murmur of vesicular expansion, on inspiration, entirely masks the sound of the air passing through the bronchia, which would otherwise have been transmitted through the surrounding denser medium. On expiration, however, circumstances have changed;—the air on passing through the bronchia produces the same sound as on its entrance; and, as now there is no vesicular expansion to mask it, it is easily transmitted through the diseased or condensed part to the ear of the observer. I do not know whether I have made myself intelligible, for I have written this page at three different times, being twice interrupted.* I believe the observation to be both important and true. You see I am getting to make nice distinctions in auscultation, per- haps you will think, too much so. But I assure you, you cannot, at all judge oS my knowledge of this subject now by what it was, when I left you. Louis chooses for us the most delicate cases; — makes us examine and report to him the result, without telling us his opinion, and even without allow- ing us to learn any thing of the history of the case, lest we should be prejudiced. I am exceedingly happy to add that it very rarely happens that we differ in opinion from this master oS his science. I Seel confident that our " Society oS Medical Observation" will be a useful one, and am sorry that I cannot pass one year * Louis has at last seized this distinction; this very afternoon for the first time, I have heard him mention it, and on my stating to him my explana- tion of the facts, he was pleased to consider it at least ingenious and probably true. 131 in sharing its labors under the directions of Louis. The object, as you know, is the exact observation of diseases, and from the cases afforded, to deduce what general facts may be rigorously deduced. The numerical method, without care, may lead into error;— but, first, it must lead to a vast deal of good; and second, as for the care to avoid those errors consequent on an omission of a full consideration of all the circumstances, if any man will, and does secure himself, it is Louis, the father of the system. His wards are the only ones I have ever seen, except your own, where the facts were all truly, fairly and scrupulously noted; and on one branch he necessarily surpasses you, viz.: morbid anatomy; for in our country it is impossible to follow this subject with such Sreedom, owing to the prejudices exist- ing among us; and at our hospital our cases are necessarily imperSect, as we do not retain our chronic cases, as they do here, till death. * * * * There are two or three young men whom I should be proud to see in Boston, especially Maunoir and Lacaze. They are young men whom I shall always remember with pleasure and respect. March 29. — Little did I think, my dear Sather, when I began this letter, that I should be obliged to close it with such unwelcome news. The cholera is in Paris; — or, to say the least, it is generally believed to be both by the public and by physicians; and I Sear the evidence is too strong to deny it. OS Sacts, I as yet know very little; — I have heard and read in the journals, oS several (Srom ten to fifteen) cases at Hotel Dieu and in the city. I have conversed with those, who have seen some of these patients during life, and with others who have been present at some of the autopsies of those, who have died. 132 For my own selS I have been witness of an autopsy of an individual dead at la Pitie in Louis's ward, and whose whole history is like that oS cholera; —but I did not see him during liSe, as he entered and died the same night. I have this moment breakSasted since my return Srom a visit to his wiSe, with M. Louis, to learn as exactly as possible the circumstances of the case. His case and dissection were as follows. Man, chiffonier, aged fifty, for last three years some- what out of health;— cough and asthma for ten years; — still he had good appetite, eating well and worked as usual. For six weeks has complained of colic pains from time to time, but has preserved a perfectly good appetite, and eaten as usual; — wife does not know whether he had diarrhoea during this time or not. Habits good ; did not drink ; this was confirm- ed by friends as well as wife. On 26th, was as well as ordi- nary, dined with his wife as usual, and went out to follow his customary occupation of chiffonier; — did not return that night, which did not alarm the wife, because when employed late, he often remained the other side of the river to sleep in a cham- ber, where the gleanings oS the day were deposited. In the morning, 27th, she went to this spot, and there Sound her husband upon the floor, helpless and speechless, though yet retaining his mind sufficiently to indicate to her that he had intense pain in the abdomen, and had been vomiting ; — the material vomited was, as she says, like wrater, or like a potage aux choux with beans ; — he could neither speak, nor make use oS his limbs ; — she having called Sor aid, he was imme- diately carried to the Bureau Central des Hopitaux, where he again vomited as beSore, and thence to la Pitie. She first saw him at eight, A. M., and he arrived at la Pitie at two, P. M., or beSore perhaps; — it was impossible to as- certain with precision at what hour he was taken sick, as he was 133 speechless, and no one with him ; — Sor date, we know only that it must have been after dining with his wiSe on the 26th, as he then ate, and was as usual. Arrived at the hospital, he was seen by Mr. Eager, a young man who observes with great accuracy ; — his countenance was almost black ; his limbs cold ; from time to time terrible convulsions, or cramps ; he did not again vomit, but had numerous dejections, liquid, somewhat yellow; no pulse ; speechless and helpless as be- Sore, but still retaining his intelligence ; and died at eleven, P. M., making in all not much more than twenty-Sour hours oS sickness at the most, and very probably not so much. This morning, thirty-six hours aSter death, he was examin- ed by M. Louis, in the presence oSM. Andral and a host of students. I attended very closely to the morbid appearances, and noted them on the spot. Externally. Nothing very remarkable in the Sace ; —- hands and nails almost black; limbs contracted, and exces- sively stiff, or raides, as the French say, requiring great Sorce to extend them Srom their flexed position. Head. Brain, nothing peculiar, unless the arachnoid was more injected than common, where it enters the ventricles at the great Sente oS Bichat. Larynx, Pharynx, Par Vagum, cervical ganglia, natural. Chest. Peculiar Seeling oS pleura, collee, sticky like court- plaster to the touch, not allowing the finger to glide over it as on a polished surSace ; —slight adhesions oS pleura on both sides ; — both lungs emphysematous; — right lung a little en- gorged, but the subject had lain upon this side. Pericardium healthy ; heart oS natural consistence, but containing a large quantity oS black, coagulated blood. Abdomen. Remarkable injection oS omentum and perito- neal coat oS intestines, especially the small; all the intestines 134 more dilated, and the stomach larger than common; — that portion of the small intestines which was the most dependent, viz. that contained in the pelvis, was less injected than the rest. Do not imagine that I have here written less by mistake for more, for the circumstance is an important one, showing that the color was not owing to a mechanical cause after death. Interior of Alimentary Canal. Stomach contained a quan- tity oS reddish fluid, but less red than that presently to be noticed, with a Sew beans. The mucous membrane was of its natural color, thickness and consistence. The mucous membrane of the small intestines, from their commencement to about eighteen inches Srom their extremity, was oS a very peculiar deep red.color ; — the intestine contained a vast quan- tity of red fluid, exactly resembling a solution of brick-dust, (to my eye ;) and, moreover, in various parts, we saw little patches oS white mucus in small spots, adhering, but not very closely, to the membrane beneath; they resembled small, thin portions oS boiled rice, but had not the aspect of false membranes;—indeed, they were exactly like the white shreds you see in the last dejections of a man with sporadic cholera. The mucous membrane of these small intestines was of the same peculiar red color ; its thickness was a little in- creased, but its consistence natural; — we Sound, I think, three beans in this intestine. I should add, that two or three oS the patches oS Peyer's glands were a little developed, and that there were a few iso- lated glands more prominent than usual; — but these were very slightly marked, and I do not think they could either oS them have been called morbid. The liquid flowing Srom these intestines had a somewhat sour smell to me, like that oSall undigested vegetable food, which has been vomited, or which we find in the stomach ; but some oS the gentlemen thought 135 it peculiarly like sour wine. Louis, however, agreed with me, that it might have been produced by any other substance, which was undergoing decomposition. The mucous membrane of the large intestine was by no means so red, neither was the fluid therein contained ; — its consistence, however, was a little less than natural, and its thickness somewhat increased. In this intestine we Sound, at least, twenty beans undigested. Bladder, liver, spleen, coeliac ganglia, all healthy ; —unless liver was rather more red than usual. Aorta contained a great quantity oS black blood, liquid ; —we Sound, however, two or three small coagula in its thoracic portion;—the blood was not pitchy ; — color oS aorta pale, natural. Spinal marrow examined in whole extent, healthy. I must first notice the co-existence oS asthma with emphy- sema oS the lungs ; because we learned the two circumstances entirely apart Srom each other, and thereSore without pre- judice. For acute morbid appearances you see we have nothing, except the peculiar appearance oS the intestines, chiefly the small, and their contents. I believe the case to be cholera, Srom the suddenness oS the death, the history oS the symp- toms, and the coincidence oS several similar cases in other parts oS the city. I know well that it admits oS question, but cannot here discuss it. Shall I leave Paris because the cholera is here ? IS I do, where shall I go ? These are my two important questions. And 1 can answer neither as yet. Surely, in the present state oS affairs, I should regard it as very useless to leave the city, Sor I do not Seel that I am in danger. Should circumstances change, I shall act accordingly. The disease has left Edin- burgh, and should it prevail here to such a degree that Andral and Louis think me exposed to real danger, I will leave. In 136 the mean time, all the students see the disease, and, though I shall not run much after it, my curiosity is excited, and prob- ably I shall see it. I am in full health, have no fears, will lead the most simple and hygienic life, and be assured I will be prudent. Were you on the spot, you would not regard my situation as in any way dangerous ; — of this, I am sure. Should my motions, or any other circumstances require it, I shall write you a duplicate by the Liverpool Packet of the 8th. But I beg and pray of you not to allow yourself a moment's anxiety. I will be prudent, and there is not one chance in five thousand that I shall suffer by the disease. Paris, April 1,1832. my dear father,-- I lament to tell you that the cholera, which was yet a little doubtful when I last wrote, (three days since,) is now reigning in Paris ; and I must add to a frightful degree. You will learn details from the journals. To this moment there are at least three hundred cases, and a full half already dead. But you are anxious for me ; — you suffer because I still re- main here ; — perhaps you even reproach me with an undue inattention to the rights and feelings of my family. A word upon this subject. 1st. What is my actual danger? I do not deny that the first blow is very strong, in truth frightfully so. But who are the subjects affected ? Up to this moment, ex- clusively the lower classes. I have inquired of many physi- cians and among them of those whose practice is extensive ; — they have not seen a man in easy circumstances affected; — the journals say the same. Thus as yet my danger is very slight, though living in the midst oS disease. But again, why 137 need I stay in Paris ? In the first place, the disease came upon us so suddenly that we had no time to leave. On Wednesday I first heard of its existence, and already, Sunday, there are three hundred patients. We could not have left the first day, for we were not yet assured ; and now what are my circumstan- ces ? I am here with perhaps thirty American students, and of them all, 1 may say with truth, my mind has not been the least occupied with medicine for some years. We are in a city where we may see a disease of the most frightful nature, — which will, in all probability, soon reach our own dear coun- try. We are bound as men and physicians to stay and see this disease ; — as a physician you know it and feel it; — as a father you dread it. For myself, I confess, I should be un- willing to return to America, and not have at least made an effort to learn the nature and the best treatment of this de- stroyer of life. I feel bound to remain with the rest; — for no one thinks, as yet, of leaving. As yet the probability is that it will continue and even increase ; —but this is not sure. Should it thus continue, I probably shall not stay here more than one or two weeks ; I shall have seen enough of the dis- ease, and if it reigns as now, all clinical instruction will con- tinue to be, as it actually is, interrupted. Wherefore then stay longer. But we may hope that a little calm will soon follow, and that this severe debut will be followed by a rapid march and prompt termination. If so, all my instruction will be continued; I need not lose the remainder of my lessons from Louis, etc. As it is, then, though there is some danger, it is very slight. I shall therefore stay. Again, feeling it to be a duty, and really having my mind greatly interested and ex. cited, I do and shall see the disease. But should the danger become truly great, I shall leave at once for Scotland; and should the disease so continue that, after a fortnight, I cannot 18 138 recommence my ordinary studies, I shall likewise leave the city. In the meantime I shall to-day engage lodgings with my two Philadelphia friends, on the other side oS the river, in the most healthy part oS Paris, where the disease has not yet ap- peared ; — I shall live simply, sleep and rise early, and in every way pursue the most strict hygienic rules. Thus much Sor myselS, and I hope you are satisfied. I Sorgot to notice that I am in perSect health, and that, although my mind is necessarily excited, yet I have neither fear, nor anxiety. Now, for the disease ; — one word ; — it is death. Truly, at Hotel Dieu, where I have seen fifty and more in a ward, it is almost like walking through an autopsy room; —in many nothing but the act of respiration shows that life still exists. it is truly awful. —As for treatment, nothing is yet decided. I cannot find that any of the thousand different modes essayed is in truth very powerful; — and certainly, whatever be their potency, their effect is almost null. The physicians are in a state of the greatest incertitude, not knowing which way to turn. I cannot pretend to give you any detailed account of symptoms or treatment. I can only say that the disease is in truth almost a conver- sion instantaneously from life to death. In my next, by Liverpool on the 8th, you shall receive something more precise. — My head is now, as one may say, montee, and I haste for the estafette. Paris, April 8, 1832. my dear father,-- I almost weep to write you again from Paris. It is now the first moment of my liSe that I have been placed between two 139 duties, each strong, each binding, and where my great diffi- culty is to decide which is the most so. But I have decided, as I know, against your wishes. God grant that circumstances may be such that you shall soon accord with me, when the time is passed. A medical man has duties ; — I am a boy in medicine ; — granted ; — but I am like the other Americans here about me. An opportunity Is offered us to study a dis- ease, which will probably visit our hitherto untouched coun- try. Were the disease about you, would you fly ? You could not, Sor the public would look to you; — you would not, Sor your sense oS duty would prevent you. I am in a measure in the same condition. From a week's accurate, patient, la- borious study oS the disease, before and aSter death, as to its nature and the effect oS treatment upon it, I am now assured that there is much to be learned and much that is therapeuti- cally important. I doubt whether our proSession will ever be able to divest it oS its greatest horrors ; — this I do not hope Sor; — Sor I see no ground Sor such hope. But I do believe that an exact study oS the latter part oS this disease, after the reaction is established, and observation of the effects of treat- ment upon it, may lead to much that is useful. Persuaded of this as I am, I Seel it a duty thus to study. IS I can be the means oS directing the attention oS our physicians to certain points, an attention to which will enable them to save one in twenty oS those affected, and that one would have died without it, — what is my duty ? to stay and study. As an individual I do not hesitate thus to answer ; — but when I remember you, my dear Sather, I tremble that I have thus answered. I am with Andral. During five days we have had eleven very exact autopsies ; with which, with the whole history oS the cases, beside numerous others, some dead, some living, now to die, some in Sact dying now around me, (Sor I write in the 140 ward oS la Pitie,) some I am happy to add in a Sair way to re- covery, I will acquaint you hereafter. But 1 will write no de- tails now ;— I purposely avoid them. I will but add two circumstances which shall, or ought to serve to diminish your anxiety. — 1st. As yet, although the disease increases in a truly awSul manner, there are but Sew cases in the upper classes. 2d. Of those affected with the disease, there are very Sew oS my age, or near it. I must have seen five hundred patients, at least, and oS those not ten under thirty. I cannot indeed recall five ; —and not one have I seen in the dissecting-room. The only young man under Andral's care now lies in the bed behind me, convalescent. Yet, there is some danger ; it is in vain to deny it; but it is not great. And I am happy to add that, since the appearance oS the cholera, I have been in a little more perSect health than beSore, though that had seemed impossible. Most oS my Sriends have had a little diarrhoea, or cramps, etc. ; I not any. Not one oS my ac- quaintance has been seriously sick. I live as usual, but with excessive care. I work harder than ever in my liSe beSore. A month hence, I will send you the results on paper; — but it will be a year before 1 can show you the full results; for I am learning more on the pathology of mucous membranes (in- testinal and gastric) than ever beSore. But oS this by-and-by. I have determined to send you no details as yet; — but I keep a daily record Sor you, which will be long, and probably, unless the disease becomes such, that I esteem myselS in es- sential danger, I shall send you one hundred detailed observa- tions, (oS which I have already thirty,) and Sorty or fifty of the most thorough and accurate autopsies that you ever read. From these, when collected, I propose to draw what conclu- sions I can as to the nature and treatment of the disease, in 141 making a nice analysis and synthesis of all the circumstances. I flatter myself that I can do this in such a manner as will be truly useful. I shall do it in England, taking my papers with me, and devoting my first one or two weeks there to this work. I would prefer vastly to have sent you one of the half dozen sheets I have written this day; but it has been my determi- nation to avoid advancing an idea till, all is done. Not a single fact has yet occurred to show that the disease is contagious ; aucontraire; — not a physician, nor interne, nor student oS the hospital has been affected. A week or two, my dear father, and you will hear from me in England. Havre, April 25, 1832. On my way to London, as you see, my dear father, and perhaps will wonder why; surely, when I last wrote you, I expected to stay in Paris a fortnight longer. I have left because the cholera has almost ceased, not because it had increased in severity. I have left for want of cases to study. In very truth during the last three days, in a service of fifty beds under Louis, we had not a single new case of any sever- ity ; and he advised me, as I was beginning to suffer from fa- tigue, (for never in my life have I worked so laboriously,)' to leave, contented with the sixty or seventy cases and more than thirty autopsies. In London, as you know, the disease is about extinct, (seven cases a day). In Paris it still exists; I saw cases and deaths till the very last moment, but much fewer and much less severe. You have no conception of the mortality ; and allow me, your son and pupil, to say to my father and master, you have no conception of the disease, and will not have till you have seen it. The French- 142 men even, who look upon death and dying with as much sang froid as any people, were thrown off their balance. Never shall I Sorget Louis's altered Sace and aspect Sor the first week ; — emaciated, wan, wretched, like one who had receiv- ed a blow from which he had not recovered. There are few men living so familiar with death, or the .dead. Liverpool, June 30,1832. my dear father,-- I received last night with great pleasure yours oS May '19th —■• 25th. The last releases me Srom all apprehension as to your judgment upon my stay in Paris. I rejoice that you view it as I do. A word on cholera, and then I will dismiss it. Not a day passes, that I do not picture to myselS the possibil- ity oS its actual, or Suture existence on our own side oS the Atlantic. Of course I keep myself always ready to see iS there be any truth in the reports oS the new modes oS treat- ment of it. In London, as I told you, I saw a few cases with Dr. Stevens, but none of them were at all satisfactory, for various reasons which you shall have in detail in your own study, or in mine, by-and-by. In passing through Yorkshire, where the disease is prevailing, I inquired, whenever I had an opportunity, of the success of the saline injections. At York 1 was enabled to visit the cholera-hospital, and saw three or four patients, among whom was a boy aged seven or eight, who had been thus treated and was convalescent. How bad his case had been, I know not. They assured me it was very severe; but I have seen so many mistakes upon this head, that I Seel inclined to question the authority of those who have not seen more than fiSteen or twenty cases, when I know that, even after an accurate study oS hundreds, the prognosis, or, in 143 other words, the estimation oS the real severity oS a case, is very difficult. Be that as it may, I am anxious and willing to hope that this boy recovered through the agency oS the saline treatment. I next saw a young woman, aged twenty-two, who had been three times injected, and whose case was accurately detailed; whereby it was clearly shown that she was pulse- less, that blood could not be obtained at the debut, and, Srom the notes, I cannot doubt that it was a severe case. Well, what was her present state ? You shall hear. They thought she would pretty certainly recover ;—I would bet ten guin- eas she is dead at this moment. Face flushed ; skin every where hot; lips and tongue getting dry and brown; respira- tion much embarrassed; a sort oS Sainting or sighing; pulse one hundred and twenty, hard ; some disposition to drowsi- ness, Sell asleep while we talked to her; respiratory murmur loud and vesicular in Sront; could not be raised to examine her behind, where I suspect we should have Sound crepitous rale. Compare this,* if you will, with the cases of two women under Andral, infirmieres of the hospital, in St. Rosaire, Nos. 20 and 22 ; their result leads me to anticipate death here. Again, in Leeds, I inquired if this treatment had succeeded, and was answered in the negative. My conclusion, as far as I am able to form one, is, that this injection undoubtedly pro- duces a temporary excitement, but that, as yet, we have no proof that it arrests the disease. It does not strike at the cause ; and how can we suppose that it should ? This chem- ical rage enrages me. I shall see medical gentlemen here to-morrow, and learn what has been their experience. You shall have it by the next packet. * The reference here is to the writer's " Cases of Cholera in Paris," which he had sent me a month before this letter. 144 * * * * I have been nearly a Sortnight reaching this place on my way to Edinburgh, and I would that every Sortnight of my liSe had been as well employed. At OxSord we staid three days to see the great men collected together at the British Association, in imitation oS the German Society oS Naturalists. Of this, more, by-and-by. Thence, through Leamington Warwick, Kenilworth, etc., to Birmingham, in each of which places I saw and learned much that was new to me. Through Derbyshire, Derby, Matlock, Chatsworth, Castleton into York- shire, Sheffield, Here, S. — and I parted, much to our mutual regret. He is a fine fellow. 1 went to York, and to give you an idea of the hospitality, which 1 everywhere experience, 1 will draw a little sketch of my Yorkshire expedition. Arrived at the capital of this rich and extensive county, I called on Mr. K. with Mr. W.'s letter. He and his wife re- ceived me with kindness; I spent the evening and breakfasted with them the next day. He pointed out to me all that was interesting to a stranger, and introduced me -to Mr. Phillips, the curator of their Museum. This gentleman gave me what I may call a lecture of nearly an hour upon the outlines of geology, of which they have a very fine cabinet, so arranged as to speak itself of the beauty and order of the system ; and, I assure you, I would travel over twice the distance for the sake of gaining the clear view, which this gentleman gave me of this interesting subject. I felt quite indebted lo him; he has raised a new cabinet in my mind, and so raised it, that whatever accident throws in my way, I may easily attach there. Not satisfied with this politeness, he gave me a letter to the curator at Leeds, Mr. Hey, grandson of the cele- brated Hey. Here I added to my knowledge, which was so newly acquired, and was treated by this gentleman more like 145 an old friend, whom he was glad to see again, than as an entire stranger. Had you seen us together, and listened to our conversation the next day, you would not have supposed our. acquaintance of only twenty-four hours date. While walking with this gentleman, he happened accidentally to mention the name of Dr. Teale, as a friend of his. I at once asked if it was the neuralgia Dr. Teale. He said, yes, and I begged to see him. He asked him to tea with us; we had an hour or two of free pathological conversation. Dr. Teale promised to show me some interesting cases and mor- bid specimens, iS I would stay and dine with him the next day. Though anxious to get on, I consented ; and glad am I that I did. Dr. Teale invited two medical gentlemen to meet me, brother proSessors in their new college in Leeds, and I spent Srom Sour to eleven, P. M. most agreeably in their society. I have not talked so much pathology Sor a long time. Dr. Teale is a very sensible, enthusiastic man; not inclined to theory; appa- rently a good and vigorous observer; industrious and well inSormed; weighs and values well his evidence beSore he admits truth; in fine, a man in whom I should place confi- dence. You see I passed a pleasant evening. * * * * I do not regret passing through Leeds ; my mind worked three day's worth, while there. I learned some new things and had a great, general review oS much pathological ground. We walked Sast, turned into many pleasant lanes and bye-paths, and midnight came beSore I suspected it. All this Srom Mr. W.'s letter to Mr. K. Thus it is in England; and Dr. Teale begged me to come again. How boundless is their hospitality. OS my papers on cholera; oS course I am anxious to know iS you will publish them. You will see that I had to restrain 19 146 a strong desire to enter more fully into the pathology of the disease. But I am young; and what I have condemned in others who are older, would have been doubly guilty in myself. Mr. F. calls, and I must close to go out with him. Hospi- tality again, hospitality ! Quel peuple ; je vante que nous sommes d' Angleterre. J'aime ce pays, comme notre mere, d'ou vient notre bonheur. Good bye, my dear father. Your son, J. J. Edinburgh, July 10,1832. my dear father, -- If you are not heartily tired of cholera, I must beg you to read what I have seen in this city. I was informed on my arrival, that the disease had re-appeared here, and with increas- ed force; yet twenty cases a day is the outside. On the Sol- lowing morning, Dr. Alison introduced me to the Cholera Hospital, where I recognised the old and Samiliar, but appalling features oS the monster, I had so much observed in Paris. The most interesting object oS inquiry was, oS course, as to the suc- cess oS the saline injection; — and the Sollowing is, in Sew words, the sum oS inSormation I have been able to obtain. It is derived from several physicians oS rank here, and three or Sour young men. 1. They employ this remedy only in the bad cases; viz. when the system is prostrated ; pulseless, blue, cold, &c.; collapse. 2. In such cases the effect is to produce excitement oS the circulation, he. 3. ASter this excitement is produced, it is sometimes oS short duration, and recourse is had a second, or third time to the injection. 147 4. This excitement is sometimes Sollowed by a second col- lapse, during which the patients die. 5. It is again, and not unfrequently, Srom their statements I should say very oSten, Sollowed by too great a re-action, and the cases close with cerebral symptoms and death, unless ven- esection, leeches, &c. prove successSul. 6. The effect oSthis injection seems to be, not to cure the dis- ease oS itself, Sor, first, a majority oS those injected die ; second, those who have survived, most, iS not all, have taken calomel and opium in Sull doses ; third, the cerebral affection just no- ticed, almost always, or very often, succeeds the injection, and proves fatal, if it be not immediately overcome by antiphlogis- tic treatment. 7. So Sar as the injection is proved to be useSul, it seems to be by producing reaction, and thus allowing time Sor the employment oS alteratives; or bringing on the stage oS excite- ment, which, though very dangerous, is sometimes to be over- come by antiphlogistic treatment. This last, which is the result oS the observation oS these gentlemen, coincides exactly with the opinion I expressed to you in a letter from Liverpool. Each of these gentlemen assured me, that he did not doubt having seen a few cases recover under this treatment, followed, as I have beSore said, by antiphlogistics and alteratives, which would have proved Satal without the injections; because then the last could not have been employed. S. The injection employed is composed as Sollows; R. Sodae Muriat. 5 ij, Sodae Bicarbonat. 9ij, Aquae octant: v, — misce. This is used at the temperature oS 112° — 115°; — its heat is preserved during the operation, by allowing the vessel containing it to stand in another containing hot water. The injection has been continued until the object was obtained; viz. return oS pulse, warmth and natural color. The operation is performed 148 with a small syringe, and quite slowly; for example, ten or fiSteen minutes, to five or eight pounds. 9. ASter the injection, the Sollowing is given, varying pro re nata ; R. Hydr. Submur. gr. iv, Op. gr. i, — misce, every two hours. I am not sure as to quantities and times, but the object is to salivate as quickly as possible, and for this purpose mercurial Srictions are added. I have said nothing oS vapor baths, hot cloths, &tc, which of course, in some form, are con- stantly employed. 10. After all this, they watch Sor reaction, and at the first symptom oS excess, bleed locally or generally. 11. One woman is well, and now about, who had some time since fifty-one pounds of saline fluid injected, besides a solution of quinine and morphia. There were, of course, sev- eral injections in this case. Thus I have given you, in a hurried manner, (for my time is much engaged,) what I believe to be the essentials of what I could obtain from these gentlemen. Yet once more. 12. Dr. G. insisted very strongly upon the great temporary relief to suffering, even if the cases afterwards proved fatal; saying, • he should deem himself culpable for neglecting it, even if this were the only ground. I shall next give you what I myself have seen, continuing a daily report till I send my letter. [Here follows the records of three cases treated by injec- tions, which are omitted, as not interesting at the present day.] July 12. — * * * * I dined to day with Dr. S. —, he tells me he has used the injection in eight successive cases; they all were fatal. Dr. C. says he has seen it tried a good deal, but is by no means sure of having seen it once successful. The truth is, that its immediate effects are so striking, and there is often in cholera such a Salse convalescence, that it is 149 really very difficult to prevent one's mind Srom receiving an impression in Savor oS this remedy. We see the patient re- vive ; good pulse, good countenance r every thing promises well Sor twenty-Sour or Sorty-eight hours, and then death soon follows'. I have already seen three cases at Edinburgh, which were regarded as nearly convalescent, or quite safe ; — one of them is dead, and I am almost confident, from present appear- ances, the other two will die. I forgot to mention the testi- mony of another gentleman, with whom I have conversed, against the injection; —Dr. B.; as also Dr. T., by whose learning and familiarity with medical literature, late and old, in such an elderly gentleman, I have been as much surpris- ed, as entertained and instructed. # * * * Let me suggest one measure to be adopted in our own dear city, in case the disease reaches it; — and we have reports that it is already at Quebec, though God forbid it be true. Let each of our physicians take acertain part of the town un- der his charge ; — let it be his duty, not only to visit all the poor when they are sick, but twice a day, while the disease remains ; let him call at each house, and inquire if any be sick, i. e., have lost their appetite, have diarrhoea, or any pre- monitory symptoms ; in this way you will get at the disease early among the poor. For the rich, there is no danger ; they will call you from your beds often enough, with false alarms and vain fears. If you wait for the poor to come to you, it will be too late ; you must, therefore, go to them ; and the labor will not be great, when divided among so many. I know of no means so likely to lessen the mortality. 150 Dublin, August 19, 1832. my dear father,-- I would to God I knew how it is with you at this moment. When awake, I do not allow myself to think much of chol- era in Ameriea, and never to Sancy that my Sriends can be touched by it; — but in sleep, it occurs in my dreams, and they are such as sometimes alarm me. I must await the end. I have not received any letters Srom you Sor some time; — as I have been wandering and uncertain, I directed them to be detained at London, after I left Edinburgh, and this circum- stance will hurry me back to London. I am already repaid Sor coming to this city, by a Sew hours study yesterday, at the museum of pathological anatomy, at the college oS surgeons. I have added to the stores of my knowledge, memory and note- books upon this subject. It is my intention, so to have seen every thing in the morbid way, that you cannot find me at Sault on the most close examination. I have already seen much, that Srom books I had longed Sor, and only regret that you are not at my side, that we might burn together, as we looked upon the riches of the science we love. Do not imag- ine that I am going to allow myselS to become a mere patho- logical anatomist, instead oS a pathologist in the more liberal sense oS the word. Remember, though I now write mainly oS specimens, preparations and paintings, that Srom Paris I wrote much oS symptomatology, aye, and studied it much, too. That I do not much expect in England ; — it is almost impossible. I may see practice, you will say ; I will, but I expect Sully, very often to be much in doubt as to the nature oS the case, in which the practice is exercised. I was very much delighted with the Giant's Causeway, oS which I would give you a description, but that in print you will find so many superior to any thing I can give you. The 151 counties oS Antrim, Downe, Deny, &c, in the north oS Ire- land, through which I rode, are beautifully cultivated; and in them are some oS the neatest, best built villages I have ever seen, inhabited by people whose dress, countenance and whole aspect, indicate comSort and prosperity. The mud hovel is there scarcely to be seen. Indeed, to my eye, these little towns are superior, most decidedly, to most oS those I passed through in Scotland, either north oS Edinburgh, or west oS it. Such an appearance oS prosperity and comSort in Ireland, was to me as surprising as it was grateSul; Sor I don't Sorget my Tracy blood ; — but 1 am told, that at the south it is quite different; and iS I can possibly get three or Sour days, I shall ride through it to see Sor myself. I am here struck, as I was in Switzerland, with the difference between the protestant and catholic coun- ties ; — the first, prosperous, the last wretched ; in the first, rich fields and good roads, indicating that time was precious and well-spent also ; — the last uncultivated, or poorly so, with bad roads; a token of the very opposite. I cannot for- get having made the same remarks some years since when travelling from New-England into catholic Canada. The anatomical department at the College Surgical Muse- um, is so arranged here, and with so excellent a catalogue, that with a little study I may fix some very important general principles, illustrated by preparations, on the subject of com- parative anatomy of the internal organs. I shall devote as much time as possible to this, after I have finished the morbid anatomy ; — every specimen of which I examine, taking a note oS all that is new or peculiar. The finest institution I have yet seen in Europe, is the Ly- ing-in-Hospital, in this city ; — it is very extensive, extremely neat and comSortable, almost vying with the Massachusetts General Hospital; and I should imagine more truly useSul than 152 almost any other, as affording certain and positive relieS to suS- Serings, which, uncomplicated, with cold and hardship, are suf- ficiently severe. I trust we shall soon have a similar institution. I shall endeavor to procure what lean of the regulations and reports of this, so far as any have been published. The citi- izens, especially the professional men, are extremely, and very justly proud oS this, their Savorite establishment. As to cholera, the experience of the gentlemen I have con- versed with here is the same as elsewhere, viz.; that art is vain against it. I have seen one new thing upon this subject; — a patient of Mr. Cusack's, in whom mortification oS halS of both feet followed the disease. He has seen a second case of the same. They have suffered here most sadly, but the cases are now reduced to six or eight a day. * * * * Aug. 21. Still in Dublin, my dear father; neither do I regret it. I have picked up a good deal at the museum, — having examined each specimen of morbid anatomy; and a fine col- lection it is, though there are defects. The collection of comparative anatomy of the internal or- gans is so admirably arranged, catalogued, described and label- led, that I cannot resist the opportunity to study the subject by means of it, and with text book in hand, am now employed in examining with care these specimens. My thoughts are now on tongues and stomachs, instead oS diseased hearts, &c. 1 can learn more Srom this than Srom J. Hunter's even, because there is neither catalogue nor label, there.—Again, this will prepare me Sor the other. London, September 14, 1832. I have to-day finished my study oS the museum at Guy's, which has cost me many hours. It is certainly the finest I 153 have seen in Europe, and does great honor to Dr. Hodgkin ; who, by-the-by, is one oS the deepest men in reading and ob- servation that I have seen. * * * * London, September 22, 1832. my dear father,-- I received a few days since yours oS August 20, — Cholera had just commenced ; — slowly; — how has it been since ? I anxiously await the arrival oS papers to inSorm me. It is use- less to speculate upon it; I cannot but hope and believe that the precautions and general character oS the Bostonians (than whom I have seen no people, at home or abroad, more marked Sor solidity oS judgment and good common sense) will prevent it from being excessively severe. * * * * # # # # JVIy purposed occupation Sor the week, the exam- ination oS Hunter's museum, has been interrupted by a most melancholy accident. * * * * It is truly grievous that there is no catalogue oS this superb collection, — I would give more Sor one during the next Sort- night than Sor any book I know of. — I can understand the general plan, and many of the individual specimens; — the more from having studied as I did at Dublin. The more, too, I could have said, had I studied as I ought to have done at the Garden of Plants. And when I can understand the peculiar object of an individual specimen, it is so beautiful and so demon- strative, so speaks of its great designer, that I am only the more vexed, that the greater part are as a dead letter. You can judge of the immense disadvantages, under which I must study it, and the comparatively little knowledge I can obtain from it, when I describe to you in what manner a catalogue is now be- 20 154 ing made by Mr. Owen. He has devoted himself to this task for the last year and a half, and really his zeal and industry are quite proverbial. Well, in this year and a half he has advanced about four hundred specimens; just about beginning with the organs oS digestion now. In order to do this, he tells me he has already dissected more than two hundred species oS animals. His only resources are a very meagre catalogue of Hunter's, which is so mingled with a Salse and pretended one by-------as to render its authority very doubtSul. When he does not know a specimen, therefore, he begins to dissect all the animals Srom which he has reason, Srom his previous knowledge or reading, to suspect that it was taken. He tells me he has sometimes dissected thirty animals to ascertain a single specimen. By so doing he is constantly adding to the riches oS the museum; but the Sact that this is necessary will show you how lamenta- bly limited must be the advantages I can enjoy in this study. Yet, as I tell you, I find myselS able to recognise many things, which would have been a perSect secret to me, but for my study at Dublin. Again, that study teaches me how vastly superior is this museum oS Hunter's, though much less useSul to the student Srom the want oS a catalogue. * * * * * * * * I have just come Srom Bartholomew's hospital, where I have seen Lawrence, Earle, &tc, and the museum, which is small but neat and instructive, — mostly devoted to surgical diseases. In it is a specimen oS diseased lung, similar to one at Guy's, in which emphysema exists to a very marked degree, with tubercles. I think I wrote you oS a puzzling case in Louis's ward last spring, where I could not come to a diagnosis of anything but a combination oS these two affections. These two specimens have been very interesting to me, as proving the coincidence oS the two things, and rendering the diagnosis probable. 155 London, September 28, 1832. Would you were here, my dear father, to enjoy with me the study of John Hunter's works, and to kindle with me in my admiration of his genius ; the elevation and extent of which I know not even now ; nor does any man living, though my conceptions of his vast and comprehensive mind have been greatly elevated within the last fortnight. His museum is in telligible to no one in its full extent. The materials there col- lected and arranged, are often indicative of peculiar ideas, which are lost to the world for want of their great interpreter. This is especially true, as I suspect, upon the subject of gene- ration, on which the museum is peculiarly rich in the number and variety of its preparations. Digestion, respiration and generation have been the most interesting departments to me ; and beautiful indeed is the endless variety of means to obtain these several ends, varying as they always do in accordance with the nature and circumstances of the individual cases. The collection at Dublin, on the subject of circulation, is even better than that oS Hunter's, so that I did not meet with so much that was new to me on that score. While visiting the museum, I have been reading those valuable papers in Hunter's work on the animal economy, which Dr. Hodgkin, among his numerous other kindnesses, procured Sor me. Will you believe it, in London, the theatre oS this great man's liSe, I Sound considerable difficulty in procuring this work. * * * * * * * * Sept. 29. Let me give you an account oS some new ideas oS Dr. Carswell's upon the seat oS tubercles, which he has been unSolding and illustrating to me this morning. I am anxious to keep his arguments in mind, and cannot do better than write them you; — the present exercise will impress them upon my mind, and the sheet will serve me Sor notes at my return. 156 1. He believes that tuberculous matter may be deposited in any tissue ; — we find it in all organs, bones, brains, glands, &c. 2. He believes again that, although it may be and often is deposited in the cellular tissue, (circumscribed cavities,) yet its preference is for free surfaces, or mucous membranes. The first point we shall all agree upon ; the last is new to me and excites my doubts; especially, with respect to the lungs, I had always supposed tuberculous matter to be depos- ited in the cellular tissue in the vast majority of cases, although I have occasionally seen it upon the mucous surSace oS the bronchia. He thinks, on the contrary, that its most common seat in the lungs is upon the mucous membrane. His arguments are as Sollows. — First, Srom comparative anatomy. Cow; — this animal, as you know, dies very often of phthisis. In their lungs the bronchia are filled with tuberculous matter; — of this he has a most splendid drawing, showing this deposit from one of the bronchi into many oS the ramifications of the bronchia. When an incision of the substance of the organ was made, .round tuberculous masses were seen upon the incised surface, which I should have mistaken Sor tumors, or tubercles in the parenchyma, but that he proved to me in others upon the same specimen, that these were but transverse sections oS the bronchia, containing tuberculous matter. Here, as in other cases that I shall relate, he arrived at this knowledge by com- mencing his dissection at the bronchi and tracing their divis- ions, instead oS incising the lung only in various directions. Second. In the human lung by a very nice dissection, in the manner just noticed, he has been able to trace the tuberculous matter in the bronchia to the vesicles, always on a Sree mucous surSace. OS this he showed me one drawing quite illustrative 157 of his opinion, and assures me that he has very oSten been able to demonstrate it. Remember, he does not deny that tubercles are also Sormed in the substance; he only wishes to show that this, instead oS the usual, is the less Srequent seat oS it. The little central point in the tubercle, which it has been so difficult to account Sor, he conceives to confirm this notion ; Sor it is easily explained upon the supposition that the tube was not entirely Silled, in which case a transverse section oS it would present a small orifice in the centre. So much Sor evi- dence derived Srom the lungs ; now Sor that to be derived Srom other parts. IS he can show that there is a great ten- dency to tuberculous deposit upon other mucous secretory sur- faces, he claims an analogical argument in his Savor. 1. He reSers to the Sollicles oS intestines in phthisis, which, previous to ulceration, are filled with tuberculous matter. 2. He shows very many specimens oS tuberculous deposit upon the Sree sur- Sace oS the Sallopian tubes and uterus, without any such deposit in their substance. He also assured me oS many more in the hepatic ducts, vas deSerens, he.; — all theseoSthe human sub- ject. 3. He showed a very remarkable specimen in the liver oS a rabbit. It is well known that these animals can be ren- dered tuberculous (i. e. in the liver) at will, by exposure to damp, bad Sood, he. This organ then presents at its surSace what have always been taken Sor round, defined tubercles. Dr. Carswell on a careSu! dissection Sound this to be an error; and he traced these masses by one continuous line oS tuberculous matter through the smallest to the hepatic duct, and into the intestine, even; all oS which is most beautiSully displayed in his drawing. This is a very remarkable discovery most assur- edly. (I will just note here the existence oS two other drawings upon the same paper, illustrating the disappearance oS the tu- berculous matter on the restoration oS the rabbit to a proper 158 diet, &c, which are yet more interesting ; but as not connected with the present point, we will talk of again). In the testicle of a goat, which he showed us, the vasa seminifera were filled with tuberculous matter. The animal, having enjoyed a large seraglio Sor a long time, was entirely shut out Srom the females, and one oS the testes became atrophied, the other diseased as above. It is upon these arguments that he rests his opinion. I will not comment upon them, but shall observe, if they be true. Dr. Carswell is about to publish a work upon morbid anatomy; elementary, with plates, and not very expensive. I shall send you two copies oS his conspectus, begging that you will get P. to advertise the work in his journal, and I beg you to pro- cure what subscribers you can. He has two thousand draw- ings, as Sar superior to any thing oS the sort I have ever seen, and I have examined the whole of them, as Raphael to a modern French artiste. London, October 1, 1832. # * # # I dined with Dr. M. Hall, and was indebted to him for one oS the grandest spectacles that human eye can behold. I witnessed the circulation in the web oS a Srog, under a microscope oS one hundred magnifying power. I know not whether you have ever seen this or not; iS not, you have no conception oS its beauty. With what ideas does it fill the mind ! — the whole animal world thus teeming with life and motion, and this motion in the most defined and regular vessels, and regulated by unvarying laws. The artery is distinct, constantly dividing into smaller arteries, until it is at last sep- arated into two capillary vessels. These are always of the same size, and thus differ from the arteries in this respect. 159 They run in every direction and at last terminate in veins, between which and themselves, as to Sorm and size, there is again the same distinction. In the second place, the blood is seen to move with different velocities in each oS these three order oS vessels. As it courses its way along the artery, rapid as lightning, you cannot distinguish the globules; these be- come quite apparent in the capillaries, and yet more so, J think, in the veins ; at any rate, you see them very distinctly in these two last series oS vessels, whereas, in the arteries, they succeed each other so rapidly, as to Sorm a continued line to the eye. It is a most glorious sight, and most ennobling to see the blood thus actively pursuing its course till it reaches the great and common reservoir, the capillaries; there delaying its progress in order that the Sormative vessels may make what use oS it they will; and then slowly making its way back to the organs, where it is to be replenished with what it has lost, or give up what it has acquired. When the web was wet with alcohol, and inflammation had commenced, the capillary cir- culation stopped entirely aSter a while ; the blood was stagnant in these vessels, while it continued to flow in the others. Upon this, (which is a phenomenon I know to be true, Sor I saw it,) Dr. Hall Sorms an hypothesis concerning inflam- mation. Pakis, November 1,1832. * * * * The glory oS the week has been Andrei's intro- ductory lecture on diseases oS the brain. It was the most eloquent thing I ever heard, one speech oS Mr. Webster's and a sermon or two oSDr. Channing's excepted. I could scarcely restrain myselS, it was so grand and beautiful. What powers of mind and vastness of comprehension has this man ! What 160 gave me peculiar pleasure also, he declared boldly and freely for the numerical method, saying, it was the only mode of advancing the science oS pathology. Paris, November 13,1832. # * # # What Louis has given us is positive, and it is a matter oS astonishment to see to what beautiSul and unex- pected results his mode oS studying has led him. Will you have an example, now beSore my eyes ? 1 could give many, but will limit myself to the Sollowing. One oS his laws, drawn Srom the study oS his Sacts, is, that in the adult subject, whenever tubercles exist in any part oS the body, they oS ne- cessity exist also in the lungs. A second law is, that every chronic peritonitis, chronic Srom its debut, is tuberculous; i. e. he has never seen one that was not so. Ergo, iSone discovers by symptoms, during life, a chronic peritonitis, one may be sure that the patient is tuberculous, and that he has a tuberculous affection of the lungs ; and he may safely diagnosticate this, although there may be no symptoms whatever of pulmonary disease. I must have written you last year of one case, in which I saw him make the diagnosis correctly. A second is now in the ward, of which I will give you the details on my return, as I have taken the observation at Louis's request. To me the case is interesting in another view, as being one of those, of which I wrote you in my last, where I had observed the form of bronchial expiration then alluded to. 161 Paris, November 24, 1832. * * * * But the most interesting circumstances of the last two or three weeks are the lectures of Andral upon diseases of the brain, and the unparalleled variety and number of these diseases, that we have seen through their whole course and after, in Louis's wards. It is really a little remarkable ; for I came back from London wishing to attend to this subject, and every thing has favored it. Next week, B— and myself com- mence a private course upon this subject at Salpetriere, which will yet multiply our chances for obtaining information upon it. We had yesterday a very perfect case of ramollissement of the left lobe of the cerebrum, which had caused hemiple- gia of the right side ; two days before a cancerous tumor in the cerebellum, with ramollissement about it. I have already told you of two cases of tubercles in brain; besides these, three cases of cerebral disturbance, in which no morbid affec- tion oS the brain was discovered after death. Nov. 26. — To the cases just mentioned, when I was inter- rupted on the 24th, we have this morning unfortunately been obliged to add another. A woman, who, three or four days after her accouchement lost her child, entered the hospital; was delirious in evening and during night, and for next forty-eight hours had loss of consciousness, repeated epileptiform convul- sions, paralysis, not complete, of left side of body, and raideur, or rigid contraction of right arm. These symptoms continuing, — death. Autopsy : — brain in a normal state ; no organic de- rangement. Morbid anatomy, then, does not tell us all; Sar, Sar Srom it; and, I may add, that iS I have learned better to appreciate what this science can teach us, by a more extended observation than it was possible Sor me to enjoy in America, I have not the less learned that it is by no means the only 21 162 mode in which we are to study the intricacies of pathology. How much chemistry is to yield, how much a more intimate knowledge oS physiology, how much a more exact apprecia- tion oS the various influences oS the different physical agents upon us, it remains to be decided. This last subject interests me much at this moment, as I am now reading Edward's work on the influence oS the physical agents upon liSe ; one oS the most remarkable works I ever read, both on account of the subject, and the peculiarly vigorous and philosophical mind of the author. I hope to see him soon; Dr. Boslock gave me a letter to him. But our poor pathology and yet worse thera- peutics ; —shall we ever get to a solid bottom ? shall we ever have fixed laws ? shall we ever know, or must we be ever doomed to suspect, to presume ? Is perhaps to be our qual- ifying word forever and for aye ? Must we forever be obliged to hang our heads, when the chemist and the natural philoso- pher ask us for our laws and principles ? Must we ever blush to see the book of the naturalist, his orders and his genera, with their characteristics invariable, while we can point to nothing equivalent ? Our study is that of nature, as well as theirs; the same cause acting upon the same materials must ever pro- duce the same effect with us, as with them. But they know all their elements. Do we ? In their calculation no figure need be left out. Is it so with us ? If honest, must we not confess that we are ignorant of many circumstances, which must, however, vary the result ? IS honest, must we not ac- knowledge that, even in the natural history of disease, there is much very doubtful, which is received as sure ? And in therapeutics, is it better yet, or worse ? Have we judged, have we deduced our results, especially in this last science, from all, or from a selection of facts ? Do we know, Sor example, in how many cases such a treatment 163 Sails Sor the one time it succeeds ? Do we know how large a proportion oS cases would get well without any treatment, compared with those which recover under it? Do not imagine, my dear Sather, that I am becoming a sceptic in medicine; — it is not quite so bad as that; — I shall ever believe at least that the rules oS hygeia must be and are useSul, and that he only can well understand and value them, who has well studied pathology. Indeed, I may add that, to a certain extent, I have seen demonstrated the actual benefit oS certain modes oS treatment in acute diseases. But is this benefit immense ? When liSe is threatened, do we very often save it ? When a disease is destined by nature to be long, do we often very materially diminish it ? I doubt not, that we do sometimes and under certain circumstances. But on the other hand, I must acknowledge that, what I have seen here of disease and its issues, has rather inclined me to believe that I individually overvalued the utility of certain modes of treatment in Ame- rica. You cannot conceive of my impatience to get home and see again, what I once saw, and what a second time I shall look at with new eyes. I have been led into these reflections (and I hope you will read them as they are, passing, conflict- ing doubts, which must ever arise in the mind of a man on every subject, upon which he has not determined facts, as the basis of his opinion) by the study of, or rather the look I have been taking at physics and chemistry and natural history. I have been led into them too, by the study of these darkest of all dark subjects, diseases oS the brain. There 1 look in vain Sor a constant and fixed cause oS a constant and fixed effect, so far as our senses and present modes of exploration enable us to appreciate the causes and the effects. There, again, even aSter we seem to have fixed upon some almost characteristic distinctions, which will translate with compare- 164 tive certainty the causes, I am condemned to read that having thus discovered the cause, we can go no Surther. There is a ramollissement, there is a tumor; but we can remove neither. There is a haemorrhage ; but some facts, of which I have been eye-witness, teach me that, even without treatment, these sometimes advance toward a certain degree of cure, and the symptoms thereof disappear to a certain extent; and beyond that, the art of man can never, or almost never go: the lesion remains ; the individual is maimed for life, and that life is not worth the having. Is it not true, my dear father ? Your life, which has been so long and so extensively useful, has it not been so more through hygienic, prophylactic, than through strictly therapeutic means. Think for a moment of the diseases, which prove fatal to the life of man in our country. Probably nearly a Sourth die oS tubercles; certainly a Sourth, if we except those who die of old age. ASter this Sourth how large a proportion dies oS some conSessedly incurable organic disease. Will you know to what results reflections of this sort have driven me ? I am brought to think that the medical man's life may be most usefully spent in the collection oS Sacts, which shall throw light upon the causes, internal and external, (I mean those which exist within and around the individual,) producing or leading to organic diseases, tubercles and the rest. How can this be done and what will be its effects ? Let me say a word upon each oS these heads. It can be done, well done, scientifically done, in one way only. Numerous histo- ries oS the lives of individuals, Srom the uterus to the grave, must be careSully collected. Their weight, and size, and parentage; their comparative growth and development; the care oS their inSancy; length oS time at the breast, &c.; their mode of physical education as to diet and exercise; and 165 their diseases, all in detail; their idiosyncrasies in every partic- ular ; and a host oS things, which appertain to every individual and influence his physical existence. This cannot be done by one man; — there must be a soci- ety, — a body oS men, all impressed with a sense oS its impor- tance, all Seeling and knowing that without it we cannot reach truth. Reflect Sor a moment upon the delights oS such an association. Suppose there were ten oS us in Boston and its environs, who should thus associate and observe careSully dur- ing ten years, or twenty ? We begin with the children, who are bora under our care; each oS us keeps a record oS all thus belonging to him; these records are to be copied by a clerk into a book, which is the property oS the society. Each month we meet together; the subject oS the evening is the additional material during the past month, which appears upon the pages oS our book. What would be the advantages oS such a society ? Call it Utopian, call it ideal, iS you will; I'll not deny it. I Sear it may, nay, perhaps, must be so; but again I ask, what might be the advantages oS such a society ? 1. We meet, so many students, so many practitioners, all inspired with the holy desire to discover truth and to turn it to advantage. We meet, each presenting to the whole what has occurred to him, receiving the light and aid which the com- bined efforts oS the whole can afford. Every individual case, then, oS disease will be more Sully considered and have an opportunity oS being better treated. 2. We create a school oS accurate observers, and the good effects of this alone are endless. 3. We amass materials, Srom which may be deduced a good and connected general history oS the most unknown diseases, those oS children, not painted by the imagination, but rigorously deduced Srom Sacts. 4. We collect in time a vast 166 quantity of material, which shall go to prove incontestibly some oS the most important points of hygiene. We show, Sor ex- ample, that children nursed only ten months have only halS the chance Sor a continuance of life to the adult age that those have, who are nursed sixteen or eighteen. We show that of two Samilies, equally disposed to phthisis, in one, who Srom infancy, led an inactive liSe, &c, all are dead at an early age ; while in the other, where means were taken to invigorate the system, all live, &tc. We will suppose that these, or similar and equally impor- tant truths, could be rigorously deduced Srom the Sacts we had collected ; that we could prove them, and show our prooS to the world, as the public treasurer renders his annual account to the public, by figures and columns not to be mistaken. 5. Again, in thus learning what description oS individuals and what sort oS life predisposed to such and such diseases, we may arrive at an earlier diagnosis and thus be able to procras- tinate, if we cannot prevent the occurrence of disease. But the advantage, both to the parties and to the public, which might result from such a course are too obvious. 1 have shown how I think this may be done and what would be some oS its effects; but there is yet another and a more important one in my mind than any, which would be produced immediately upon and through the physician. I speak of the effect upon the public mind, — the influence it would have upon the education of youth and the public hygiene in general. What mother would dare tear her child from the breast at eight or ten months, after we had shown her and made it accepted truth, that one of two children thus treated would meet with a premature death ? How many parents would be stimulated to increase their efforts to give vigor to their chil- dren, when it was made clear as that twice two is four, that 167 without it a wretched liSe and an early death would be the consequence. I may deceive myselS upon this subject; — though I have not yet written you halS I Seel and think; — I may overvalue its advantages; but on my honor, I do now believe it would be both Sor science, pure science, Sor utility, and consequently Sor the only two highest ends oS action to men in our profes- sion, the noblest thing that could be done. Imagine, Sor a moment, that such a society should spread Srom its little centre at Boston; that after a few volumes from New-England, Phil- adelphia and New-York, then London and Edinburgh, he., should raise their societies ; — that the work should go on; — look forward only fifty years; — imagine a man like Andral to bring together and to extract the truth from the immense mass of materials collected; — would there not be truth and useful truth there ? To set such a wheel in motion would it not be to have been useful ? I long to talk with you upon this subject, my dear father. For two months past it has occupied many a musing hour in my mind. And yet I beg you'll say nothing of it. Don't think me crazy; I don't expect all that 1 write. I only hope that an idea has struck me which is practicable, and if practiced will lead to good. Paris, December 1, 1832. * * * * A woman, aged thirty-five, entered la Pitie day before yesterday, and died that night; — she was examined to-day. Her state was such that we could learn extremely little, except what we saw; — great prostration, weak, fre- quent pulse, enormously distended abdomen, which was ex- 168 tremely painful on pressure and meteorized; (very clearly a peritonitis). Further, there was some imperfect account of a uterine haemorrhage, some one or two years since, and oS other symptoms oS uterine disease ; — Sace a little yellow ; — by auscultation crepitous rale behind, at left ; (pneumony, the occult affection perhaps oS fifteen days' duration.) More de- tails unnecessary. M. Louis said, before opening the body, that a fatal acute peritonitis, which was not secondary to some other disease, was a thing he had not seen for five or six years, and perhaps never; — so that he thought it probable we should find evidence oS some abdominal disease, anterior to the peritonitis. The woman was excessively Sat; I do not remember to have ever seen so much Sat about a subject. There was an hepatization oS left lung, — and peritonitis; false membrane, and pus over lower two thirds of abdomen, having centre in pelvis over uterus. On first aspect 1 should have taken it for a pure, uncomplicated peritonitis; but on accurate examination we Sound the uterus greatly enlarged; its body occupied by a cancer; its lips both destroyed by ul- ceration ; on the left superior corner of the organ was an ab- scess of the size of a walnut, filled with pus and of very thin parietes. Thus much for the case. Now for the reflec- tions which flowed from it. First. M. Louis again repeated what I have before said, that an idiopathic intense fatal peritonitis was a very rare disease. Second. This led us farther, — and on thinking over and talking over the subject with Louis, I have got to realize more strongly than ever, this evening, what I have often writ- ten you in part before, viz.; how false are our ideas (I mean those of the medical public and medical authors in general) upon the danger of many diseases. 1. Pericarditis is called 169 a very fatal disease. 2. Peritonitis the same. 3. Pleuritis often the same. 4. Gastritis the same. 5. Erysipelas the same. And yet, in truth, M. Louis for eight or ten years passed entirely in hospitals, making daily autopsies, has never, or almost never seen, any one of them by itself fatal in a sub- ject previously healthy. When I have heard him, from time to time, announce these laws, I have doubted ; but on refer- ence to my note-book, and my memory of individual cases, I have found that my experience coincides with his. I have but once in my life seen either of these cases alone, in a healthy subject, fatal; — a pleurisy in a child ; — even here 1 am not sure; — and in the next place it was a child ; — he pretends to have observed adults only. Paris, December 26, 1832. * * * * I have just seen an extremely interesting case at Hotel Dieu, under Chomel. A man about sixty years of age, chronic catarrh, pneumonia of five days on entrance ; then evidence of hepatization of upper right lobe by bronchial respiration and bronchophony ; no symptoms of disturbance in cerebrum, or digestive organs ; bled ; next day delirium added to other symptoms, which remain the same, except that ex- pectoration is lessened ; third day (eighth of the acute disease) delirium continues ; cough, expectoration, dyspnoea and pulse much diminished in frequency and quantity, while the physical signs remain the same, and the countenance indicates more pros- tration ; — death twelve hours after. No suspicion of arachni- tis, for no disturbance from light or sound, no headache, no affection of eyes; delirium only, and that so common in pneu- monia. But now that we have found a purulent effusion un- 22 170 der almost the whole arachnoid both of brain and spinal mar- row, I cannot help remembering that diminution in the fre- quency of the pulse, that cessation of the pulmonic symp- toms, while auscultation told still the same story ; and also that the delirium was a little more constant than it ought to have been, sympathetically. Louis tells me he has seen one such case equally latent, complicated with pneumonia, and not diagnosed before death. It is certainly remarkable for its la- tency, and has greatly interested me. You shall see it more in detail at my return. And now, that I am upon the subject of pneumonia, I must tell you of two cases I have seen this morning, the first time that I have been able to see precisely the same thing. 1st. A man, aged fifty, cancer of cardiac orifice, no symptoms whatever except emaciation, difficulty of deglu- tition, and occasionally regurgitation of part of the food. The two last symptoms had almost ceased within a Sew days. To the above must be added gradual diminution oS appetite, which had also risen since entrance ; — emaciation advanced; — he was eating what we call the half, i. e. a pretty good al- lowance oS bread, halS a pound. In twelve hours from last visit, when he seemed as usual, he died, — having shown signs of increasing feebleness, &x., Sor about that length oS time. We Sound a cancer at cardiac orifice and more than a hundred melanotic tumors in abdomen, with cancer oS liver; but oS all that at another time. Now Sor the lungs; the right lung, especially lower lobe, was externally darker, it con- tained less air, a more bloody fluid, its bronchia were redder than the left and its own upper. Was there here the first stage of pneumonia ? Before I came to Europe, 1 presumed that these great pathologists could always distinguish inflam- mation from congestion ; but it is not so easy a matter beSore 171 heptization ; they do not love to be too positive about it. Such was the case with Chomel, — however, he thought it very probable ; the more so, as at the moment we had two other men in the ward, who, while there with chronic disease, had both oS them been seized with pneumonia characterized by sputa, crepitous rale, he.; — and it was highly probable that a pneumonia oS twelve hours had killed this man, already so prostrated. So much Sor the first case : observe, how chance Savored my prosecution oS that subject that morning; I had got an idea or two Srom Chomel, but I Selt, as always, the doubt in these cases. To proceed, I went with B—, (who is now my constant companion and Sellow-student, and whose mind, and talents, and eminent virtue, I mean honesty, love oS truth Sor its own sake, with a due degree oS vigor in pursuing it, I prize daily more and more) to la Pitie. 2d. There, a woman, dead, in stage oS reaction Srom cholera ; the night beSore death, (twelve hours beSore death,) I happened to be with B—, in ward, and ausculting found a crepitous rale in lower lobe, right lung. The evening before I had ausculted the whole chest with great care, — respiration perSect. Now there was a pneumonitis oS the first degree. On dissection (I speak only oS the lung)and a very careful ex- amination oS the right lower lobe with the upper, and with the two oS the opposite side, 1 was able to establish the Sollowing distinctions. Had I not come glowing Srom Chomel, I could not have done so well. 1. Externally the right lower lobe was of a deeper violet color than the rest. 2. It was not by any means so much collapsed on raising the sternum. 3. On cutting it, it crepitated less. 4. The fluid which flowed from it on incision, was less frothy. 5. This fluid was also most de- cidedly more red. 6. Fromsomeof the bronchia oS right lower lobe, was pressed out a little purulent fluid, which was seen 172 nowhere else. 7. The mucous membrane oSthe bronchia of this lobe was oS a deeper red than any oS the others. 8. This lobe seemed to me heavier than the others. From these eight characteristics, I think I may inSer that there was inflammation, especially as I heard crepitous rale there twelve hours beSore death ; although there were no granulations, no Sriability, no solidification, no hepatization. Having made this accurate analysis oS the characters oS this morbid part, and having ar- rived at this more nette idea, than I ever had before, oS the true distinction oS the first stage of inflammation Srom mere congestion, I was proud and delighted; showed it to my Sriends; repeated it half a dozen times, and do not abstain Srom writing you in Sull, Sor I was truly happy over it. I pray keep the letter. You may say 1 should have known it beSore, but if you look at my cases of cholera described by Louis and Andral, or at Laennec, or at Andrei's clinique, you will see that no where is the thing drawn out so clearly as I have done it in the last page, by comparing together the two lungs. Paris, January 16, 1833. * * * * In very truth I look forward with Sear and trembling to the day when I must employ my time to earn money, in- stead of to learn truth. I once laughed when I was told the student's is the happiest life. Persuaded as I am that there is very much in the exercise of our profession, that developes and satisfies the affections, — that delights the moral man, —yet I must acknowledge that, had circumstances favored it, I should have been pleased to pass at least eight, or ten years in the study of the sciences of pathology and therapeutics, in the hopes of establishing some important truths. I am afraid, my 173 dear father, that we are in the habit of regarding many things in both these sciences as axioms, which are very far from being proved. As an individual I can be satisfied of a thera- peutic truth but in one of two modes. 1. I must see the treatment employed in a large number of cases, which are in n o way selected ; I must know and observe all the peculiari- ties of the disease, not only so as to know what it is; but what is the history and nature of the individual who has it, the history, or the general issue of the diseases of the season, he., &ic. These cases, being collected, are my raw material; I must study and class them. I must then count and see how often under such and such circumstances the treatment has been successful. This I have never done, with regard to any disease but cholera; but until it is done, my belief, as a scientific man, is, and must be insufficient to satisfy my mind. Such evidence is not necessary to prove that relief of symptoms follows treatment of various sorts; — of this no one can doubt ; he sees it, who looks. But 1 speak of arresting, or materially shortening disease. On this point general impres- sions, such general impressions as my mind is capable of re- ceiving, amount to nothing ; for they are for a thousand rea- sons most deceptive ; especially upon a subject like this, where we are previously inclined by our hopes, our interest, our humanity, coupled with those of the patient and his friends, always to look upon the bright side. Such then must be my mode of determining the truth with respect to any subject, that I investigate myself. Look to the history of cholera through the world; the successful remedies, almost as count- less as its victims, that have been vaunted ; the assured fronts and language of those who talk of their hundreds and thousands, and none lost; or yet worse, of the man who had one hundred patients, and saved one hundred and three; for 174 three women were safely accouched in the midst oS the dis- ease. We live indeed in darkness, and it costs more time to discover the Salsity oS pretended truth, than it would, perhaps, to reach something truly valuable. Am I wrong ? is there any other way oS establishing truth ? 2d. Here, my dear Sather, is the only second mode, in which my mind (I do not say my will, — Sor it is not an affair oS volition) will be persuaded ; i. e. that if I do not see, he, who has seen, should write me such an account as to prove that he has investigated the subject in the same way. This is to me a painSul subject, Sor I would Sain believe in all the therapeutics which you believe in; and yet the evidence that it is true must be derived from your and my general im- pressions. Now, when I have had such ample opportunity to see the futility of such evidence; when I hear men like An- dral and Louis both declare, that they have been misled nine times out of ten, when they have trusted to such evidence; and that on a minute examination of the very facts, upon which and from which these general impressions have been founded and derived, they have discovered their error; when I come to examine English books, Srom which we receive the great mass oS evidence with respect to therapeutical success, and see how they mingle, even the best oS them, diseases vastly distinct in their natures; I ask myselS, honestly, how Sar can I trust all this ? Do I believe that bleeding arrests inflam- mation, as I believe that a certain combination oS symptoms Indicates such and such a lesion? Is not the last proved by numerous demonstrations ? Have I ever seen one instance oS what the books talk so easily oS as to the first. I assure you, my dear Sather, in the present state of my knowledge, in my present view oS the existing state oS medicine, I believe that we admit many things in America as axioms, which are very 175 Sar from being proved. We have too long believed that, be- cause demonstration, on many points, was impossible in medi- cine, it was not worth while to study it like an exact sci- ence. It is a very Salse position. Just reflect Sor a moment oS what materials our therapeutic literature consists; almost without exception, chosen cases to prove the efficacy oS such and such remedies. Is this the way to proceed. Suppose the chemist went to his laboratory hoping to find oxygen in everything, and made known to the public those cases only in which he Sound it; would his science advance ? What a pity is it that ours is a mixture oS science and trade; or what a a pity, scientifically considered, that we cannot be entirely in- different as to results; then we might walk securely. But when we are hoping, and our patients are hoping, we are de- ceiving ourselves, and often the patients themselves, and us also. How difficult is it ? shall we, dare we, can we trust to general impressions received Srom such sources, and in such a state oS mind ? ISon any subject rigorous prooS is absolutely ne- cessary, it surely is to establish a Sact in therapeutics. But enough; though when with you I wish to enlarge more upon this subject, and were it not Sor two reasons; 1, that I must earn my bread ; 2, that I too dearly love that world of the affec- tions to which our profession introduces us ; I would devote my life to the accurate determination of some essential points of therapeutics. Remember, I do not deny the utility, in its fullest extent, of all the powerful agents which I have seen you employ; — on the contrary, I am inclined to believe in them to a certain extent; — but my mind (not my will) can- not receive the scanty evidence, which experience, lectures, and books have furnished as proof that all is true. 176 Paris, January 25, 1833. * * * * But we have had two instances of a more rare affection of the lungs this last week; gangrene. The first was in a young girl, with whom we first made acquaintance last year at la Pitie. She then entered Louis's ward, in March; cough excessive, oppression, respiration at last up to sixty-six in a minute, excessive sub-crepitous rale, the largest and most numerous I ever heard, over whole right lung behind : all this of recent origin. Louis doubted between bronchitis and acute phthisis; the actual symptoms could not be explained by either, but the excessive dyspnoea led him to hold the last in suspicion. This point could be decided only by the march of the affection, for we were then only five or six days from its debut. The cholera came; she was sent up into another ward; for a day or two I remember well going to auscult her; the same symptoms continued ; but the progress of the epi- demic demanding all my time, I lost sight of this as of many interesting cases. We heard no more of this young woman until the beginning of this month, when she entered again Louis's ward, with variola. Cough had continued during past year, but that and dyspnoea had decreased since we saw her; now not much emaciation; rale behind at right continued; nothing peculiar under clavicles ; for several reasons you will see the idea of tubercles was given up. But what, during this time, had been the pulmonic disease, which thus produced cough and maintained a constant sub-crepitous rale over so great an extent ? Only one single affection would explain it; dilatation of the bronchia. Such, then, was the diagnosis ; but, one symptom of this affection was wanting, viz. the broncho- phony. This it was impossible to have, from the aphony of the patient, caused by the variolous affection of the larynx. She died. Very beautiful dilatation of the bronchia, but also sev- 177 eral gangrenous spots in the lungs; some forming little cavities, filled with dark, gray, fetid, pultaceous matter; others yet consistent, but equally fetid ; none opening into bronchia, which was the reason why this gangrene was not discovered. You know the characteristic sign is the odour of the sputa. This case is to me exceedingly interesting ; I know not if I have given you an idea oS it; but it is so associated with nu- merous pathological points oS interest in my mind, that you will be sure to hear of it again at my return. You must know I have grown garrulous, loquacious since I came abroad, and shall need many a rebuke when we meet. [The second case is omitted because given in detail, in a subsequent part of this volume, Case 23.] # # # # j must not forget to mention that this is the third pulmonic gangrene we have seen in the dissecting room within ten days. Is it common just now ? or is this accidental ? You shall know if I see more. This disease, as it seems by the ex- perience of Louis and Laennec, is by no means necessarily fatal. * * * * * * * * How sad is this auscultation ? these positive physi- cal signs; which, though in themselves not enough, yet put the seal of certitude upon what before was doubtful; destroy the plausibility of many a willing interpretation of other symp- toms ; and leave us to fold our hands and await the event. But it must not be so. It is time that the pathological world should turn its attention to the causes; those things which pre- cede and lead to the various organic diseases, and especially to this one which counts so many victims. It is time that we should begin to collect those new observations, which alone can furnish evidence upon this point; I mean the circumstan- ces of the natural history of individuals. For shame upon us, that the antiquarian can spend years of toil and labor to decy- 23 178 pher an Egyptian hieroglyphic, the naturalist a life of hard- ships and privations to ascertain minute points of no practical interest, and that we should pass our lives getting money, when, by study and devotion to what is intrinsically of equal interest, simply as an exercise of the human mind, we could reach such results oS essential importance to the happiness of millions. I suggested this thing to Andral at his house, a week since. We have learned to diagnose tubercles early, said I; we can tell a man that he has cancer of the stomach ; but, that done, what must we add? —that a certain death awaits him, and that we can neither shorten, nor alleviate it. Is this the end of our studies ? Arrived at this shore, shall we land and be idle ; or, like honest and enthusiastic explorers, shall we advance into the country and look farther ? I added, the only mode oS advancing is to have the lives oS a great number oS individuals; see under what circumstances they have lived, and what has been their end ; Srom these premises we may have, indeed, we must have important conclusions. He answered, " yes ; but men will not do that." I know well that they will not; I know well that I have got to be exposed to a thousand temptations, and to nine hundred and ninety-nine, at least, I shall yield. But I pray God I may have strength to pursue this subject. There is none, which seems to me so important. La verite* est dans les Saits. On this subject* as on every other, Sacts prop- erly collected, must lead to good. My dear Sather, I am very serious on this point; I wish you would write whether you sympathize with me upon it. The question is not, is it easy ? Nothing is easy to do well. The only question is, will it be useSul ? The only question is, is there any other mode oS ar- riving at the truth ? Jan. 29. My dear Sather, I have just received yours oS December 20th, and in it there is one sentiment, as to which I 179 most heartily agree with you. You say, " in spite of all they say of the wickedness of this world, you often reflect how many excellent men and women you have been acquainted with in this world."* I am rejoiced to read from my dear father an expression of my own experience; each day I see it verified ; and my principle is, instead of always acting upon the defensive, to be willing to show my colors, and make friends with any worthy man. From this circumstance, my Sriends are numerous, and I have and do enjoy the acquaint- ance oS many, who reward richly one's confidence and sym- pathy. * * * * * * * * I have not heard Srom-----, since I last wrote you. His wiSe was then not very well, but I trust she is now better. I love to speak and write oS them. Each day convinces me that the true happiness oS man consists in a due and active development oS his intellect and affections. Neither alone is sufficient; with a happy development of the two, how much happiness is there in this world. Paris, February 6, 1833. # # # # Seriously, my dear father, I see that my life has got to be in future a little different from what my imagination loves to paint it. I must exercise a profession to get bread ; whereas, willing to work, with a horror of an inactive life, I still would love to work solely to satisfy two passions, a love of * I have printed the above for the sake of what follows, as that throws light on the character of the writer. In truth, the occasion of my remark, which he has quoted, was my felicitating him on having formed an acquaint- ance, and, in some cases, a friendship, with so many excellent people in Eu- rope. 1 remarked to him, that it was an evidence that this world is not so bad, as it is often represented. 180 science and an exercise of the affections. And yet, 1 presume, the auri sacra fames will touch me ; curse the day that it commences. Paris, March 22, 1833. # # # # As for medicine, since I have been in the habit of writing off cases at la Pitie, which takes up most oS my time, I find 1 give you Sewer details. In truth, my letters to you be- Sore, were a sort of note-book ; now I have no use Sor it. But I must tell you of one or two cases of a few days past. You remember the question, which often arises, on finding the gray, semi-transparent bodies in the lungs, which are very small; whether they are tubercles or not. I believe that they are. The proof is, 1st. That it is excessively rare to find them unless there be at the same time opaque, yellowish, de- cidedly tuberculous bodies likewise. 2d. In other organs, the same things are found in the early stages of tubercles. For example, to go no farther back than the experience of yesterday and to-day, — 1 have seen these same grayish white, semi-transparent bodies on the inner sur- face of an ulcer of the intestine, on the peritoneal coat of the intestine, on the substance of the spleen, on the surface of the liver and on the pleura. 3d. In the lungs we know that the tuberculous deposit com- mences superiorly and progresses downwards ; well, at the summit we find opaque, yellow tubercles ; a little lower exist tubercles, opaque at their centre and transparent, or semi-trans- parent at their edges; still lower, plain, simple, grey, semi- transparent bodies, without any opacity. These arguments are, I believe, unanswerable ; we owe them to Louis. We have had to-day a tuberculous peritoneum ; and in the same subject there were just tubercles enough in the lungs to 181 save the law. But the interesting point to me was, that I had heard " my prolonged expiration" on the right side and not on the left. Now, although the lesion was excessively slight, yet it was decidedly more on right than left; in truth, in the apex of the left were four or five little disseminated tubercles ; but in the right apex was one little conglomeration of them, as large as a small cherry, near the surface. Is it possible that this was recognized by physical signs ; by auscultation ? I know not why it should not be, and yet I dare not affirm it. I can only say, that in my notes it was written six or eight times, " a slight prolonged expiratory sound under right clavicle, which is not heard at left." Now this must have been owing to something; and, before the body was opened, I declared my belief that this right apex was the most affected. I dare scarcely believe that this sign is to prove of so much value. It is and ever will be rare to meet with an opportunity to test it in such a way, i. e. where it has occurred from so slight an alteration ; because accident alone, or some secondary lesion, will cause death at so early a period. It gives me great hopes, however, that I have really discovered a very important early sign of tubercle, perhaps the earliest that is appreciable. I have now many proofs of its value, though not enough to show its relative value to other early signs. Paris, April 5, 1833. * * * * Up to the time of Louis the same distinction had not been made, as now, between an acute disease, in a previ- ously healthy subject, and in one who was already diseased. The pathological laws, which reign over the acute disease in these two instances, are very different however. Again, I 182 mean previous to the light which Louis has thrown upon our science, the Sorce and beauty oS which I Seel daily more and more; attention was not paid to all the functions during life and all the organs after death; at least by the French and English authors who have written ; Sor it is with pride and delight that I each day repeat to myself, " Yes, my Sather examined in every disease, all the Sunctions;" he Selt the importance oS knowing the state of all, in each disease; oS each oS them. But did he examine all the organs after death ? No; this is peculiar to Louis. He can tell you in each disease not only the lesions of the organ originally affected; but also the pro- portion of the secondary lesions, which follow each disease. This is perhaps one of the greatest services, which my French master has rendered to science; and as I begun, so I finish, from an inattention to it, as well as to some other essential points, many of the observations of the best authors lose one half their value. May I give you a single example oS the beautiSul results, to which Louis has arrived by this scrupulous examination oS all the organs in every disease. Variola,— which, thank God, I shall not see at home as I have here,— what is the usual cause oS death in this disease when it proves fatal? Authors talk of the exhausted system, inflammation of alimentary canal, inflammation oS the brain, he. — all this is nonsense ; Sor it cannot be proved. But what has Louis Sound to be the cause oS death ? While at la Charite (six years since) oS twenty cases, sixteen died of laryngitis; false membrane lining the larynx; swelling, ho. oS mucous mem- brane ; great diminution oS calibre oS glottis. This he has seen confirmed at least as many times more; as I have also six or eight times al la Pitie. Well, why was not this essen- tial and all-important lesion known beSore? simply because pathologists did not open the larynx oS variolous subjects. 183 They were, in respect to this point, in the same condition as the ancients with respect to morbid anatomy in general. I choose this example because it is striking; but both oS my beloved master's works* are Sull oS similar ones. Paris, June 6, 1833. * * * * I must not Sorget to tell you that I have this moment seen a new case oS Bright's kidney, the second which Andral has Sound since I showed him mine. But what espe- cially fills my mind at this moment is the most superb case oS pneumonia I ever saw, now in our ward. Superb! why ? Srom its therapeutic interest. How delicious is it, among the mass oS dying and dead, when the only occupation is to de- scribe the phenomena during and aSter liSe, and now and then to palliate; how delicious it is, I say, to see here and there a severe case oS acute disease, dangerous Srom its nature, arrested; its duration reduced Srom twenty to Sour, or five days. Listen. A man aet. 36, on the night oS the 3d oS this month, at eleven P. M. was roused suddenly Srom his sleep by severe pain in left side; to which were added oppression, cough, and preumonitic expectoration. He was perfectly well when he went to bed, worked, he. as usual during the day. No more sleep that night; — increase of symptoms with heat, anorexy, thirst, he. Entered hospital in state of extreme dyspnoea, he. at nine, A. M. next morning: then bronchial respiration over the middle third of left chest behind, with a little crepitous rale and bron- chophony. (Hepatization of large portion of left lung already at tenth hour of the disease). Bled to twenty ounces, when he fainted. I saw him again at two, P. M. The crepitous rale had * The reference here is to Louis on phthisis, and on typhus. 184 disappeared,—nothing but bronchial respiration. Respiration, thirty-six a minute; (I forgot to mention flatness on percussion over same space;) still much fever, anxiety, pain, dyspnoea, although great relief since morning. Next morning the 5th, same condition except that the general symptoms, as also the rational symptoms, had decreased in intensity, whereas the bronchial respiration was still more distinct; as yet no return of crepitous rale. Venesection to fifteen ounces. In even- ing at six, P. M. great relief expressed by patient as to all symptoms. Respiration twenty-two instead of thirty-six, as last evening ; — bronchial respiration almost disappeared, and its place supplied by the returning crepitous rale, with some vesicular expansion, although still a little oS the bronchial char- acter;— flatness less. This morning, 6th, man expresses a state of " perfectly well;" says he can turn in every direction: in spite of thirty-five ounces of blood lost, is infinitely stronger than at entrance ; — pulse seventy-six, instead of one hundred: respiration twenty-two, instead of thirty-six; no pain, nor other symptoms ; asks Sor Sood; vesicular expansion abundant at the left, behind, with crepitous rale and scarcely any bronchial respiration. The man is nearly convalescent, and here we are at the fifty-fifth hour of a grave pneumonia, which occupied the two inferior thirds of the left lung behind, which began severely, wrhich had already reached hepatization at its tenth hour, which was attended with such severe symptoms as to make patient, enter at that early hour. My dear father, I rub my hands with joy. I hope for treatment during the first hours. 1 say hope; for although I may safely say I have passed one quarter of the hours of day-light, indeed halS, in the wards oS la Pitie Sor six months, and although this is No. 21, of my cases of pure pneumonia, which I have collected in the greatest detail there, still it is also the first that I have seen 185 apparently controlled by venesection; — the first bled under less than twenty-four hours. I have no time to write another sheet, and ought almost beg pardon for filling this with so rapid and abridged a history to an American physician, to whom such cases are not rare. Paris, June 27, 1833. * * * * I received your letters of the 13th and 21st ult, three nights since, together. They cost me thirty drops of laudanum, for my heart beat so hard and my head worked so fast, in consequence of the thoughts, speculations, castle-build- ing, &c. to which they gave rise, that I could not sleep, and knowing I must be up at six, A. M. I could not afford to play the dreamer with my eyes open, all night. So you consent to my observing a certain number of years, if I see fit, after a due consideration of the matter, and you advise me not to decide until upon the scene of my future liSe I may better know, weigh and appreciate the circumstances which should govern me. My dear Sather, I thank you equally Sor the permission and the advice, and promise as implicitly to Sollow the one as I grateSully accept the other. I know well, there are a thousand circumstances to consider relative to this subject, perhaps some occur to me which strike you with less Sorce: perhaps my life here and my experience of the men in the first places may have given me certain hopes, and at the same time certain horrors, which you do not realize so strongly as I do. I say perhaps, and perhaps only; — for you are so apt to look at every side of a question, that I dare hardly presume. Cer- tainly on the other hand, certainly you will present to my mind views of the subject, which 1 neither see nor feel; 24 186 and it would be only to continue in the sad way I have always followed, to listen too little to the wisdom and kindness of the best of fathers, did I allow myself to decide on any important point of life without his aid and instruction. Be assured then, my dear father, that my mind shall be kept open to conviction. I ask only that, once there, you shall endeavor to keep my mind in a right state, and not let the judgment be biassed by desires and temptations, laudable in themselves, but baneful to him who would Sor a while make science his sole mistress. The more 1 advance in liSe the more 1 see and feel convinced that its great and chieS happiness is self-education; self-devel- opment, intellectual and moral. God knows I have enough of both to do. May I only be industrious at the work! I tremble when I reflect upon the number of subjects as yet unknown, but which must be known to me. The two letters, which follow, were addressed to a medical friend, who kindly sent them to me. The playSul style of controversy will be readily understood from the extracts here printed ; though it would be more so, iS the letters were given entire. I have, however, erased all personal allusions. I trust that the letters will not be thought devoid oS interest. J. J. Paris, December 9, 1832. my dear doctor,-- IS you will deign to receive a word Srom a poor youth, who strives to estimate morbid anatomy at its true value, placing it neither above nor below its proper rank, he will be happy to say a word in selS-deSence. But, first, let me thank you Sor your kindness in writing me such a good long letter, Sull of pleasant words and kind rebukes and wholesome counsel. 187 I am glad that you are not displeased with my little memoir upon cholera. I grieve that you misunderstand me upon some points, and that we cannot agree upon a few others. 1st. You misunderstand extremely my estimation oS morbid anatomy. I see I must make a rapid confession oS Saith in order to let you see in what light I consider this science. 1. I conceive it to be one of the modes by which we are to obtain a knowledge of the phenomena of disease,— but by no means the only one. 2. I conceive and know that in some cases it affords very important positive knowledge as to the nature of disease. 3. 1 am equally aware that in many cases it af- Sords negative information only. But this negative informa- tion is as important, perhaps, as the positive. It is as useful to know that a thing is not as that it is: each is a truth in na- ture : each enters equally, as an element, into science : to omit either, is to be guilty of an equal omission. 4. Besides those cases, in which morbid anatomy teaches us nothing positive, are yet many others, in which, although from it we may gain posi- tive knowledge, we are still sure that something more has ex- isted, and has influenced the organs and the economy during life. 5. Indeed, in all cases of disease, there is ever an un- known something which morbid anatomy can never teach us : viz. ; that state, or condition of the parts, which precedes, and is the immediate cause of, the morbid process ; and which we know must exist, though we can neither see nor feel it. En resume, then, I esteem morbid anatomy as always affording evidence, either positive, or negative, which must be taken into the account by every rational pathologist; but, on the other hand, there lives not the man, who is more firmly persuaded than myself of its insufficiency to afford us an answer to all that we must look for in this dark science of pathology. It is but last week that I wrote my father very much in these 188 words : " If my life in Paris has enabled me to appreciate, much more fully than beSore, the advantages oS morbid anato- my, my mind has not been the less struck with this all-impor- tant truth, that morbid anatomy is very Sar Srom sufficient to satisfy all the desiderata of the pathologist." I take the trouble to go a little into detail here, because I regard the man, who esteems this science as the " fons et origo," and the only true one, oS important and well-established truth in pathology, I regard such a man, I say, as taking a very limited view oS this science, and as being very deficient in his mode of pur- suing it. I am unwilling that you should regard me as such- But though you will be pleased w;ith this avowal, you will ask me, what other evidence I am willing to admit in order to de- cide the nature of disease. I am ready to answer, two other modes of evidence are admissible ; but both are to be used with extreme caution, most especially the last. 1. The symp- toms ; — these, it is evident, will be variously esteemed ac- cording to the varying physiological views oS the observer. The ground, then, is dangerous; for there are theories upon the animal economy, so mechanical, so chemical, so wanting in beauty, leading so little to the delightful views of God and his power, which certain others do inspire us with, that, I thank God, my mind is made to admit the last rather than the first. It must be allowed that the evidence afforded oS the nature oS a disease, by the symptoms oS that disease, is to be adopted with great circumspection. I could cite examples of an abuse oS this species oS evidence ; but to you is useless. 2. Anal- ogy ; how much may we trust to analogy ? I doubt not it is useful. Each day I employ it; indeed, without it I could scarcely live. But I fear it greatly ; I know how liable it is to abuse. 189 And, now, my dear doctor, that I have spent half a sheet upon this subject, I will begin another to answer your second complaint against your humble servant;—a few words will suffice. 2d. You abuse me because I will not generalize: in other words, because I will not adopt, as my sworn creed, those opinions which originated with your ever to-be-respected friend and master, and which have been confirmed and strengthened by your own laborious observation and research. In the first place, I know that you would despise me more than any other could, did I pretend, through a desire in every respect to coin- cide with a man to whom both my reason and my affections have so much attached me, to adopt all his opinions, when I was not satisfied that they were true. 1 do not yet know the facts. I am by no means in a condition to decide the question, whether fever be only a local or a general disease; and, if either, whether it has always one seat, or always consists in the same phenomena. Instead of not generalizing enough, I have done so too much ; many questions are now doubtful in my mind, to which I was inclined to give a very positive an- swer before I came to Europe. And why have they become doubtful ? Simply because I have learned facts which I did not, then, know ; and I think it wise to wait till I have become yet better acquainted with them, and to search for others, before I form any general opinions upon some most important subjects. Instead of being in a hurry, I sincerely hope that I shall yet wait ten years or more : and above all, I trust I shall always be oS my present mind upon one point, viz.: to prefer to ac- knowledge myself in doubt, where the nature of the subject necessarily renders it doubtful, than to attach myself to any opinion, the truth of which I know to be very far from demon- strable. My mind is so constituted that I enjoy more to say, 190 " well, this point is unsettled; there are such arguments or such facts for one view, and again such others for the other ; we cannot yet decide ; " than to cry with the ardent and rest- less theorist, " I know that there is a certain degree of doubt^ but I will believe, for on the whole it seems to me true." It may be politic, or even useSul at times to suppress the little doubts, which arise against what we regard as important truth, which is to affect the public; — as we may say nothing about our Sears of the possible ill-effects oS a bold course oS medical treatment, which we think on the whole useSul; and yet, as scientific men, in both cases, it would be the height oS Solly Sor us not to distinguish between probable and certain, demonstra- ted truth. I apply this to myself, the student, who am not yet sufficiently advanced in my knowledge oS Sacts to Sorm an opin- ion upon certain subjects. There are several in which my father has and I had implicit belief, but which now I doubt; he knows them to be true; I do not. It is the same with you; you have studied your subject, long, Sully, in all its de- tails ; you have arrived at an opinion ; but that does not neces- sarily make me a subscriber to it; because you are learned, it does not make me the less a mere learner; because you have run the course and attained your end, and examined closely your object, and thus fixed firmly your opinion, it does not prove that I am not simply on the road, as yet unacquainted with much that you are familiar with. In other words, because you, from your abundance of knowledge, have a right to gene- ralize, I, in the depth of my ignorance, have no such right. I might possibly have taken the liberty of trying to prove to you that you generalize too soon, as you have accused me of the contrary extreme ; but I Sear your heavy cannon, and I will, thereSore, be silent, preSerring to answer by the deSensive, in- stead oS answering your question with another, as the robber 191 says to Alexander, or Alexander to the robber in one oS my school-days' dialogues, Sor I Sorget which. Paris, June 18, 1833. my dear doctor,-- We had yesterday the pleasure oS seeing your Sriend A.; and, although our interest with the Northern Courts is not so immense as your words would seem to imply, we shall endeav- or to render what little services are in our power to Mr. A., whom I see to be a good fellow, because he seems duly to appreciate your character. * * * * Do you mean to overwhelm me with ridicule ? When I have chosen my science, and you yours, do you think it just to take it Sor granted that, because the one is eminently calcu- lated to develope the mind's best powers and the soul's best affections, the other cannot and is not equally so ? As a sci- entific man, you must surely Sorget yourselS, when you attempt to prove that botany, or geology, or any other oS the sciences, as a science, is better calculated to improve the intellect, or to afford pleasure to the student, than is medicine ; or, rather, the accessory sciences which compose it. What is the pleasure, what the occupation oS a truly scientific man ? Surely, from an exact and detailed observation of what his senses can demon- strate to him, upon a given subject, to trace the great general laws of nature upon that subject. This I maintain to be the fundamental attraction of every science, to one who will view the subject as a man of science should. This being taken for granted, and I think you will hardly deny it me, I would beg you to point out the real distinction, scientifically speaking, between tracing the pollen-tubes to the ovula of an asclepias, with the eye, and following with the ear the various modifica- 192 tions oS sound produced in the chest by a pneumonia. Why, with my stethescope, may I not as much enjoy a crepitous rale, (oSthe first order,) or a bronchial respiration oS the purest tone, as Brown, with his microscope, a little channel leading Srom one part to another oS his flower. In both cases what do we do ? Appreciate, by the nice use of our senses, the phenomena ap- preciable by them, and then Srom those phenomena, connected with our previous knowledge, arrive at some law of the exis- tence of these two beings; an asclepias on the one hand, a pneumonia upon the other. Perhaps I deceive myself; but I think not; if any distinction exists between these two things, point it out, I pray of you. The reason that medicine, (or, to use a better term, the reason that pathology and therapeutics, or the natural history of disease before and after death, and the influence of external agents upon the march of disease,) is so despised as a science, is, that it has never yet been studied as a science. But the time has come ; it actually now takes rank with the other sciences ; only it is the least advanced of them. We have learned that positive knowledge may be gained, where we formerly admitted the most loose assertions of each popular author, as he came along. Studied as a science, I maintain that it has as strong a claim as any other, upon the best heads; and upon any one, whose object is to develope to the utmost his intellectual powers. Why, then, abuse me for studying it ? Should I make duty my guide? My duty is to prepare myself, as well as lies in my power, upon this obscure and difficult subject, which is to be the practical subject of my life. Is it enough for me to know what the books can teach me ? They contain more falsehood than truth ; and I cannot distinguish between them without studying nature. My duty, then, reduces me to the necessity oS observing nature in her diseased operations in the human economy. But how much 193 time shall I give to it ? As much as possible, is the only an- swer ; because even that will not suffice. Again, shall we leave duty to those who Sollow its dictates more than myselS; shall I ask oS taste, shall I take pleasure Sor my guide ? Same answer; my education and habits oSliSe have so constituted me, that it is my greatest pleasure to pursue disease in its myriad wanderings. It is: I do not say it will be. Since, then, duty and pleasure lead me to one object, why should I turn my back upon it ? But, again, Srankly I will acknowledge one thing, viz. that in my castle-building Sor Suture liSe, I some- times tremble; and your sentence, of "pity poor Jackson's wife," has made me tremble anew. To effect what I propose to myselS, and what I truly think will be the best possible use of my means and time, will occupy me most intensely for years. I do not mean that I shall not have minutes at my dis- posal and hours too ; but that, in all the best and brightest oS those minutes, when my mind is truly awake, it will inevitably recur to the subjects oS my study. All this need not be; I can put bounds to what I propose. I can, Srom the moment I reach home, devote but a given time to the objects oS sci- ence. But, my dear-----, as a kind Sriend, you should look, with a little oS your heart's as well as your mind's eye, upon my situation. You should reflect upon my Sather, what he is, and where he is, and what will be his disappointment iS I Sail short in the race. It must, then, be my object so to Sollow my studies, as best to secure what he desires and depends upon. Upon this point, I believe, honestly, that I am better able to judge, than either yourself, or he. I believe so, because, pur- suing the science later than either of you, I know and feel more deeply what is to be its march for the next half century. I know how it will be followed by those, who are to rank as mas- 25 194 ters. But, again, if pleasure, happiness, be the only end of life, I do not agree with you as to the means of gaining it. I do not here refer to any difference as to the estimation of do- mestic enjoyments ; I always appreciated them most highly. I reSer to science as a source oS happiness. In what way should a man cultivate it, so as to obtain the greatest possible individual pleasure Srom it ? Should he be superficially ac- quainted with several branches of science, reading what others have observed, or, perhaps, observing in general what others have pointed out in detail; or should he be one oS those, who himself observes and describes Sor others ? In other words, is the happiness, which may be derived Srom the contemplation oS the laws discovered by others, to be compared with that, experienced by him who discovers them ? Is a knowledge of generals, which, after all, a man, who knows not the details intimately, must receive partly on trust,—is that knowledge, I ask, productive of the same pleasurable emotions, as a knowl- edge of details ; of those details upon which the generals are founded ? We all admire the beautiful laws oS gravity, oS electricity, oS chemistry. But have we ever experienced a millionth part oS the elevation (" exaltation") oS Newton, or Franklin, or Davy ? Surely not. The same is true upon a smaller scale. I am much happier in pursuing my science in a strictly scientific manner, i. e. by an actual observation oS all diseased phenomena by my own senses, than iSI read Sor years the results oS the labors oS Cuvier and Brown, and Decan- dolle, &c. &c. Really, to study any science, with the hopes of at all advancing it, requires all one's time, and all his mind; but, iS he loves that science, he will be repaid by what he discovers. MEDICAL CASES COLLECTED BY JAMES JACKSON, Jr., M.D. MEDICAL CASES. Of the Sollowing cases, the first ten are copied from my son's common-place book, in which they were recorded beSore his visit to Europe; and the first oS them, as will be seen, in less than eighteen months aSter he began his medical studies. As cases, they are proSessedly imperSect; he had scarcely seen the subjects oS them during liSe, and the notes were made by him as contributions to morbid anatomy. Yet I have selected these Srom among many, because each one contains something sufficiently definite and sufficiently interesting Sor the patholo- gist. OS the remaining twenty nearly all were collected in Paris. The notes oS these are very Sull, but they are very briefly expressed. It was impossible to print them as they were; they have been written out in terms as Sull as is requisite and usual in medical cases. As Sar as possible the words oS the original are preserved, especially the most important words and expressions. In doing this I have been assisted by Henry I. Bowditch, M. D. All the cases oS pneumonitis and two oS those oS typhus were drawn up by him. He was peculiarly qualified Sor this task, as he was in Paris with my son in the winter and spring oS 1832—3, and with him in all his labors in the hospital, where these cases were collected. Inspired 198 by the same desire Sor knowledge and love oS truth, these young men derived the greatest enjoyment Srom laboring to- gether as brothers. They sought only to aid each other, and promised themselves the highest gratification in working side by side again, after their return to their own city. He, who remains, will, I am sure, continue his labors as a worthy mem- ber oS " the Society of Medical Observation," with a generous regard to the " sacred office" with which he has been invested. In these cases the remedies employed and the manner of using them are not always stated very Sully. I have, however, taken care that the prescription shall be inserted in all instances, where the remedy was possessed of much medicinal power. The autopsies might have been arranged in a more uniform method, and at one time I designed to do this. That is, in the description the external appearances might have been noticed first, then those oS the head, chest and abdomen in regular order. I did not do this, but Sollowed the order oS the original notes in each instance Srom these considerations. I presumed that the different parts were there described in each case in the order, in which they were actually examined; and it is right that they should be described in that order. The reason Sor this will appear, iS we remember that, when the heart and its vessels are opened and emptied before the head is examined, the ap- pearances in this will sometimes be varied from what they would have been, if the brain had been examined first. And even, when this last is done first, and the blood flows very abundantly, as it sometimes does, from its vessels, there may be some difference produced as to the fulness of the superior vana cava at least, and possibly something more. In regard to the selection which I have made from the cases left by my son, I wish to add some remarks to those made in the memoir. I have omitted cases, which did not terminate 199 fatally, not because they had not any value, but because they were much less valuable than those, to which autopsies were attached. IS we have an autopsy, we have some test, by which to decide on the accuracy oS the case; and we always may derive some certain advantage, if the whole case be stated accurately, as regards the phenomena before and after death. But when we have a case, which has not terminated Satally, we must rely much on the reporter. IS the reporter be a young man, as yet little experienced, some distrust will be attached to his statements in the minds oSmany. Such cases thereSore will not be universally received as affording grounds Sor im- portant InSerences. I have not selected any cases of emphysema of the lungs, except where this affection happened to be combined with tubercles. Yet there are not perhaps any cases left by my son so valuable, as those on emphysema. I omitted these cases, because I knew that M. Louis had prepared a paper on this disease, and that this paper was in the press; that for this paper he employed the cases collected by my son in addition to his own, and that he would publish such of these as he thought would be useful. I therefore was not willing to take the chance of publishing the same cases, and have thought it best to refer my readers to the forthcoming paper by M. Louis, in which I well know he will do ample justice to the labors of his pupil, and will bring Sorward, at the same time, the results oS his own researches in this common and very interesting disease. N. B. ASter seeing the cases in print I shall very probably find some explanations necessary. IS so, these will be given in a note at the end. I shall certainly subjoin there the Sormuke Sor some oS the articles, which are mentioned by their titles in the prescriptions. The reader will thereSore look there when reading the cases. 200 CASE I. ORGANIC DISEASE OF THE STOMACH. Dec. 30, 1S29. —Examination of J. R. J. R. was a man of an uncommonly strong and muscular frame. He lived to the age of 72 in the enjoyment, until very recently, of the most uninterrupted good health. He drank cold water and in general was a man of very temperate habits in all points: but his friends thought that, of plain food and drink he took a very good share, and he might perhaps be called a large eater. He was accustomed to take much and regular exercise, and thus had preserved an excellent habit of body. During the last summer, having had occasion to take a long journey, he suffered great exposure and fatigue, and there was induced a very troublesome and serious costiveness, which was overcome with some difficulty. Shortly afterward, in October, he experienced a difficulty in swallowing, which was soon Sol- lowed by a vomiting oS his food. For these symptoms he was treated with emetics, &c, in hopes oS throwing off the disease; but in vain. The costiveness and difficulty oS swallowing, without nausea, or loss oS appetite, continued. He had pain, though not ex- treme, about the epigastrium, a little to the right oS the ensiSorm cartilage. The difficulty oS swallowing was somewhat dimin- ished, when he laid upon the left side. For the last fortnight he had continually vomited a bloody fluid, of a coffee-ground aspect. These brief notices oS his case I gathered Srom his physician, who was kind enough to invite me to attend the post-mortem examination. Autopsy. External Appearances. — Body by no means extremely emaciated, but had lost some flesh. Tumor in left axilla, which was examined; it was nearly as large as a common 201 kidney, was mostly composed oS Sat, with some glandular mat- ter, indurated, and oS a reddish-gray color. Thorax. — The organs in this cavity were in a remarkably healthy state. Abdomen. — On opening into this cavity, there was first per- ceived a tumor, oSmore than an inch in diameter, between the omentum minus and the stomach. This, upon being opened, was Sound to be partly Satty, partly an indurated schirrous mass. Opening the stomach, there were observed many dark spots, oS an eighth oS an inch, or more, in diameter, scattered about its mucous membrane. These were probably owing, or per- haps we may say certainly owing, to the coagulation oS the blood effused Srom the mouths oS the vessels in this membrane. Passing the finger from the cardiac orifice, for about four inches up the oesophagus, there was felt, first, a considerable stricture, and, secondly, a thickening and induration of the part. On a more close inspection of the parts, as they laid, there was found a very perceptible tumor upon the right and outer part of the oesophagus, but it was not connected with the tumor of which I have before spoken. Here, then was the main seat of the disease; and on cutting into the oesophagus, that we might view the internal coat, we found one very considerable patch of this completely ulcerated; and on rubbing the organ with the sponge, without violence, the mucous membrane was seen with a ragged edge, and became immediately detached, so as to be raised for the space of three quarters oS an inch, towards the upper part, with perSect ease. The pyloric orifice was somewhat diseased, being a little thickened and indurated; but very evidently the most essential part oS the disease, as well as that which was most clearly indicated by the symptoms, was at and about the cardiac orifice. 26 202 The left lobe oS the liver was uncommonly small; its ex- tremity not reaching to the left side oS the spine. Indeed the whole organ was of a very small size, but was very healthy in its aspect. The gall-bladder was very much distended with black bile. The small intestines were oS an unusually small calibre; not sufficiently large, Sor the most part, to admit the entrance oS the middle finger, as I should judge; Sor I did not make the experi- ment. The accumulation oS Sat about the parts in the internal cavities was very observable, as it generally is in old subjects. Remarks.—1st. It has occurred to me whether the absence of nausea and oS anorexy was not in part owing to the seat of the disease; or, in other words, had there been disease oS a similar character and equal in amount within the very cavity oS the stomach, would not these affections have been more likely to ensue ? 2d. The Sact of his being better able to swallow when in- clining to the left side, is explained by the seat of the tumor in the oesophagus, which was mostly upon the right. 3d. In what way shall we reconcile the sudden occurrence of symptoms, which began to appear in the autumn, (the pa- tient having previously enjoyed good health,) with such a mass of disease, which must have been a long time forming ? My father thinks that the fatigue and exposure during the journey, and the costiveness induced thereby, acted as exciting causes to an aggravation of the local disease. Thus ulceration and the consequent symptoms and sufferings ensued. We may learn from this the importance oS avoiding all such exciting causes, as much as possible, during any serious chronic local disease ; as by the practice oS this preventive method we may retard the issue oS the same, although its termination may be sooner or later necessarily Satal. 203 CASE II. ORGANIC DISEASE OF STOMACH. Jan. 26, 1830. — Emmanuel Joseph, a Portuguese, set. 44, entered the Massachusetts General Hospital on the 18th. He had formerly been a sailor, but for the last few years had worked on one of the wharves in the city, and was apparently a man of good habits. He had been wrell, according to his own account and that oS his fellow-boarders, till within about three weeks; at that time, being troubled at his stomach, he took an antimonial emetic, which operated very severely ; this he followed in a day or two with a cathartic of senna and salts. When he entered the hospital, he had a constant vomiting, with constipation, and some colic pains, not very severe. At the first visit, from his description of his sufferings, the physi- cian suspected the existence of an organic disease of the stomach. He was treated with cathartics, which he did not for a time retain upon his stomach; however, these with ene- mata were persevered in, and about the fifth day he was reported to have had copious discharges of an unequivocally fecal character. This had beSore been doubtSul. Extreme thirst, (he once drank his own urine,) vomiting, distressing Seeling about the epigastrium, and great coldness in these parts for the last Sew days at least, were the most prominent symp- toms. The abdomen, instead oS being distended, was much sunken and flat, and its parietes very rigid. Generally, there was great prostration oS strength, great emaciation, very marked lividity oS the skin, and a low Seeble pulse, somewhat varying in frequency. Attempts were made to support and revive him Srom this state, with stimulants, — brandy, etc., but in vain. These seemed to alleviate his sufferings, by allaying somewhat his extreme thirst, and, in a degree, overcoming his acute sen- 204 sations oS internal coldness; but his disease was such as not to be lived through, and stimulants were oS no avail. Autopsy. The abdomen only was opened. The mucous coat oS the stomach wTas extremely corrugated, presenting a very pecu- liar aspect. The pyloric orifice was almost entirely oblite- rated ; there being a schirrous tumor, or schirrous deposit, very hard and firm, between the mucous and peritoneal coats of this organ. The disease extended just to the commencement oS the duodenum. Two spots within the mucous mem- brane were much reddened, very evidently in a state oS inflammation; there was a small quantity oS thick mucus, and a little purulent matter, upon the internal mucous surSace of this tumor. In many parts of the small intestines, in the cae- cum, and, perhaps six inches up the colon, the mucous membrane was in a state oS high inflammation, but in no part had it advanced to ulceration. This surSace presented a very beautiSul crimson color, such as I have never beSore seen ; but this examination being made beSore the body was cold, much sooner after death than I had ever beSore witnessed, I cannot say how much is to be attributed to that circumstance. The spleen was very small, not a third part its usual size. Remark. — The circumstance of the long existence of this disease, which must have taken a long time for its Sorma- tion, without any disturbance to the patient, is quite worthy oS observation, although by no means new. By the Editor. — These two cases, Nos. I and II, are incomplete in their details; yet the Sacts are sufficiently valuable to be recorded. The writer learnt afterwards that instances oS organic disease oS the stomach, without grave symptoms until a late stage, are not so rare as has been com- 205 monly supposed. These two cases are among the first recorded by him, and both of them occurred within eighteen months after he commenced the study of medicine. CASE III. PHTHISIS. METALLIC TINKLING. Dec. 28, 1829. —I was invited this morning by Dr. Fisher, physician of the House of Industry, (South Boston,) to attend with him the examination of a woman, who died the night before. I had seen the patient about a month ago, and was made acquainted, at that time, with a few particulars of the case. She had been for some time, as I was informed, and as her appearance fully indicated, on her bed, with unequivocal marks of phthisis. The circumstance most observable at that time, and for which I was invited to see her, was, that the me- tallic tinkling had been heard in her chest, through the medium of the stethescope. This was observed upon the left side of the thorax, in a somewhat confined spot. It was just below and partly upon the scapula, and also, if I did not mistake, over the space between the scapula and spine. On applying the instrument, I heard it very distinctly several times. It was audible immediately upon the termination of inspiration, as expiration commenced, and this with great regularity. Dr. Fisher likened it to the sound produced by the blowing of air into a wet bladder. Another gentleman thought it most like a drop of water falling into a glass bottle, half filled with fluid. For myself, I should say it was something between the ticking of a watch, and the sound produced by striking a small bar of steel upon any resounding body. Whatever this sound may have resembled, however, it was most unequivocally metallic 206 in its nature. This patient had diarrhoea for some days pre- vious to death. Autopsy. Before using the scalpel, we tried the succussion, according to the mode advised by Laennec. While one of us held his ear near the part, another tapped the shoulder of the subject, being in an erect posture, with force sufficient to shake the upper part of the body, and we thus successively heard, very distinctly, a metallic sound; not, indeed, so decidedly metallic as we had before heard through the stethescope ; but, still, somewhat partaking of a metallic nature. External Appearances. — Nothing externally was worthy of notice, except the red color of the most dependent parts, as contrasted with the paleness of the anterior parts of the body. Thorax. — Upon opening into this cavity, there were ap- parent, at first sight, marks of great disease upon both sides. There was a little serous fluid in the pleural cavity, perhaps six or eight ounces. The sternum and cartilages of the ribs being removed in the usual manner, the organs in situ presented the following appearances ; adhesive bands between the two folds of the pleura, upon the right side, prevented any observation before detachment of the same, of that lung, so unbroken was their extent from the top to the bottom oS the thorax. The right edge oS the pericardium extended somewhat beyond that oS-the sternum, and this whole membrane was oS a larger size than common. Upon the left side the adhesions between the two pleuras appeared to be equally as extensive and strong as upon the right; the lower lobe also oS this lung being in part adherent to the pericardium. The upper lobe presented at once the appearance oS a large cyst, and upon handling and tapping this with the finger we Selt assured that 207 it was a large cavity filled with air and fluid, and we again heard a Saint metallic sound. Putting a ligature upon the trachea and blood-vessels, the whole oS the lungs, together with the heart and pericardium were taken out, the adhesions natural and morbid being re- moved. The lungs were adherent, not in every point, but very gen- erally to the parietes oS the chest. In the right lung, about opposite the Sourth and fifth ribs, was a large abscess not very deep, ragged, having the pleura for its external wall. A great portion of this lung was healthy, but in many parts tubercles were perceptible, and there were one or two small abscesses similar to the one above described. Of the left lung, one half of the lower lobe was healthy, of a natural color and crepi- tated on pressure. Of the upper lobe a very small portion only, and that the most dependent part, had preserved its organ- ization. The morbid half of the lower lobe was studded with tubercles of various sizes, both within and upon the surface. The remainder of the upper lobe was, as I have said before, one great cyst, evidently containing air and fluid. It was thought best to puncture this under water, so that we might receive the gaseous portion in a glass. Our object was so far accomplished as to prove incontestibly the existence of air in the cavity; but we could not form any precise estimate of the quantity, as a part of it escaped our glass. Upon opening into the cavity we found nearly a pint of purulent fluid, of a cream-like consistence. The walls of the cyst were one third of an inch in thickness. Externally was a dense, hard, reddish coat, viz.; a false membrane, which before removal was strongly adherent to the costal pleura. Immediately next to this was a somewhat thicker coat, white, rather tough, resembling in appearance the cartilaginous texture. 208 Within was a suppurating surface for the most part very red and uneven. Upon the left side of this there were three or four elevations, about a quarter oS an inch in height and thick- ness and two or three in length. These were oS a red color, and such was their aspect, that we supposed them at first to be blood vessels, whose cavities had been obliterated. They were Sor the most part adherent to the internal surSace, but in one place, of less than an inch in length, a little elevated, so that the finger could be passed underneath, as under an arch. We now cut down from the trachea, that we might follow the bronchia and ascertain if there was any communication between this cavity and the outward air. Three or Sour sev- eral openings were discovered, two oS them oS considerable size, admitting easily the introduction of a common-sized di- rector. We found also that we were wrong in our previous supposition with regard to the long red elevations, above men- tioned ; for by following along the bronchia with the probe we Selt here, as at many other points, an obstruction to its farther progress precisely in the direction of these obliterated canals. It was very evident then that these were not blood, but air- vessels, and that our first conjecture was a false one. Heart. This organ was oS a full size, I should say rather large. Dr. F. thought not. It was pale and flabby. There was a small quantity of water in the pericardium ; — certainly not more than usual. Over the right ventricle was a small spot of a light florid color, as if fully injected with arterial blood, quite peculiar in its appearance; not circular, but of an irregular circumference. This color subsided after immersion in water, so that two days after removal, no traces of it were to be seen. The parietes oS the ventricles were more thin than common, particularly the right. 209 Abdomen. — There was some water in this cavity, but not to any large amount. The liver was much enlarged and oS a firm consistence. Its color was unnaturally dark, and on cut- ting into it, there was discovered a more granular surSace than usualj The leSt lobe descended so low, as entirely to obscure the stomach Srom our view. Upon the external surSace oS the intestines were several dark, elevated, firm portions, indicating to us the existence oS ulcers within. The spleen, mesenteric glands, kidneys and pancreas were natural, — unless the last somewhat enlarged. The mucous coat oS the stomach was very thin, soft; and red. All the membranous parts oS the canal were in Sact uncom- monly thin, and so easily torn, that the scalpel was hardly used in the detachment oS the whole intestinal canal Srom its attach- ments. They were simply torn apart by the hand. Through the whole oS the small intestines, the mucous coat presented, Sor the most part, the same appearances which I have described as existing in the stomach. There were also Srom ten to fifteen ulcers, varying in size Srom that oS a ninepenny piece to that oS a halS dollar, and presenting more oS a tu- bercular appearance, than I had ever beSore seen. In one spot I observed a perSect and entire tubercle as large as a small pea, but oS a more oblong shape, and oS a tarnished white color. The large intestines were also much diseased, their coats having become very thick; — but I unfortunately neglected to examine these parts with sufficient attention to obtain a proper knowledge oS the same. Remarks. — 1st. One practical advantage to be derived Srom this examination is, that pneumo-thorax does not always exist when the metallic tinkling is heard. With this latter affection there is usually combined an effusion into the cavity oS the 27 210 pleura, and hence is to be derived the indication for an opening into the thorax. But were we to think proper to operate in such a case as the above, we should find ourselves much in error. Laennec mentions two cases similar to this, (37, 38, 1st. edit.) entitled " Tintement Metallique dans une vaste ex- cavation tuberculeuse." 2d. The little tubercle, which I have mentioned to be in an entire state upon the surface of the mucous membrane, was worthy of remembrance; as it seems to show that the disease in the alimentary canal, so often observed to come on at the latter end of phthisis, probably begins in the glands. CASE IV. PHTHISIS. METALLIC TINKLING. Jan. 25. 1830. — J. M., a baker, who had led an intemper- ate life, entered the Massachusetts General Hospital eight days since. He had been troubled in his chest for the last two years, the attack having commenced in his left side. Having travelled from New-York in the steam-boat, during the preceding week, his disease was aggravated, and on this account he entered the hospital. His first appearance was that of a man in the last stage of phthisis. His strength was much exhausted and he was very considerably emaciated; pulse 120 to 130, hard, during his whole residence in the house. His right side only was fairly examined by the stethescope, as he laid in the corner of the room, with his left to the wall, and was too weak to admit of much disturbance. Under the right clavicle, pectoriloquy was distinctly heard at certain times, at others less distinctly. I forgot to remark, above, that his expectoration was decidedly » 211 purulent and rather copious ; and once or twice I observed a little blood in the cup. Under the right clavicle was also heard the mucous rattle at times; at times, too, a metallic gurgling, not exactly the " tintement metallique ;" but a sound which was compared by the physician to the boiling of a fluid in a thin metallic vessel. It gave to my ear, a distinct assur- ance of air bubbling through a fluid. In the lower part of this side, the crepitous rattle was heard. Autopsy. Thorax. — On raising the sternum with the ribs, which had been sawn off behind the cartilaginous portions, there were found strong adhesions of the right lung, through its whole extent, to the surrounding parts. Whether there were ad- hesions upon the left side, I do not know. In the upper lobe of the right lung, there was an extensive abscess, with very thin parietes, in the upper part, so that it was unfor- tunately torn open, in the attempt to detach the organ from the adherent pleura. I say unfortunately ; for it was desire- able that it should not be opened until we could carefully ob- serve it, and ascertain if there was any air in the cavity. This abscess continued down almost the whole extent of the upper lobe, irregular in its shape, and with parietes increasing in thickness, as we cut toward the diaphragm. I should rather say this was the case generally, for there were one or two spots, especially one toward the mediastinum, which were so thin, as to have been penetrated in the dissection. This abscess contained a reddish fluid, of middling consistence ; but, whether it was colored by the blood effused during the dissection, or before death, is uncertain ; I should rather incline to the last opinion. The whole of the lobe was not included in this ab- scess ; and the portion excluded was of a whitish gray color, condensed, not admitting the air. The lower part of the pari- 212 etes of the abscess, which excluded the portion of the lung just mentioned, from its cavity, was very regular and striking, being nearly an eighth of an inch thick, of a cartilaginous ap- pearance and firmness, rendering very obvious the good end answered, by the adhesive process, in the original inflamma- tion of this part. The two lower lobes were mostly in the first stage of inflammation, presenting on a section of almost every part a scarlet color, and much blood and air following the knife. There was one small abscess in the lower lobe filled with a true purulent fluid. There were also two groups, each of the size of a marble, composed of small granulated bodies, which did not present to my eye the appearance of common tubercles, but I did not accurately examine them. We now detached this lung with its bronchus, and having in- serted a blow-pipe into this tube, it was found that the air pass. ed freely through six or eight fair openings, into the large cavity first described. The left lung was likewise much diseased. There were in the upper lobe two abscesses, one of very considerable size, containing a purulent material, precisely similar to what was expectorated during life. This lobe almost entirely, and the lower part of the lower lobe, were composed of granulated bodies, wrhich caused a rough surface to be presented on the cut surface. These bodies were of a light, almost white, or yellowish-white color; and the organ was not so much com- pressed by them as to prevent the admission of air; for bub- bles of air followed the course of the knife, in every part. I saw none larger than common sago, as we see it; but one gen- tleman told me since, that he met with some much larger. The appearance was not unlike that described by Laennec, under the head of the second stage of inflammation ; except- ing that instead of " les petits grains rouges," these were white. 213 He is describing the appearance after death, in an acute pneu- monitis. May not this be an analogous state of things arising originally from that cause ; but from the habits of the subject, never having been restored by the healthy and natural proces- ses usually instituted for the purpose of restoration ? Or, in other words, was not this state of the organ, the result of a pre- vious common inflammation, modified by its long standing, and its want of disposition to recovery. By the Editor. — I will only add, in regard to this case, that the observations, collected by the writer at a later period, present similar facts, as to tubercles, but they are related in different terms. It is on account of the metallic sound, attend- ing large vomicae, that I have admitted this and the preceding cases. CASE V. PHTHISIS WITH PNEUMO-THORAX. Oct. 18, 1830. — S. L. entered Massachusetts General Hospital, on August 13th. For two years he had had some difficulty in his chest, of which pain in the left side was one of the symptoms. A few days before entrance, there had taken place a somewhat acute attack, the violence of it being mostly over at this time. His pulse I observe to have been but seventy-two until sometime in September; — at this time there came on symptoms oS a pretty acute pleuritis, which was met by active treatment, but not entirely overcome. The leftside remained dull on percussion, and the murmur of respiration was not heard there, while it was puerile upon the right side. This state of things lasted until within the last ten days; — 214 I had not seen him until then. From this time the following symptoms and phenomena were observed. Dyspnoea, not striking, — can lie only upon left side, some cough and a little expectoration, not of purulent matter, — pains shooting through the left side, and soreness of integuments there on pressure,— intercostal spaces of left side, raised even with ribs, and oedema of that side; left thorax not moved in respiration, and apparently larger than right, though not so by measure. Murmur of respiration puerile on right side; wanting in every part of left, unless just below clavicle. On percussion, more full upon right than upon left thorax. Flat on left thorax, except on the breast, and especially the upper part, where it was not quite flat. In the course of a few days the metallic tinkling was heard by the physician just above mamma. I wras not sure that I heard it at any time. By succussion, the sound of a fluid in motion, was observed in the thorax. This symptom varied, sometimes being entirely absent, and the sound was not at all times equally loud. I heard it but once ; it was then most unequivocal. The man told me he felt the motion of the fluid in his chest, when he made any effort to change his position; — but added that this had not been the case till within the last month. The impulse of the heart was entirely wanting in its natural position, but was Selt under and rather to the right of the sternum. Two days before his death, I was very confident I heard the murmur of respiration down to the mamma of the left thorax. The intercostal spaces also were less elevated then than before. He had walked out till within ten days of his death, and pre- served his appetite, although he was taking digitalis in pretty large doses. His pulse was only seventy-two, the morning oS his last day. He had been sinking, especially in strength, Sor a Sew days rapidly. His respirations on this morning were 215 but fifteen in a minute. This man was by trade a brick maker, aged 24. Autopsy. External Appearances. — Great emaciation. Left side of chest apparently larger than right; — intercostal spaces much less elevated than a few days since, — but more so than on right side. Left hypochondrium more prominent than right. Ensiform cartilage turned to right side, so as almost to lap over cartilages of false ribs. On percussion, report as before. Thorax. — The trachea was now secured by a ligature pre- viously to puncturing the chest. On puncturing between the fourth and fifth ribs of the left thorax, about on a line with mamma, the flame of a lighted taper, held at the orifice, was seen to flicker very perceptibly for some seconds on compres- sion of both sides the chest. The gas which escaped did not take fire, and had not the smell of sulphuretted hydrogen. On puncturing the right thorax, the air, flame and smoke were at once sucked in and the flame was extinguished. The sternum being raised, the right lung was seen collapsed, ap- parently healthy. The heart and large vessels were under the right half of the sternum. The left thorax was almost filled with a fluid which was estimated to be three quarts in quantity; — it was a darkish, serous pus, or purulent serum, with large masses of coagulable lymph floating in it, and at the bottom a large quantity of porraceous matter. I could liken this fluid to nothing but soup; the appearance was to me novel. After removing two-thirds of this fluid, a blow-pipe was inserted into the trachea, and the lungs inflated, in order to ascertain, if there was any communication between the lungs and the pleuritic cavity. In a few minutes bubbles were seen to rise in the 216 upper part of the cavity, evidently proceeding from the escape of air at that part of the lung. The left lung was compressed close to the mediastinum, to which and to the pericardium and diaphragm it was adherent. The apex of the lung, in which a small abscess was situated, (which abscess had been the medium of communication between the bronchia and pleura, by opening into this last cavity,) was not adherent to the pleura, but remained disengaged. The substance of the organ thus compressed was of a dark color, firm, not admitting the air in any part that I saw, although others thought it expanded under the blow-pipe. The right lung was slightly adherent in some parts to the pleura and pericardium. It contained tubercles scattered through its different parts, and little black elevated granules ; also in some parts of its surface were livid sulci, looking like a contraction of the pleura inwards, in consequence of a cicatrization. In feeling and incising these parts, there were evidently tubercles underneath the pleura and quite superficial. The heart was firmly adherent to the pericardium throughout its whole extent. Internal cavities of heart not examined. Remarks. — 1st. The course of the disease in this man appeared to be the following: — There had been formed, on some previous occasion, a small tuberculous abscess in the apex oS the left lung, which had opened both into the bronchia and pleura; and its contents, being effused into this last, caused a violent pleuritis, which could not be overcome by the most vigorous depletion. Hence all the subsequent symptoms. 2d. 1 would observe that this is the fourth case within a year, where I have seen the pericardium adherent to the heart. It is proper that I should take warning from this, that 217 the disease is not very unfrequent, and is to be thought of when there exists any thoracic inflammation. 3d. This case shows that inflammation of the pericar- dium will often go on secretly, without betraying any such prominent symptoms, as we might naturally expect. This man in his detail of symptoms, mentioned none that would indicate that this disease had ever occurred. We are not, hence, to conclude there were none such ; but if they had been very prominent and severe, he probably would have mention- ed them. 4th. The very slight degree of dyspnoea, which this man evinced, are very well worthy of notice, as there existed such extensive and serious disease. By the Editor. — This instance of pneumo-thorax is the first, which was ever observed in our hospital after the work of Laennec was known to us. Though the hospital records would furnish many more details of the case, I have preferred to give it in the words of the young reporter; since the facts stated by him are sufficient to make it intelligible to those who have read the work above-mentioned, and I trust that all medical men have read and studied it. CASE VI. PHTHISIS WITH PNEUMA-THORAX AND CHRONIC PERITONITIS. Jan. 5, 1831.—Mr. B. aet. 45, entered the House of Industry, at South Boston, about two months since, with some symptoms of advanced thoracic disease. I saw him a few moments about three weeks ago, when I observed that the 28 218 right thorax generally was dull on percussion, and that the murmur of respiration was generally wanting on this side. On the third of this month, two days since, I was again invited by Dr. Fisher, to see him, as he presented some new and in- teresting phenomena. I forgot to mention that on the first visit, I thought I heard an aegophony, about the lower angle of the right scapula. He had now the symptoms of pneumo-thorax with hydro-thorax. 1. The right side, as he sat up, resounded on percussion in the upper part, indeed over two thirds the whole side, much louder than the left; — on the right side the murmur of respi- ration was not audible except close to the spine, where it could be heard for almost the whole length of the chest; — on the left side it was more audible than usual; — indeed, Dr. Fisher says he heard the respiration distinctly upon the left side of the sacrum. 2. On succussion, the sound of a fluid shaking against the thoracic parietes was very obvious, and tested by frequent trial. 3. About the upper part of the right scapula, the " tinte- ment metallique," was very distinctly audible. Autopsy. External appearances and observations. — The right side, to the eye, both on front and back view, appeared very evidently larger than the left. On measurement, however, over the most protuberant part, it was found to be scarcely half an inch larger than the leSt. The experiments oS percussion and succussion yielded the same results as beSore death. On shaking the body and ap- plying the hand to the right side, a very distinct fluctuation was perceived. On examining the abdomen by percussion, the right iliac re- gion sounded flat; and a tumor was Selt directly in the situa- 219 tion oS the caecum, or commencement oS the colon. Head not opened. Thorax. — ASter tying the trachea, as firmly as possible, we punctured the right thorax between two oS the ribs, and there immediately issued a stream oS air, which had an evi- dent effect upon the flame oS a lighted paper held over the spot. On laying open this right cavity it was seen to be one-third Sull oS a serous fluid, with some Sew shreds and masses oS co- agulable lymph. The lung oS the right side was compressed closely, and adherent by recent, or at least slight, adhesions Sor the most part to the spine. The rest oS this right cavity was filled with air. Having removed a portion oS the liquid we next inflated the lungs by a blow-pipe in the trachea. The right lung expanded itselS to a certain extent, showing plainly that it admitted air during life. After both lungs were quite filled with air, we began to see bubbles at the upper part of the right side, arising in rapid succession and quite numerous. We had now two of the proofs of the existence of air in the pleu- ritic cavity. We were now to look for the point, at which the air passed from the lungs into this cavity. This we found by a careful dissection of the upper part of the upper lobe ; — passing a blow-pipe into several of the ramifications of the right bronchia, we at last saw and felt the air issuing from a very small point on the surface of the lung. On further dis- section of this, it was found to be an opening from a very small and superficial abscess, not larger than half of a common pea. It must, probably, have been somewhat, though not very much larger, before the lung had become thus compressed. Both lungs were filled with tubercles in different stages of ad- vancement. 220 Upon the surface of the heart there were three of those white spots, one an inch square in size, which have been thought by some to be effusions oS coagulable lymph. The pericardium contained about three ounces of serum. Abdomen. — Stomach — various spots oS mucous coat red- dened,— no thickening. Intestines not distended; — rather under than above the natural color ; — adherent to each other by old bands, and to the omentum and peritoneum above. Serous coat in many places studded with small tubercles. We did not look at the mucous membrane oS any but the ileum at its caecal end, the caecum, and the beginning of the colon. Over the caecum and colon at its commencement was a tumor, somewhat larger than a common horse-chesnut, sur- rounded by a mass of effused water, in consequence oS an ad- hesion involving some oS the contiguous small intestines. This tumor was white, firm in its texture, looking, as was observed by a physician, like the material which he had seen, as a matrix oS tubercles oS the peritoneum. The coats oS the ileum to the extent of six inches, of the whole caecum and oS a part oS the colon were greatly thickened and indurated; their calibre, consequently, being much diminished. The spleen, as I was informed by Mr. H., Sor I did not see it, was preternaturally soft; seeming almost like a sac of the peritoneum, containing a fluid. Remarks. — It is worthy of notice that this man had had no great trouble in his bowels since his entrance at the House of Industry. So far Srom being costive, which we should have expected from the appearances on dissection, his bowels were regular without medicine. Dr. D. inSormed me, that he had at one period, diarrhoea, since his entrance, and he also remem- bered to have heard him complain once oS pain in the right iliac region. 221 From the appearance I should certainly have expected oc- casional obstinate obstruction oS the bowels, alternating with diarrhoea. CASE VII. PHTHISIS. SUDDEN DEATH. Nov. 30, 1830. — Dr. — invited me, this afternoon, to attend the examination oS Mrs. A. aet. 45, who had died oS phthisis. He had seen her only three or Sour times, she having been under the care of a quack during all the preceding part of her sickness. She had the ordinary symptoms of phthisis; those which belonged to her individual case, and were worthy of note, are the following. 1. There was a very distinct pectoriloquy, upon and below the right clavicle. 2. Whenever she turned herself upon the left side, she began at once to cough, and to spit purulent matter very co- piously. 3. She died suddenly, as if from suffocation; which Dr. — had previously suggested would be very likely to happen, from the circumstance of this large abscess being so near the great branches of the trachea, that these might be stopped up, by its contents, on any sudden or violent motion of the body. Autopsy. Thorax.— On raising the sternum, the leSt lung was seen projecting over to the right side, its edge being beyond the sternal end oS the right clavicle. Left lung, especially the upper lobe, filled with small, crude tubercles, not suppu- rated. Right lung, — very large abscess in upper lobe, extending down into second; whole organ impermeable to air. 222 Abdomen. — Liver much enlarged, — stretching over epi- gastrium, and from right hypochondrium down for one or two inches below the crista ilii, its lower edge being covered by that bone. Other viscera not examined. Remarks. — 1st. On feeling oS the abdomen, I was so much struck with its firmness and apparent solidity, that 1 was anx- ious to discover the cause. It seemed to me, that the liver must be enlarged, Sor the feeling was altogether that oS a solid organ, and 1 thought it a good opportunity to test the correct- ness oS this sensation. I was much gratified, thereSore, to find the organ as it was. 2. This case was not a common one, inasmuch as the woman was Sorty-five years of age. I inquired of her husband whether she had borne many children, and whether she had nursed them. He answered, six, and that she had nursed them. This may be only a coincidence ; but I thought it well to record it. By the Editor. — The reporter was probably aware of the many points of interest in this case, which his statement throws no light on. At a later period of his life, his interest in the subject would probably have led him to obtain answers to some other questions, though he might not to all, which could be raised. The case is given, imperfect as it is, because it ex- plains the sudden death. CASE VIII. TYPHUS. SUDDEN DEATH. Oct. 28, 1830. — E. D. a woman, about 20 years oS age, died on the 26th, very suddenly, in the evening. She 223 had Sever, during which she had some soreness oS the abdo- men, and tenderness on pressure; within the last Sew days some hemorrhage Srom bowels; in whole about three pints ; the greater part oS this five days beSore death. On the morning oS the 26th, the physician observed that her pulse was very small; she was otherwise much as usual; her coun- tenance flushed; she had rather less appetite, but was, in aspect, rather more bright. He told me at noon oS this small- ness and weakness oS pulse, saying, that it made him look at her careSully, but she said nothing which corresponded with it. On the evening of that day, after a long nap, she awoke, and asked for water; the nurse went to get the water, and, on returning to the bed, Sound her dead. Autopsy. The physician's remarks, beSore looking at the diseased parts, were as follows. "In head, probably no disease. In chest, some old trouble about the heart, at most denoting Seebleness. During the fever, some slight marks of disease in left thorax, which had ceased; perhaps there may be effu- sion into lungs or pleura. In abdomen, —disease, probably, within intestines. There may be disease in peritoneal cavity, but the tenderness on pressure was not like this, and there probably is none. Blood discharged by stool was probably from ileum, or large intestines. Is there ecchymosis there ? Proba- bly, pretty certainly not. This there must be, if a vessel has been ruptured ; which, probably, is not the case. Probably, disease is in the mucous membrane. There may have been concealed hemorrhage elsewhere." I had thought whether the heart might not be found col- lapsed and empty, as in Chevalier's cases, and that this was the cause of the sudden death. 224 External Appearances. — On percussion, chest re- sounds well every where ; emaciation not great; no remarkable appearance of bloodlessness. Brain, natural throughout. Thorax. —A quantity of dark red colored serum, without coagula, in both pleural cavities, evidently effused from ex- halants. Same in pericardium, except much less dark. Right ventricle of heart empty, or nearly so, — collapsed, flaccid. Abdomen. — Small amount of similar dark, bloody serum in peritoneum. Stomach and duodenum natural. In jeju- num, one or two small ulcers in mucous membrane. In ileum, especially toward caecum, and particularly at the junction of the two, for about six inches, ulcerations of mucous membrane, of various sizes, an inch square and smaller. I observed one or two spots in which nothing but the peritoneal coat was left, which was very evident upon holding the intestine against the light. Also were seen, in two or three places, the commence- ment of the disease, viz. an elevation, redness and hardness oSa mucous gland, apparently, more certainly a small, elevated, hard, red pimple upon the mucous coat. The edges oS the ulcers were full, rather dark, and somewhat hard. In the mesentery, connected with the lower part of the ileum, there were shown, very finely, the enlargement and hardness of the mesenteric glands; also, in another part, the enlargement of the vessels leading to a collection of ulcers, which were ver^ beautifully displayed. Every moment I was reminded of Dr. Bright's beautiful plates, the truth and accuracy of which were here most fully confirmed. The dark, red, livid ap- pearance on the peritoneal coat, opposite to the disease within, was very striking. There were three spots upon the lower surface of the vagina, of about half an inch diameter, 225 perfectly black, looking very like sphacelus. The womb also was dark colored. There was an hydatid attached to the left fallopian tube. Remark. — The sudden death seemed to arise Srom the Sailure oS a supply oS blood to the heart. See London Med. Chir. Trans. Vol. I, p. 157 ; paper by Mr. Chevalier. By the Editor. — I have inserted this case only on account oS the sudden death, and the appearance noted in the heart on dissection. My young pupil had conjectured, more truly than I did, the cause oS the sudden death ; though some years previously, and aSter reading Chevalier's paper, I had seen a case oS sudden death, with similar appearances oS the heart. The phenomena In the intestines will be justly estimated at the present day, at least by those who have read the work oS M. Louis on typhus Sever. Some subsequent cases in this work will detail these appearances more Sully. I could Surnish more Sull notes of this case, which would show its character more unequivocally, but prefer to leave it as it was written. CASE IX. RUPTURE OF GALL-BLADDER. Feb. 8, 1831. —J. L., Esq., aet. 86, was taken sick on the sixth, and died in twenty-eight hours from the first seizure. On eating a small piece of brown-bread in the forenoon of that day, he Selt some pain at the stomach, to overcome which he took a little brandy and water on his return home. At two p. m., without paying any regard to this occurrence oS the morning, he took dinner as usual. At halS past two p. m. he 29 226 sent for a physician, who Sound him suffering most agonizing pain at the epigastrium, with his countenance, pale, shrunk, ghastly, looking exactly as if he had received some great injury ; as a man would, for instance, if he had received a shot in the abdomen. He got at once two or three successive doses of ipecac, after which he vomited, but not very freely, a part oS his dinner. Still the pain was not in the least checked, but re- mained so severe as to cause constant and loud cries Sor relieS, though a man of the greatest Sortitude. He now began to take laudanum, oS which he got about seven hundred drops beSore six p.m. Of this he vomited a part, retaining, perhaps, a full half: after this the pain was somewhat lessened, but not gone. On his return, at seven, finding this mitigation, and hoping that another Sull opiate would complete it, the physician gave two hundred drops which was retained entirely. The pulse during this time were not accelerated, nor in any way greatly altered, still retaining the firm Seel oS an old man's pulse. In the course oS this visit, when moving in bed, Mr. L. suddenly complained of a severe pain in the right hypochondrium. As the pains were not entirely removed by this last opiate, the physician thought best to bleed him, and took away § xiv, not being stopped by Sainting, but by the sigh which Srequently precedes that. The pain was now much more relieved. In the course oS the evening the physician was about to apply a sinapism over the right hypochondrium, where he had complained of this sudden pain, but Mr. L. said, that the pain was not there, but all down that side of the abdomen, and more especially in the groin. This led to an examination oS this part, more accurately, in order to ascertain iS there were any marks oS hernia, but none were Sound. This side was somewhat tender on pressure, but very little however. Mr. L. said, that many years ago, thirty or Sorty, he was sick, and had always supposed 227 since that time, that his liver was adherent to the surrounding parts. Whenever he took cold, or in any way became a little disordered, he would have some pain in the right hypochon- drium ; he was, also, in the habit oS lying upon the other side, as he Selt some uneasiness when on the right. These symp- toms, however, he described as having been very slight, never being sufficient to affect, materially, his health, or comSort. Even after the bleeding, neither the pain in the stomach nor that in the right of the abdomen were completely overcome. He continued through the night to vomit occasionally, until two a. m., after which he had some sleep. On the morning he was more Seeble ; — his pulse was very weak, but he did not suffer much pain ; — at twelve, his pulse was no longer to be Selt at the wrist, and he died at about six p. m. Autopsy. Abdomen. — Distended. — Within this cavity was Sound a large quantity, perhaps a pint or more oS bile, mixed with a small portion oS blood. About the gall-bladder, and between this and the duodenum, was a large quantity oS grumous and halS coagulated blood. On dissecting through the capsule oS Glisson, and tracing the ducts to the gall-bladder, we Sound a hole oS one-third oS an inch diameter in this viscus ; — and its coats were very soft, tearing under the least pressure. The physician thought that the appearance oS the perito- neal coat oS the intestines was not more red than natural; — but it certainly seemed to me that, beside the deep and livid red color, which we very oSten see in the intestines, there were also some patches oS a much more florid and brighter shade, which gave evidence oS a commencing inflammation. The stomach was healthy. Remarks. — On looking through the index oS Morgagni de Sedibus et Causis Morborum, I do not find reSerence to any 228 cases of rupture oS the gall-bladder. Lieutaud reports one case, in which, subsequent to a swelling in the right hypochon- drium, a fistulous opening was Sormed between the gall-bladder and the external parts, through which pus and bile were con- stantly effused. He likewise has collected two cases oS rup- ture oS the gall-bladder into the cavity oS the abdomen, in consequence oS a blow upon the right side. He does not seem to have met with any case like that oS Mr. L. The cases above reSerred to, are in Vol. I. p. 211. Baillie says, he once saw a gall-bladder, in which was " one ulcer which had destroyed a part oS all the coats." (Morb. Anat. works by Wardrop, Vol. II. p. 215.) He does not give any account oS symptoms, or other morbid appearances in this case. See a case quoted by Abercrombie on Stom., etc., p. 391, Srom the Nouveau Journal de Med. 1821. CASE X. RETENTION OF URINE. Jan. 26, 1831. — Examination of Miss H. aet. 3, by Dr. — . This child had Sever Sor about a Sortnight, — some appearance of slight bronchitis at the commencement, — always a very rapid pulse, and no symptom oS cerebral disease; — no especial difficulty in alimentary canal, — bowels easily evacu- ated, and no diarrhoea. Within the last Sour days a tumor ap- peared in hypogastrium, which gradually increased in size, till it filled the whole abdomen. On inquiry the physician was assured the urine had passed naturally and abundantly. The day oS her death, she was freely purged with Ol. Croton, gtt. 1. — This tumor was tender to the touch, not resonant on per- 229 cussion, oS a somewhat firm feel. Such is the account, Dr. — gave me beSore the examination. Autopsy. External appearances. SurSace pale, bloodless;—body not much emaciated ; — tumor in hypogastrium yielding, in one spot especially, to the pressure oS the finger, — and giving the idea that a fluid was contained within. Abdomen. — On opening this cavity by a crucical incision, the bladder was presented to view, elevated out oS the pelvis, as high as the umbilicus and much distended. Ureters, espe- cially the left, greatly distended ; — pelvis of leSt kidney dis- tended and Sull oS urine; the urine being drawn Srom the bladder, was Sound to be somewhat more than halS pint, and had a dark brown, not very copious sediment. I examined the whole tract oS intestines with my Singers, careSully examining the appear- ance oSeach part, to see iS there was any indication oS disease oS the mucous membrane. There was none such in any part. There were eight or ten slight intussusceptions, evidently oS very recent occurrence. The internal surSace oS these, and oSthe stomach were not examined. — Liver healthy. — Tho- rax, — not opened ; — resounded well, by percussion, in every part. — Head not opened. Remarks. — 1st. On Sarther inquiry oS the old lady who had taken care oS the child, it was ascertained; 1. that about Sour days since, the child went twenty-Sour hours without passing any urine. 2. That it was on the Sollowing day the tumor began to appear. — 3. That ever since that time, the urine had been passing constantly, as every diaper which they removed was wet. 4. That the child had not, at any time within these Sour days, passed a quantity oS urine at once in a vessel, but that the appearance oS the cloths alone was evi- dence oS its evacuation. Here is ample evidence oS retention in the first instance, and consequent incontinence afterwards. 230 2d. I may learn Srom this that when a tumor appears thus suddenly in the hypogastrium, the bladder is to be suspected. 3d. I may also learn, that the evidence oS the patient, or the nurses, in regard to Sree evacuations oS the urine, in such cases, is not enough. We should satisSy ourselves in one of the Sollowing modes ; — 1. By the Sact that the patient has passed a quantity oS water, at one time into a vessel; or, 2. By the introduction oS the catheter ; which last mode is the most satisSactory. 3. By percussion above the pubes. CASE XI. TYPHUS FEVER. Hospital La Pitie. Ward St. Paul, 3. Under the care of M. Louis. Jan. 6, 1833. — Defaint, aet. 24, a manufacturer of oil; born at Trefaille, has been in Paris six weeks ; never sick till now, not had even catarrh ; of strong, robust aspect; hair red- dish, eyes blue, complexion ruddy ; has worked much harder since in Paris, than before. On the first instant, and previous days, had worked and slept as before, with the same diet; had regarded himself as well, but for five days he had been very thirsty, his food was less grateful than usual, though he did not lessen it much, and his strength was a little diminished. On the second instant he took breakfast as usual, and worked till noon, when he was seized with diarrhoea, accompanied by pain in bowels; had twelve dejections, very watery, before evening ; at same time had nausea, though no vomiting; also tremor and chills ; went to bed at once but could not get warm ; accord- ing to his own sensations, did not get warm that night, nor in- deed has he felt warm since ; especially his feet have been cold ; every exposure to the air has occasioned a chill; from 231 the first, anorexy with increasing thirst. Also from the first day headache, dizziness, sight imperfect, noise in the ears, and slight deafness. Little sleep on the night of the second instant; and none since, which he attributes to the headache and fre- quent borborygmi. Pains in the loins and limbs, especially in arms, since third ; slight cramps once in left leg ; epistaxis yes- terday for first time, slight ; none since; urine abundant as he thinks; no sweat; he has felt that the abdomen was hard and swollen; pain in bowels at times with borborygmi, which he has both heard and felt. Has kept his bed from the second instant. Slight cough since the third, without expectoration; respiration somewhat embarrassed, owing as he thinks, to some difficulty in lower part of the trachea, though he does not feel any pain there, and in epigastrium; he has not any proper pleuritic pain, though he feels something prick him in the side when out of bed ; but now he does not feel it on fullest inspi- ration. He thinks he has not been delirious. Some palpita- tion Srom the beginning. Entered yesterday; and part oS the Soregoing was collected yesterday. Present state, as noted Jan. 5, two p. m. Has been in the hospital an hour; walked here supported by the arm oS a Sriend, and thinks he could not have walked alone; was a quarter oS an hour on the way, walking very slowly, and was greatly Sa- tigued on arrival. Expression not very unnatural; Sace red and violet, warm, not very hot; eyes injected, suffused ; eye- lids heavy ; tongue not very moist, with whitish coat, thin at centre, reddish at tip ; thirst strong; deglutition easy, except a little pricking on swallowing saliva; abdomen large, sonorous on percussion and painSul on pressure over right iliac region, not so over left; no rose pimples ; spleen not felt on examination, nor on percussion is there any flatness over it; on the contrary on percussion on left side, lower part, very sonorous ; no borbo- 232 rygmi at this moment. No appetite; slight nausea; four liquid dejections to-day, twenty on third and seven yesterday ; none of them bloody, so far as he knows ; pulse 90, not large nor strong ; skin hot, though it does not feel so to him; he com- plains of cold Seet and constant trembling; cough rather Sre- quent, producing pain in abdomen, though not in any limited spot; voice not halS so strong as in health; respirations 12 in a minute, apparently easy ; on percussion and auscultation over chest, everywhere natural, so Sar as can be decided by the imperfect examination which he permits ; no rhoncus. Head- ache not severe, more dizziness and pulsation in head, than pain; a buzzing in the ears, (tinnitus aurium), especially on rising up ; suffers Srom noise though not Srom light; says his mind is slow, and so it appears ; talks with great difficulty; prostration not extreme ; can rise to his seat with comparative ease; pains over trunk and limbs as iS beaten ; sensibility oS surSace everywhere increased. Jan. 6. Half past three p. m. p. 100; skin hot, rather moist, than dry ; perSect prostration. (Venesection § xiv. Seltzer water.) Jan. 7, a.m. Was bled § xx; no buff on the blood; p. 96 yesterday, and to-day, regular, small; tongue moist, white at centre, natural on edges; Sace flushed, skin hot and dry, not burning ; same difficulty in swallowing saliva; Sour dejec- tions since afternoon of fifth; no pain in abdomen, none on pressure anywhere; a little tympanitic in the middle; no rose pimples; feebleness greater; dislikes motion and questions; answers shorter; memory good; cough not very frequent; respiration and sound natural on auscultation and percussion. He insists very much upon the injury he suffered Srom drinking a great quantity oS water for five or six days, and to this he at- tributes his loss oS strength and disgust Sor Sood. Little sleep, no delirium. 233 (Venesection ad § x, vel. p. r. n. Enema of flaxseed tea. Seltzer-water. Liquid Sarinaceous diet.) Jan. 8. — Eight ounces oS blood taken ; this covered with a soSt buff; coagulation imperSect; p. 96 regular ; heat a little ele- vated ; skin not dry ; tongue less moist, less pale at edges, more coated ; no headache, but dizziness always ; cannot rise to his seat without help, and some nausea Sollows the effort; Srequent dry cough ; meteorism rising to epigastrium. Great agitation last evening; no delirium. (Enema as yesterday. Gum potion with two drachms oS syrup oS white poppies.) HalS past Sour, p. m. — Vomiting oS bile immediately after morning visit; none since, nor dejection. Increase of flush, heat and dryness, also of headache and feebleness; p. 96 re- verberating, or with a double stroke, hard; resp. 36, unequal; occasional sighs ; cough frequent; abdomen very sonorous on percussion ; great pain in it. Inclined to groan and to despair. Jan. 9. Morning. — No delirium in night; looks and feels much brighter ; p. 96 ; tongue nearly natural, rather redder at edges; two or three dejections ; no pain in abdomen, less me- teorism ; respiration pure ; rising to seat does not now produce nausea; tinnitus aurium continues ; no sweat, nor epistaxis, nor rose pimples. (Syrup of Gum. Seltzer-water.) Half-past four, p.m. — Aspect fallen; stupid; skin hot; subsultus tendinum; p. 96, feeble; resp. 36. He feels as strong as in the morning, but evidently is more prostrated. Jan. 10.—Tongue a little more coated; two dejections; no pain in abdomen; less dizziness; on his right side; ex- pression good; no delirium; cough as yesterday; p. 92, regu- lar ; a little subsultus tendinum. 30 234 (Solution of syrup of gum, two mugs, with three drachms oS syrup oS white poppy.) Four p. m. — p. 96 ; resp. 36 ; asleep ; skin not very hot; cheeks less flushed than last evening; occasional contractions in muscles of face and limbs. Jan. 11. — More sunken; feels weaker; tongue not so well protruded, a little thickened or swollen ; great thirst in night; two or three dejections; little meteorism; abdomen scarcely sensible to pressure; spleen not Selt; no sweat, nor eruptions; no delirium ; tinnitus aurium continues ; more deaS; heat not great; p. 100, rather small, regular; respiration pure; cough more Srequent and harder. (Solution oS syrup oS gum. Seltzer water. Gum potion. Enema.) Jan. 12.—Tongue less moist, red about edges, trembling, protruded imperfectly; not many dejections, though one involuntary; abdomen distended, especially at epigastrium; no rose pimples; p. 88, a little fuller; heat rather greater; respiration higher ; more stupor, roused with difficulty, unwil- ling to answer; more deaS; no delirium ; heavy and stupid through the day yesterday. ("Same prescription.) Jan. 13.— Stupor continued yesterday; no delirium ; tongue red, slightly moist, painSul, twice as thick as at entrance, pro- truded with difficulty; thirst; two dejections involuntary ; three rose pimples, not well marked ; abdomen more distend- ed ; p. 96; dry heat; resp. 28, sometimes a little high; cough the same; pains every where; Sace a little emaciated. (Same prescription.) Five, p. m. — Asleep on his back, roused with great difficulty ; respiration pure, loud in front at the right; at the 235 left expansion very slight, and there sonorous, sibilant rale ; the same result on both sides behind. Jan. 14. — Tongue softer, moist, not red, nor painful; two dejections involuntary, and one copious, voluntary, while bed was making this morning; meteorism the same ; no delirium, but more stupid and more deaf; does not speak, answers by signs; no pain; p. 94, regular; no subsultus tendinum; resp. 30. Five, p. m. — p. 96; heat of skin much greater, acrid; much flushed; sonorous, sibilant rale in Sront, on both sides. Lies most on right side, indeed never noticed on the left. Jan. 15 and 16.—Symptoms not much altered; the rose pimples more distinct and more numerous; on percussion sufficiently sonorous back and Sront, but rale the same, and at the right some mucous rale. (Same prescription.) Jan. 17. — Got up during night; attitude natural; tongue red, moist, thick; impatient; prostration; p. 106, small; an imperSect sub-crepitous rale on the right, back and Sront. Jan. 18. — Tongue less red; three dejections; meteorism much lessened; no rose pimples; deaSness continues, but stupor less ; p. 100, small. At evening symptoms worse. Jan. 19 and 20. — Generally getting worse; delirium in night oS 19th and the next morning. (Seltzer-water. Gum potion. Enema.) Jan. 21. — Was up three times in night, delirious, talking much when in bed ; much flushed, otherwise Sace rather nat- ural ; some spasmodic motions in it; subsultus less ; p. 108, small; no sudamina; meteorism rather less. (Cataplasm to feet. Same prescriptions except the enema.) 236 Jan. 22. — Delirium increased much yesterday and con- tinues now, though less in night; pulse getting more Srequent and more Seeble ; more cough ; arms rigid, that is, make some resistance to motion and remain nearly as they are placed, even resisting the Sorce oS gravity; this symptom observed at evening for six days and now in the morning; rose pimples on trunk getting livid ; hands also livid; last evening pains in and running from right ear. Impulse of heart feeble, and physical signs of difficulty in lungs increasing. Four, p. m. — p. 120, very feeble; resp. 36, same as for several days; constant tremor of tongue and lower jaw; when the lower jaw is depressed, tries to protrude tongue, but in vain; tongue dry ; some stiffness in arms; motion oS lower limbs automatic ; on his back; stupid; discharge Srom the ear; great meteorism; complains much on examination of abdomen; face flushed. (Gum potion with ten grains of aqueous extract of opium. Sinapisms to legs.) Jan. 23. — Delirium all night; this morning they thought him dead for a while; on his back; paler ; eyes halS closed ; almost insensible; p. 104, Seeble ; tongue dry,reddish; swal- lows liquids with difficulty and sometimes spits them out; upper limbs much more rigid ; some tremor in the lower jaw; resp. 24, not high; cough Srequent; sub-crepitous rale over the whole back. (Same prescriptions. Quinine, he.) Jan. 24. —Last evening more sunk, symptoms worse. No delirium in night; now tongue moist, drawn out with diffi- culty and remains between teeth; p. 100, rather less feeble; tranquil, has not spoken during the night; less rigidity of limbs, except that after subsultus they became very rigid; all of them very rigid last evening ; several involuntary dejections 237 in night; meteorism gone; abdomen well Sormed, depressed; no grimace when pressing upon it; Sace calm, eyes shut. In evening worse ; muttering delirium. (Same prescription.) Jan. 25 and 26. — Bad symptoms increasing generally. Sonorous on percussion in Sront, decidedly more on the right than on the leSt. Respiration pure, or with very little rale at one time, on right in Sront; on left in front a blowing, (sifflante) and sometimes a sub-crepitous rale heard on ex- piration as well as on inspiration, also, the expansion seeming feeble and less superficial than on right. Behind, sub-crepitous rale both sides. (Sulphate of quinine, gr. xxv daily. Lemonade with wine.) Jan. 27. — Every day worse at evening than in morning. This day, p. 104, resp. 32, some strabismus, with unimpor tant amendment in some points. Five, p. m. — Has thrown off the bed-clothes; panting, resp. 56, and at times more; p. 128, excessively small; some strabismus, pupils round, equal; suffers from a candle near his eyes ; tongue halS protruded, moist, brown on the back, not coated at tip ; on percussion much less sonorous in Sront on the leSt than on the right; cough very Srequent. (Same prescriptions. Syrup oS ether, halSan ounce.) Jan. 28. — Some amendment as to tongue, pulse, respira- tion, intelligence, expression, hearing and rigidity of limbs. No strabismus. Asks for food constantly. Excoriation about sacrum and hips. (Same prescriptions.) Jan. 29 and 30. — Same bad symptoms as beSore 28th, returned and increasing, except strabismus. No dejection Sor two days. Suffers from slight touch on chest and abdomen. (Quinine omitted on 30th. Enema of soap and water.) 238 Jan. 31. — On back; protrudes tongue, trembling; expres- sion more natural; rigidity of limbs rather less; p. 116, small, Seeble, regular; deaSness much less; does not oppose explora- tion oS chest; cough still Srequent. (Dress excoriations with cerate covered by a little sulphate oS quinine.) Feb. 1. —Worse through the day and night; got up in night to the cabinet, alone ; delirious ; rigidity the same in morning. Five, p. m. on back, expression changed since morning; cheeks red, excessively sunken; pupils dilated; eyes not fixed, but nearly so ; moves arms freely and with compar- ative ease ; not the least rigidity in the limbs ; hears and un- derstands better, attempts to answer, but speech unintelligible; skin very dry and warm; coughs from time to time; respiration high, regular, 60 ; p. 150, thready. (Sinapisms to thighs.) Died at seven, p. m. Autopsy. Feb. 3, ten, a. m. thirty-nine hours after death. Externally. — No lividity any where ; little redness on legs from sinapisms applied on morning of last day; over sacrum destruction of epidermis only; about right trochanter partial destruction oS cutis, brown externally and separation at the circumference about ulceration. Nearly the last degree of marasmus ; scarcely any fat under integuments ; muscles of good color, not pitchy. Head. — Some few drops of blood on external surSace of dura mater; a very Sew granulations (glands oS Pacchioni) along the longitudinal scissure; some cerebral veins slightly distended with blood in the posterior third only; in some part only slight infiltration under the arachnoid; none in front; pia mater is removed with difficulty, though of its natural consist- ence ; this membrane injected moderately over the convolutions 239 only. Cortical substance natural; medullary substance, une- qually, of a lilac color; no drops of blood upon its incised sur- face even after exposure to air for considerable time ; one ounce of clear serous fluid in right ventricle ; a little more in left, which is evidently more dilated ; septum natural, firm. Corpora striata, cerebellum, medulla oblongata and every other part of the brain oS natural color and consistence. Chest. — Pericardium contains six ounces oS citron colored, clear, serous fluid; right auricle greatly distended with blood; fibrinous clot in each ventricle an inch or more in length. Heart oS ordinary size, its substance firm ; leSt ventricle five lines in thickness, the right two lines. Aorta oS ordinary size and color in its whole extent. Left lung, does not reach quite to sternum; an old, cellular adhesion at the middle, over a small space ; air vesicles dilated over the whole upper lobe, especially near the Sree edge, which is round instead oS sharp; Sorm oS organ preserved; slight interlobular emphysema in the lower surSace of this up- per lobe ; this lobe elastic, light, contains little frothy liquid of a reddish color, no tubercles, not granulated. Lower lobe hep- atized; finely granulated in its whole extent; color red, more or less deeply; very little liquid and no air on incision ; offer- ing a certain resistance to the finger, which once overcome allows it to be easily penetrated ; sinks in water. Bronchia oS both lobes thin, transparent and polished ; none dilated. Sev- eral little ecchymoses on back part, under pleura. Right lung reaches to leSt side oS sternum; adhesions on back part at middle and a little at base; upper lobe, air vesi- cles more dilated than left; edge round; longer but not so heavy as left ; a little hepatization near its lower part. Middle lobe, on its external surface several longitudinal projections or elevations, one to two lines in breadth, semi-transparent, 240 elastic, evidently containing air, — interlobular emphysema. Lower lobe, on the back part and to the extent of two inches from the base, granulated; the same in two or three other small portions; the tissue oS a more uniform deep red than in left lower lobe; does not sink in water; affords more liquid and is less pliable than the leSt; no puriSorm mucus in bronchia, which are healthy as in the left. Neck. — Epiglottis, larynx and trachea natural, except an ulceration posterior to vocal chord on the right, and there a small orifice, a line and a halSin diameter, whence pus issues. Pharynx, on its posterior and lower part, four or five small ulcers, from two to four lines in diameter, where the epitheli- um and mucous membrane are destroyed, and the muscular fibres are exposed to view; one oS these is beginning to cic- atrize. (Esophagus, ten to fiSteen ulcers in lower third, larger, even half an inch in length, equally deep as those in pharynx, and two smaller in the parts above. Abdomen. — Stomach, a quarter part larger than common, containing yellow-green liquid, and some opake mucus, also yellow ; interior surface unequally pointed in red, in patches oS different sizes, most at the union oS the great cul-de-sac and posterior Sace, but much on the anterior Sace, especially near the large curvature; veins seen beneath the mucous mem- brane, especially in the cul-de-sac; no part mamelonated ; sub- mucous membrane infiltrated in great cul-de-sac ; near pylorus a patch oS a little blueish-gray color, and there the injection more in the mucous than in the sub-mucous membrane ; mu- cous membrane thin in reddest patch ; strips, five to seven lines in great curvature, ten to twelve in small curvature, two to three in anterior Sace, near cardia, over two or three inches in extent, three in great cul-de-sac; no partial thickening any where. 241 Small Intestines. In duodenum nothing remarkable, a lit- tle red near pylorus. Jejunum and ileum, externally, dark blue, or green ; cut a little easier than usual; contain mucus above and pultaceous matter below, varying in thickness, oS a yellow-green color, in some points tinged with blood. Inter- nal surSace, in its whole extent, oS deep greenish-gray color, strongly marked on the valves ; between the valves this color is in innumerable points, in the upper third, or a little below ; thirty-three patches oS elliptical, or Peyer's glands are seen, and oS these, eleven are ulcerated ; first patch in the third Soot Srom the pylorus ; fifth contains opake, white points, varying in size, and the rest have the same; they are all, ex- cept the first four, seen through the peritoneal coat, which is scarcely, if at all, thickened however ; in all the eleven, which are ulcerated, the muscular coat is seen at the bottom, naked and thickened ; the three largest are in the last eight inches ; the two last are eighteen lines long, separated from each other by a little bridge of mucous membrane, one by three lines in extent; the first of the ulcers round, the others irregu- lar in shape, as if torn on their margins, these margins projecting or raised more or less, the surrounding tissue being thickened; in the two last the muscular coat not uniformly exposed, as there, numerous, little, white lines, like thickened cellular mem- brane, are seen in the course of the fibres, across the ulcers at the bottom. Several small ulcers surround the large ones. Some solitary, or Brunner's glands, small, white, thin, without central points, in the last five or six feet. Mucous membrane very thin everywhere, the sub-mucous very little injected, in most places pale. Strips five to six lines in the first three feet; three to four in the parts below. Mesenteric glands everywhere enlarged ; some of the last as large as a filbert, and others nearly as large ; the large ones 31 242 in aspect uniSormly white, moist, rather Sriable, soft, granula- ted ; those above black, dense and smaller; one parcel just opposite caecum an inch and a halt in breadth, composed oS three or Sour glands, Sorm a pink, homogeneous mass, soft, sur- rounded by puriSorm matter. No Sat in mesentery, nor in omentum. Large intestines contain pultaceous feces, and one or two small portions moulded ; internal surface of the same color as those of small intestines, but less deep ; deeper in caecum than below. Brunner's glands with central points not numerous, nor large. No ulcers. Mucous membrane of transverse and descending colon covered with a little thin mucus ; the mem- brane itself thin. Strips two to three lines in the whole extent. Liver of good size ; a little soft, pale, containing little blood; finely grained. Gall bladder contains a little, quite fluid, yellow liquid ; its mucous membrane natural. Pancreas natural; a little red. Spleen, rather large, perhaps one quarter more than usual; of good color and consistence. Kidneys, their proper tunic easily detached,transparent, nat- ural ; substance natural as to color and consistence. Bladder contains moderate quantity of urine ; its internal surface natu- ral, violet red. By the Editor. — In this case, the diarrhoea and affection of the bowels were very strongly marked at the commence- ment. The diarrhoea was less after the fourth day, and ceased on the seventh; it however recurred at times through the whole disease. There were precursory symptoms for a Sew days, but Srom the Sormal commencement on the 2d oS January, the coldness and sinking oS strength were very re- 243 markable, and this especially in a strong and robust subject. An affection of the nervous, or animal system was obvious in the first week, but in the second week was further marked by subsultus tendinum, and involuntary dejections ; though deliri- um did not occur till the third week. In this week there was also some rigidity in the limbs at evening only ; it became more marked on the twenty-first day and afterwards, but ceased before death. This is a symptom which has very rarely occurred in cases which terminated favorably. The rose pimples are first noticed on the twelfth day ; on the twenty first they were livid, while other symptoms were also decidedly worse than before. It was not till the twentieth day, that the pulse was above 100 ; on the twenty-first it was 120, but not so many on some subsequent days. Its frequency was not so great as usual in proportion to the other symptoms. Cough and some affection of the lungs were manifest from the first; and from the twelfth day there were physical signs, which cor- responded in most respects with the state of the lungs, as dis- covered after death. In subjects so reduced as this man was, these signs cannot be ascertained with great precision. It should be noted that the meteorism, after subsisting some days, began to subside on the third week, and continued to disappear afterwards, though other worse symptoms ensued. The strabismus, which is noted on the twenty-sixth day, dis- appeared before death. On the twenty-seventh day, there was an abatement of the bad symptoms generally, but those returned the next day, and death followed on the thirty-first day of the formal disease. In the appearances post-mortem, we may note first the dis- eased state of the elliptical glands in the small intestines, of which some were ulcerated, and those nearest the valve of the colon showed most disease ; next, the corresponding changes 244 in the mesenteric glands ; last, the enlargement, though very slight enlargement, of the spleen. This last is much less than has commonly been remarked by M. Louis. The others are the phenomena, which he represents as always found in those affected with the continued, or typhus fever of Paris. Besides these were found several affections regarded as sec- ondary by M. Louis; viz. ulcerations in the windpipe and gullet, and inflammation of the lungs. Also, there was em- physema, both vesicular and interlobular, in the lungs in front, especially on the right. The inflammation in the lungs was denoted by the cough and the physical signs, particularly by the sub-crepitous rale. This rale was noticed on the back, and in such a manner as to refer to the lower part of the back, and in the front, on the left. It was in these parts that the inflammation was found. It is from knowing the manner of observing in the reporter, that I say he referred to the lower part, when he spoke of the back in this case. If he had observed the rale in the upper part, he would have noted it specially. The difference between the right and left lungs, as to the degree of inflammation, is not shown by the physical signs, as he noted them. Nor would this have been easy. The ulcers in the windpipe and in the gullet were not shown by symptoms, unless for the former, we refer to the sensation in the lower part of the trachea observed at the first examination, and the occasional reluctance to speak ; and for the latter the dys- phagia on Jan. 23. The emphysema in the upper lobes, at least in the right lung, corresponds with the great sonorousness on percussion. There was not found the corresponding want of respiratory murmur. This may be attributed to the state of disease in the lower lobes, causing a supplementary or puerile respiration in the parts not inflamed. This emphysema existed no doubt before the acute disease occurred. 245 CASE XII. TYPHUS FEVER. Hospital la Pitie. Ward St. Paul, 9. Under the care of M. Louis. March 9, 1833. — C. D, aet. 27, works at forge. Born in Aine ; had been in Paris six months before present illness. Father aet. 60, mother 58, both well, have not had asthma, nor palsy; one brother aet. 48, one sister 28, both well; one brother dead, aet. 12, by a fall on the head. He was nursed at the breast of his mother; at ten years of age he was sick in bed for six months, when he had much vomiting and some cough, without diarrhoea; since then never sick, except for three weeks, from a fall upon the neck, eight years ago ; not subject to catarrh, and never short-breathed. Since in Paris has been well nourished, and has not committed any excesses. A month after his arrival, diarrhoea for five or six days. Has been ill since 15th February, and has not worked since. Twelve days before that, he had a blow upon his head, from a fall, when he was stunned, had bleeding at nose and headache. On 15th February the headache continued, and he kept bed for a few days, but not the whole time; was without appe- tite and could not work. On 24th, went home, (twenty- eight leagues) ; staid ten days and got better; returned here on the 5th ; but, on his arrival, though he had not suffered on the road, had headache, with dizziness, and could not work; has had tinnitus aurium ever since the blow ; v/ithin two days diarrhoea, with pain in bowels, has been added to these symp- toms about the head ; five dejections last night, ten the night beSore. No epistaxis since ill. Came to hospital in carriage, could not walk. Now, Sace uniSormly though not much colored, slightly livid ; eyes moderately open ; memory good ; intellect clear; 246 tinnitus aurium in night, but not now; dizzy when sitting; sight good when lying down ; eyes a little injected ; no head- ache at present; tongue moist, whitish, with coat on lobes ; great thirst; deglutition easy ; abdomen well Sormed, slightly painSul, with Sour or five minute pustules having pink areolae ; one larger on forehead, some near axilla and on thighs ; pulse 100, rather large; great heat last night; little cough since yesterday ; whistling (sifflante) rale on both sides behind, most on the right; hypochondria supple ; more uneasiness at leSt than right hypochondrium. At evening, great heat, Sace flushed ; p. 96, hard; resp. 20 ; no headache, nor tinnitus aurium. (Syrup oS gum. Syrup of oxymel. Enema. Venesection in the Soot § xv.) March 10. — Got only Sour ounces oS blood Srom Soot; in evening ten ounces Srom arm ; felt better after bleeding. This morning no headache, no tinnitus aurium in night; no dejec- tion ; feeble, and confused in head on rising; tongue less red, moist; p. 104, regular, larger than yesterday; face less livid; mind clear, talks with ease and laughs; abdomen rather less flat; three or four rose pimples on chest and abdomen. (Oxymel. Venesection § x. Enema. Liquid farinaceous diet.) March 11. —Blood not buffed at either bleeding ; he re- mains very feeble; more prostrated; face emaciated since entrance ; has slept, but with dreams; tongue as yesterday; less thirst; no dejection ; abdomen natural in form, but rather fuller in lower half, and more sonorous on percussion ; one more rose pimple ; no headache, nor pain anywhere ; pulse not hard, nor full, nor very feeble ; whistling and sonorous rale every- where in chest; less strong in front than behind; on sitting 247 Sor one minute, respiration suspicious, 16 to 18 ; readily ex- hausted ; does not laugh to-day. (Seltzer-water.) Note by Editor. —Under this date, there are some remarks by M. Louis, which must have been made at that time, as they are written after the above, and the notes oS the case were evi- dently taken Srom day to day. In this and in the other cases, where similar remarks are given Srom the same source, I have thought it improper to print them, as it would be committing M. Louis without his consent, and, possibly, incorrectly. But I will deviate so Sar in this instance, as to say, that M. Louis raised the question whether this was a case oS typhus Sever, or a disease arising Srom injury oS the brain by the blow. He acknowledged some doubt, but decided that it was probably Sever; and, in so doing, laid much stress on the rose pimples, and the blowing (sifflante) rale, as symptoms belonging to Sever and not to disease oS the brain. In what Sollows, his diagnosis will be confirmed. Five, p. m. — Great heat; skin dry; respiration as this morning; sighs more Srequent; Sace more deeply colored; more black round the eyes; hearing remains good; rale over chest louder; borborygmi and desire Sor alvine dejection. March 12. — Countenance calm and more natural than yes- terday ; lying on his back ; tongue more moist and less red ; two dejections; abdomen not so well-Sormed as yesterday ; some new rose pimples ; hypchondria supple; no stupor, nor pain anywhere ; resp. 14, with occasional sighs; same rale as yesterday, more marked on left in front, and extremely marked on the back. At evening, an aggravation of the symptoms. 248 March 13. — P. 104, smaller ; respiration the same; abdo- men larger; no tumor in left hypochondrium ; more pimples; his only complaint is of Seebleness. (Seltzer-water. Enema.) March 14. — Exacerbation last evening not very great; prostration was increased, and his hearing more dull; one de- jection since evening ; some sleep ; mind clear; meteorism oS abdomen, especially at epigastrium; more pimples; some questions excite him to laugh. (Same prescription.) March 15. — One dejection, and, in night, hemorrhage from bowels, ten to twelve ounces oS coagulated blood ; lies on right side; greatly prostrated, which he refers to the hem- orrhage ; Sace pale and dull; more indifferent than heretoSore; tongue moist; no nausea ; pimples smaller and paler ; no tre- mor in left hypochondrium ; p. 108, rather small and feeble ; respiration as before ; cough rather frequent. (Enema of eight ounces of infusion of flaxseed, with a scruple oS rhatania.) March 16 and 17. —There was no return oS hemorrhage, no dejection ; the abdomen varied, but, on the whole, became more distended ; tongue dry on seventeenth; p. Srom 104 to 120 ; resp. irregular, sometimes rapid ; cough more Srequent; rale the same ; he asked for soup ; mind more clear, but less disposed to talk. (Gum potion, with syr. oS orange peel. Extract oS rhata- nia, eight grains, on sixteenth. Enema. Seltzer-water, on seventeenth.) March 18. — Countenance better, more natural; had the enema and returned it in bed ; tongue moderately moist, whi- tish at centre, clean at edges ; abdomen more meteorized ; five or six new pimples on each side; p. 112, rather large, 249 regular; heat moderate ; resp. 26, much less suspirious; cough considerable ; on the lower part oS back, at the left, sonorous, mingled with a little sub-crepitous, rale; this part sonorous on percussion ; Seels very Seeble, yet rises up quickly and easily; no pain anywhere; no heaviness oS head; no tinnitus aurium ; sight good. (Gum potion, with three dr. of syr. oS white poppy.) March 19. — Face more pale, its skin as iS pulverulent, sunken and altered in expression, more emaciated; tongue soft and rather moist; involuntary dejections in bed, of which he took no notice ; rather more fulness at epigastrium ; p. 102; heat moderate; resp. 30, equal, with dilatation of alae nasi; sub-crepitous rale, low on the right back, sonorous at left. (Enema of hot water, with eight drops of laudanum, to be taken in two portions. Weak beef tea in small quantities.) March 20. — Aggravation of symptoms last evening. Now, heat not great; tongue almost clean ; lies on his side ; some desquamation of cuticle on abdomen and wrists ; p. 120, feeble, small; more deaf. (Same enema, with ten drops of laudanum.) Five, p.m.—Copious involuntary dejections; abdomen more distended, and very sonorous, except in right iliac fossa ; a little flat on percussion, about angle of right scapula ; sub- crepitous rale and a little resonance of voice there ; resp. 36 ; p. 108, Seeble. March 21.—Tongue dry, brownish; p. 112; heat not great; dull and dozing, but rises to his seat with ease, and then shows some spirit and good intelligence. (Lemonade, with one fiSth oS red wine. Gum potion, with halS an ounce oS syrup of white poppies and a scruple of ex- tract of cinchona. Blister Sour inches square on right side.) 32 250 March 22. — Dejections Srequent; tongue more moist and more white ; p. 100, regular, rather small; heat not great; less sub-crepitous rale, chest sonorous on percussion ; sunken as yesterday, yet laughs and complains of blister; asked for Sood this morning. (Lemonade with wine. Increase extract of cinchona to thirty grains. Blister higher on chest.) March 23. — Slight aggravation oS symptoms last evening. Now, countenance much better, animated; intellect good, laughs; deaSness increased; two dejections ; p. 102, larger than common ; respiration better. (Same prescriptions.) March 24.—Deafness increased; heavy and dozing yester- day ; intellect good, repels with a smile the idea of his being dull and sluggish; tongue moist ; dejections all involuntary; p. 104, less full; heat not great; resp. 28; very little sono- rous rale, chest sonorous on percussion but little dilated, and respiration not loud. (Same prescription.) March 25. — No important change oS symptoms noted, except rigidity of lips, and some, doubtSul, rigidity oS arms. Diarrhoea still urgent. (Enema, with ten drops of laudanum and a scruple of rhat- ania. Gum potion with fifteen grains of rhatania.) March 26. — Countenance more flushed than usual; p. 96, large, redoubled, equal; intellect perfect, smiles; no evident rigidity of limbs ; diarrhoea less; strong dilatation of alae nasi; both sides of back sonorous on percussion; whistling and so- norous, but not any crepitous rale. (Same prescription.) March 27 to 29. — Involuntary dejections frequent; cough increased somewhat; chest sonorous behind on percussion, and 251 much sonorous rale, but not crepitous; no rigidity of limbs ; many sudamina on 27th ; emaciation. Died on 30th, four, p. m. Autopsy. March 31st, nine, a. m. Twenty-nine hours after death. Externally. —Conformation perfect; no lividity on sur- face; abdomen rather flat; considerable rigidity oS limbs; skin over sacrum thin ; muscles oS good color and firmness. Chest. — Cellular membrane about pericardium infiltrated with serous fluid, citron colored ; in the pericardium two ounces oS the same, not at all turbid ; heart oS moderate size and natural color; auricles contain dark-red, coagulated blood, in moderate quantity ; in right ventricle a small coagulum, partly red ; leSt ventricle empty; aorta at origin natural. Lungs, both Sree Srom adhesions; an ounce and a halS oS clear, citron-colored serous fluid in cavity oS each pleura ; the lungs touch each other above, not so below. Left lung, large ; vesicles generally small, some Sew dilated ; upper lobe pale, lower lobe oSa slightly livid red color; bron- chia oS upper lobe perSectly natural, and contain no mucus ; those oS lower lobe also natural, but contain a considerable quantity of white mucus, moderately adhesive, easily removed by water ; the lower lobe contains a considerable quantity of blood, but is not properly engorged, nor granulated ; it is elas- tic from presence of air, and natural in tenacity and consis- tence ; at its base, beneath the pleura, a white, cartilaginous mass, size of a pea. Right lung, same externally, less distended; vesicles gen- erally small, but some at summit, over more than an inch in extent, very large, the size oS common bird shot; also sev- eral on the border in Sront as large as the head oS a pin ; bron- chia of upper lobe contain a very little mucus near their 252 division ; those below contain more, though the mucous surface of all is natural; posterior and upper part of lower is more easily torn, or of less consistence than other parts, though there is not less air in those portions. Abdomen. — Spleen, five and a half inches in length; of a brownish red ; torn somewhat easily. Liver, of good size; less red and more unequally so than common ; the yellow substance is irregularly scattered through it in spots of different sizes. Gall-bladder contains a green, not very viscid bile. Pancreas, natural. Right kidney of a good color, friable ; the left redder, less friable. Bladder healthy. Stomach small; half or two thirds common size ; containing half an ounce of a slightly pink, unctuous liquid. Internal surface generally grayish-red and disposed in longitudinal bands ; the folds pretty numerous in the great cul-de-sac, and large curvature; not mamelonated ; mucous membrane velvet like and rather thin ; strips three to five lines in the great cul- de-sac, six to eight in large curvature and anterior face, twelve to fifteen in small curvature ; sub-mucous texture injected. Duodenum contains a rather thick mucus in small quantity; its mucous membrane grayish and a little red, in the first two thirds; reddish in the last third ; in its whole extent there are a multitude of little granulations, a line to half a line dis- tant from each other, less elevated in the first half than in the last; in points, where the valvules are not too near, strips of five or six lines, in other points two to three lines ; mucous mem- brane of natural thickness ; sub-mucous membrane injected. Small intestines, larger by one quarter than usual; contain a very moderate quantity of mucus, greenish, of an alliaceous odor; the internal surface of the first foot of jejunum is red- 253 dish, from an injestion of the small vessels ; below this it is somewhat yellow; mucous membrane of natural thickness in jejunum, strips five to eight lines; in ileum, coats much thin- ner, strips five lines only, and in the last three feet two to four lines ; in the ileum fourteen ulcers; all these ulcers surrounded by an edge more or less elevated; none of the ulcers more than an inch in diameter, most of them less; all situated on the patches of elliptical glands, some of them occupying a part only of the patches, the parts unoccupied being a little thickened only ; in all these ulcers the muscular coat is denuded more or less; the bottom of them more or less red, particularly red in those near caecum; many covered with a cellular tissue, either a little red or pale, apparently thickened either in spots or in the whole, as seen plainly on cutting through the ulcers in a longitudinal direction. Solitary glands developed in last three feet. Most of the mesenteric glands altered in some measure ; those near the caecum of the size of a filbert, red in greater or less degree; four or five transformed mostly into a matter, which is pink internally, yellow at edges; one sur- rounded by a little pus contained in a sort of cyst, on inner surface of which are seen little flakes ; glands above smaller, less red, and those near duodenum grayish and firm. Large intestines, larger than common by one half; whitish and greenish in the first two-thirds, more generally pink in descending colon, the sigmoid flexure resumes the color of first part. In caecum spots half a line to a line in diameter, a little elevated, some showing a central point, some not, and some having little orifices instead of points ; then follow ulcers of one to two lines in diameter, the smallest the most round ; at three inches from valve two ulcers, five to six lines in diam- eter, at their base showing the muscular coat. In colon many ulcers of different sizes; those in ascending and transverse 254 colon, two to three lines in diameter, round, rare, scattered; near union of transverse and descending colon, to the extent of a foot, ulcers excessively numerous, occupying at least halS oS surSace ; the smaller like those above, round ; the largest very irregular in Sorm ; the four principal ones are as Sollows; the first and second between two and three inches long, in the lon- gitudinal direction, toothed (dentille) on edges, three to five lines broad, and in structure like those in small intestines ; the third very irregular in Sorm, its surSace equal to a square inch, mucous membrane entirely destroyed, and at its bottom is only a very thin membrane ; behind which are several large vessels and a little Satty tissue ; between this tissue and the peritoneum at one point is a little lymphatic gland ; the fourth a little smaller, but similar to the third. Mucous membrane in inter- vals between ulcers gives strips oS five to six lines, is rather less adherent to sub-mucous tissue than common, thickened where ulcers are near each other ; sub-mucous tissue thickened by infiltration in intervals between ulcers. In rectum, ulcers numerous, smaller, pale, round in its upper part, then becoming very rare, until within two and a half inches from anus; here they are larger, and among them four Sorming a surSace oS nearly three inches in the circular, and one in the longitudinal direction, separated Srom each other in this surSace by very narrow bridges ; the bases oS these ulcers are oS a lively red and have transverse ridges owing to muscular fibres, which are covered by cellular tissue ; the muscular coat in them is a little thickened, but less than in some oS the ulcers above. In the rectum are numerous little crypts, with central, black points, not ulcerated. The rectum contains a light yellow, pultaceous mass. Neck. — Velum palati at the left, anteriorly, of a lively red color and thickened, with an ulcer half an Inch in length, at 255 the bottom of which the muscular coat is seen. Epiglottis oS a livid pink internally; mucous membrane thickened, espe- cially in the right and upper part, where it is destroyed to the extent oS a line and a halS by three lines; in its centre is a white line in the longitudinal direction, and this is surrounded by a red line, which last is evidently thickened and Sormed by mucous and sub-mucous membranes. Above arytenoid cartila- ges mucous membrane a little red and thickened, otherwise larynx natural. Trachea also natural, except a part, an inch below arytenoid cartilages, which is soft and a little red. Head. —Very little blood on surSace oS dura mater. Arach- noid natural; traces oS infiltration under it at back part only. Pia mater very slightly injected ; cortical substance pale gray; white substance oS good consistence, moderately moist, not in- jected, giving some little drops oS blood only on pressure. Very little serous fluid in lateral ventricles, perhaps five drachms ; all other parts within the cranium natural. By the Editor. — The diarrhoea noted in this patient, a month after his arrival in Paris, is an affection very Srequent among strangers on first visiting that city, and need not be re- garded in connexion with the disease oS a later period. The injury which the patient received in the head, in the first part oS February, and the subsequent symptoms, necessarily caused a doubt as to the nature of his disease, at his entrance into the hospital on the 9th of March. We find that on the llth, M. Louis decided in favor of the opin- ion that the patient had typhus fever. The subsequent events showed that the decision was correct and that no lasting injury of the head had been incurred. That, however, some of the symptoms, which occurred in February, were occasioned by the injury of the head can scarcely be doubted ; and then a 256 second question, arises, viz ; when did the fever commence. This cannot be answered with certainty, but perhaps the most probable period was the 5th oS March, the period when the patient returned to Paris. Fixing on this day as the commencement of fever, we find diarrhoea on the third day oS the disease ; cough on the fourth ; the whistling rale on the fifth; rose pimples on the sixth; the sonorous added to the whistling rale, over the whole chest, but especially at the back, and getting louder in the evening, on the seventh ; the same more marked in the left breast than in the right on the eighth; meteorism beginning on the seventh and increasing to the tenth, when it was fully estab- lished ; and hemorrhage from the bowels, causing great sink- ing, though not profuse, on the eleventh. The pulse was 96 on the fifth day of the disease, and was not more than 112, except on the thirteenth and sixteenth days. On the fiSteenth and sixteenth days, the sub-crepitous rale and re- sonance oS voice in the lower halS oS right back, with the ra- tional signs, showed some increase oS disease in the lower lobe oS the right lung; but the subsidence oS these signs on the subsequent days, and nearly a week beSore death, prevent our surprise that only slight evidences oS inflammation appeared in this organ aSter death. The slight rigidity oS the arms was an addition to the unSavorable symptoms, but not enough by itselS to justiSy a bad prognosis. The appearances post mortem, show, first, the disease in the patches of the elliptical glands in the small intestines, as usual most strongly marked in the last portion of the ileum ; also the corresponding disease in the mesenteric glands. The spleen was enlarged, but not greatly, and it does not appear that during life, any enlargement of this organ was ascer- tained. 257 In the head there were not any evidences oS disease, though the previous injury must have led to scrupulous examination oS this part. The ulcer in the palate was not discovered by any symptoms during liSe. The disease in the lungs has already been adverted to. The serous effusion in the cavities oS the pleura, and in the loose cellular membrane about the pericardium, probably oc- curred in the last period oS liSe ; iSnot, it may have contributed to the rapid breathing, which was noticed repeatedly. The extensive, and in some parts great disease, in the large intestine, does not seem to have added to the derangement oS the Sunctions oS the bowels. At least this was not greater than in cases, where this intestine is comparatively sound; un- less the increased diarrhoea in the third week, and the hemor- rhage on the eleventh day, may be referred to this source. It is hardly necessary to direct attention to the increased thickness of the muscular coat of the intestines in those ulcers, in which this coat formed their base. CASE XIII. TYPHUS FEVER. Massachusetts General Hospital. Under the care of J. Jackson. Oct. 15, 1833. — S. K. aet. 32, unmarried, eyes, hair and complexion dark; maid-servant; born in Salem. Entered the hospital last evening. . Ill since 7th instant, perfectly well beSore; on that day headache, distress and pain in limbs, anorexy, weakness, obliging her to go to bed. Since then she has had bad taste in mouth; no soreness oS throat, nor dyspha- 33 258 gia ; thirst; anorexy; nausea after taking too much liquid, but not at other times ; diarrhoea from the first, four or five dejec- tions a day ; urine not observed ; catamenia on 10th, lasting one day, (they had occurred in order the week preceding;) no chills ; occasional heat and sometimes sweat at night; no cough, nor dyspnoea, or very little of these; no pain in chest, nor palpitation; headache and dizziness; tinnitus aurium and deaf- ness ; no epistaxis ; no sleep; some delirium. On the 10th she had the following: R. hydr. subm. pulv. jalap, aa gr. viij—misce. After this some castor oil; and, the dejections continuing too Srequent, she had fifteen drops of tinct. of opium. After this she had not any important medicine. The above details were partly from the physician who had attended her. Now, Oct. 15th, morning; — countenance, as well as mind, very stupid; memory treacherous; cannot tell how long she has been ill, though clear and positive as to existence, or non- existence oS certain symptoms ; Seatures still, eyes fixed, look- ing melancholy ; Sace pale or sallow, and evidently emaciated; since her entrance (five p. m. yesterday) no vomiting; great thirst, oS which only she has complained; two dejections, very watery, not dark, nor painful, quite offensive to smell, one of them a pint; through the night restless and watchful, and prob- ably delirious, though silent, for she arose from bed and went to table for drink in absence of watcher, though she has seem- ed too feeble to rise up. Lips slightly dry; tongue dry, enlarged, protruded partially, a thin, brown coat over part of lobes; some soreness of gums, which have a white coat and give out a mercurial fetor; abdomen not swollen, nor painful, but a little tender on pressure at epigastrium ; some small rose pimples on abdomen, but no sudamina ; spleen not felt; skin hot and dry ; pulse varies from 112 to 120, small, not soft; 259 resp. 21, not difficult; no dilatation of alae nasi, but slight noise in nose ; lies on right side. (R. pulv. ipecac, gr. x. Let this be given in an infusion of mint, and the same repeated till she has taken four doses, unless she vomits, at intervals of twenty minutes.) Oct. 16. — The medicine occasioned nausea but no vomit- ing ; then followed five large dejections, the three last involun- tary; these were chiefly liquid, all dark and offensive, but the last was the least offensive ; during the day stupor was less than yesterday morning ; flushed and hot at times ; no delirium in night; some quiet sleep after second dejection; otherwise night not good. Now, on back; eyes fixed, not suffused ; great stillness of features ; tongue scarcely protruded, tip only seen, and that brown and dry ; no mercurial fetor ; abdomen as yesterday ; deafness quite as great; does not answer so well; there seems to be rather an abstraction of mind than stupor. Last evening she was lying carelessly uncovered, with neglect of modesty. Oct. 17. — Very restless yesterday, especially afternoon; at 5, p. m., p. 132, face more flushed, very hot; three dejec- tions, the last at nine, p. m., all watery, dark, copious, extremely offensive and involuntary ; delirious all night, without sleep; not very thirsty ; no vomiting ; no sweat. Has continued very restless this morning, but says she has slept a little. Now is on her left side, half out of bed ; mouth very sore, sordes on lips and teeth, gums covered by an opake, yellowish-white exudation ; abdomen not large, but hard from contraction of muscles; she does not reply when asked if pressure is painful, yet makes a sound as if it were so; some small rose pimples on abdomen ; no sudamina anywhere ; p. 108 ; skin not very hot; face more red, eyes sunken ; very deaf, and answers very slow ; says head feels well and no pain anywhere ; arms rigid, 260 so that they yield with difficulty to the attempt to extend them. Shortly after the above report she was seen lying on her right side. Oct. 18. — Last evening p. 108. She has continued very restless, especially in night; moaning much, but not talking till this morning, when she has appeared anxious and has been inquiring about her sickness. Three dejections, involuntary, not very large, but otherwise oS the same character as beSore; the last at five, a. m. Cannot protrude tongue ; mouth and abdomen as yesterday; p. 96, small; cheeks a little flushed, more fallen in ; some rigidity oS arms, but this not constant; when extended they return to flexed position, as iS elastic; at some times the arm will remain in the position in which it is placed, though against gravity, as in catalepsy. Oct. 19.— Last evening p. 120. Day and night have been much more tranquil, with Srequent quiet naps oS half an hour; three dejections, watery, not so dark, two of them very copious, only the first involuntary. She reports better; aspect more comfortable; lips stiff, swollen, especially upper lip; teeth dark; mouth has more offensive odour; abdomen not enlarged; p. 130, small and weak; skin very dry; no subsultus now, nor at any time. (Mucilaginous wash for mouth. A little wine and water, if grateSul to her.) Oct. 20. — Has slept much, but with groaning, and awoke Satigued; two dejections, since midnight, watery, not large, not involuntary; wine is not grateful. Pulse 144, small, weak; temperature natural; resp. 44, Seeble, slightly labored; abdo- men the same; scarcely answers, though she understands; says not any better; the Sore-arms can be extended at some mo- ments, at others they resist extension; at times the Sore-arm rises up, flexed, the biceps being felt rigid, and then it resists 261 extension very strongly ; deafness great; asks no questions and makes no remarks. Oct. 21. — Last evening p. 160 to 180, very feeble; resp. 52; heat moderate ; prostration great; said she had pain all over her. One dejection yesterday, two in night, the last the most copious, dark and least liquid, all voluntary ; exacerbation of heat from twelve to two yesterday. Now on right side, respi- ration rapid, groaning; face pallid and brows contracted, as if in pain ; she fell into this state on turning to side, five minutes since ; she has had several similar turns of distress, and espe- cially from seven to nine o'clock last evening; but most of the night has been on her back, more tranquil, and she had some sleep without groans; has said that in these turns she has dis- tress, or pain in abdomen. Tongue partially protruded, moist, greatly coated ; swallows with extreme difficulty; has refused wine mostly ; resp. 66; deafness less ; speaks with difficulty, but very promptly ; mind clear; skin generally warm, but face cool; abdomen neither full, nor tense, nor tender. (The sulphate of quinine was directed, but she died at noon.) Autopsy within twenty-four hours after death. Externally. — Universal paleness ; great rigidity of upper and lower extremities; no oedema; moderate quantity of fat; muscles deep colored, rather dry. Abdomen.— Stomach large in volume; contains a small quantity of thin, brownish liquid, with some little granular sed- iment, not unlike fine snuff; internal aspect generally pale, with numerous longitudinal wrinkles; numerous depressions in lines running along the small curvature, of which some have an ulcerated, granulated, rough surface, without polish, while others retain the smooth polish of the mucous membrane; on detach- ing this membrane over these depressions and holding this up 262 between the eye and the window we see that the membrane is not completely destroyed in any part, but materially thinner in the depressed parts than elsewhere. These depressions are, perhaps, fifteen to twenty in number, varying in length and breadth from one to three lines. Elsewhere the mucous mem- brane of ordinary thickness, giving good strips. Small intestines of ordinary volume ; contents very small in quantity; in the first quarter is a yellow paste, just sufficient to smear over the surSace ; in the next third this is more liquid, and oS a greenish-yellow color; then, Sor about a Soot, there is a dark red fluid, approaching the coffee-ground color; below this is a darker, greenish liquid. In the upper halS, the inter- nal surSace is pale, or, at most, with a slight pink tinge in some parts, and in some assuming the color oS the liquid in contact with it; in the last half, it is almost universally of a bright, florid red, greatly injected. In this last half, thirty patches of Peyer's glands are visible ; of these, twenty-one are ulcerated, most of them in part, and a few are wholly occupied by the ulcerations. Only two of the first eleven are ulcerated, but all below are so. Those not ulcerated present the following appearances, viz.; both to the eye and the touch they show a slight elevation above the surrounding mucous membrane ; in some, a part, and in some, the whole of their surfaces shows a bright, red color, and the parts so colored are more swollen and elevated than the rest; in the pale, white portion are seen numerous black points, like the orifices of glands. The ulcer- ated patches increase in size progressively from the first to the last, at the end of the ileum, with the exception of a few small ulcers at the very end, around the large ones ; the ulcers are round, or nearly so, and have all of them rounded, elevated margins ; a few of them have a thickened, muscular tissue Sor their base ; but most oS them have at their base a loose, gray- 263 ish-brown cellular membrane, in the Sorm oS a slough, attached at its centre, and loose and floating at its edges; this slough is easily detached and is very Sriable. On removing this slough, there is seen beneath, in some cases the cellular, in some the muscular coat, extremely red and greatly thickened. The ulcers vary Srom a third oS an inch to an inch and a halS in diameter; the parts of the patches not ulcerated are red and swollen. The last and largest ulcer occupies a portion oS the valve oS the ileum. Enlarged, aborescent vessels are seen leading Srom the mesentery to the ulcers above-described. None oS Brunner's glands are to be seen in the small intestines. In the upper half, the mucous membrane has, Sor the most part, its ordinary thickness, and gives the usual strips of Sour to five lines; in the lower halS, and, more especially, in the lower third, where the redness and injection are very great, this membrane is in some spots increased, in some dimin- ished in thickness, and does not give a strip oS more than two lines anywhere, and, in some places, none, though it can in these be thrown up in a strip by the scalpel. The mesenteric glands generally enlarged; those correspond- ing to the upper halS oS the small intestines, scarcely so large as a small bean, and slightly red ; those corresponding to the lower halS, as large as a chesnut, generally, that is, some smaller, but many larger; these are in color oS a deep, some- what livid red, externally, and red and gray internally; quite Sriable, and some toward the lowest part are in groups oS Sour or five, are larger than the rest, and contain pus. Large intestines oS ordinary volume ; contain scarcely any fluid, but numerous little shreds oS a greenish-brown matter, with a peculiar smell, closely attached to the mucus mem- brane. This membrane is generally oS a pale pink color, but is more deeply red in some spots. Brunner's glands are scarcely 264 seen, with three or four exceptions, in which they are discov- ered with difficulty; in these cases they are small and pale, with the central black points. Near the caecum are some spots, of a quarter to three-quarters oS an inch diameter, irreg- ular in Sorm, oS a dark brown color; these spots are neither elevated, nor depressed, and the mucous membrane, in which they appear, is not thickened, nor softened, nor ulcerated ; the color does not extend to the subjacent membranes. In most parts, the mucus membrane is of its ordinary consistence and thickness ; but, in certain patches, where there was most redness, its thickness was somewhat increased, and its con- sistence diminished, not yielding a strip of more than two to four lines. Liver of ordinary size, of a reddish-brown color, with a distinct granular aspect on the incised and broken surfaces; does not contain a great quantity of blood ; evidently consists of two substances, the light and dark colored, in about equal proportions ; of its ordinary consistence. The gall-bladder contains a moderate quantity of quite liquid, dark-greenish fluid ; internal aspect normal; Spleen large, perhaps three times larger than common, six inches by four ; rather firm than softened; of its usual color. Pancreas of a pink-gray color; consistence and structure natural. Kidneys of ordinary size ; external coat easily detached, thin, transparent, and leaving the surface of the organ smooth ; cortical substance oS a grayish-red ; whole structure and con- sistence natural. Bladder small; mucous membrane thin and pale ; consis- tence natural. Uterus normal, except a little fibro-cartilaginous tumor on the Sundus, oS the size oS a large bean ; this is hard, homoge- 265 neous, oS a whitish-yellow color; and another similar tumor, the size oS a pea, in the substance oS the organ. Ovaries oS ordinary size, or rather large; each contains several small cicatrices, where there are slight cavities or de- pressions, perhaps three lines by pne ; and one cavity larger, say three lines each way ; these have thin yellow parietes; corpora lutea. Peritoneum pale and white. Chest. — Pericardium free, containing less than an ounce oS a yellow, clear liquid. Heart not large ; contains large coag- ula oS fibrine in right cavities, and one or two very small ones in left, accompanied in both with liquid black blood, most in the right. Parietes, cavities and valves, of their ordinary dimensions, color and structure ; the substance rather less consistent, or more easily penetrated than usual. Aorta of natural appearance internally. Left lung adherent at lower part laterally, and a little pos- teriorly, also the lobes to each other ; all the adhesions by a recently organized false membrane, of a yellow color, thin, opake and very friable. The upper lobe is pale, crepitating, light. The lower lobe of a red, violet, and in some spots almost black color, externally; large; heavy ; firm ; not crepi- tating, except in a small portion at its upper part, and in another portion, about an inch square, at its inferior and anterior edge. The bronchia of the upper lobe are pale, white, thin, transpa- rent and polished; the substance of this lobe everywhere white, pale, containing air and scarcely any blood or other liquid. The bronchia of the lower lobe are red and thickened, and have lost their polish ; they do not contain much fluid, but, in one or two branches we trace a round, well-formed, firm, Salse membrane, oS an opake, yellowish-white color, into 34 266 the more minute bronchia. The substance oS this lobe is solid, with the small exceptions above stated as crepitating; in these crepitating portions a Srothy fluid escapes on incision; the solid part is red, or gray, granulated, Sriable, contains no air, and yields very little liquid on incision ; at several points a purulent fluid escapes on pressure Srom the incised surSace. In the upper part oSthis lobe is a portion, less than an inch at the surSace and an inch in depth, which is dark-brown throughout the substance, resembling in color the sloughs upon the intestinal ulcers, peculiarly Sriable, without gangrenous smell, but evidently gangrenous. There is another portion, having the same characters, in the lower part oS the lobe, rather larger than a dollar at the surface, and two inches in depth. Right lung, no adhesions; the middle lobe only covered with a false membrane, violet, firm, and, except a small healthy portion in its lower and anterior extremity, having all the marks of disease found in the lower lobe, on the left side ; in it some of the bronchia are lined by a false membrane ; at its upper and posterior extremity is a small portion, much granu- lated, friable, and having, as to color, a mixture of light and very dark red, as though blood had been effused there; but not of the dirty, brown, gangrenous aspect. The upper and lower lobes, except a very small portion oS the last, were pale and natural, both the bronchia and the substance, like the left upper lobe. Neck. — Pharynx, epiglottis, larynx natural. Head. — Dura mater very slightly injected. Glands of Pacchioni more numerous and in larger groups than usual. Very slight sub-arachnoid infiltration. Both the arachnoid coat and the pia mater raised with ease, without detaching the substance. Cortical and medullary substances rather pale 267 than injected, oS their usual firmness and consistence. Half an ounce oS clear serous fluid in each lateral ventricle. Every other part oS the encephalon oS its usual color and consistence. By the Editor. — This is a case oS a woman oS melancholic temperament, who was affected with the usual autumnal con- tinued Sever oS our climate. It is one oS the cases to show that this disease is the same as that, which was the subject oS the observations oS M. Louis in Paris, and oS which he has treated in his work on the typhoid Sever. It may be well to add, that this disease was somewhat more prevalent and more severe, than usual in the autumn oS 1833, than in common years ; though not more than in several other years, in which it has come under my observation. Likewise this patient had been residing in a part oS the town ordinarily healthy, but in which there was a larger proportion oS severe and Satal cases in 1833, than in any other equal district, so Sar as came to my knowledge. This case was not second to any in the Sormida- ble aspect oS its symptoms at an early period, Sor it was at the beginning oS the second week the patient entered the hospital, and already her Sate seemed to be nearly decided. The early prostration, confining a woman oS laborious habits to her bed Srom the first day, and the diarrhoea Srom the com- mencement, are circumstances to be noted. The bad counte- nance, the stupidity, (obviously from disease,) the inability to sleep, or to get rest, the dry tongue partially protruded, and the variable and accelerated pulse, combined with the great prostration, on the morning of the ninth day of the disease, justified an unfavorable prognosis. A gentle emetic was ex- hibited with the hope oS checking the dejections, which were not Srequent indeed, but quite proSuse. The unSortunate action oS the medicine perhaps hastened the progress of the disease. 268 The bad symptoms were certainly aggravated from day to day, and new ones added. Among these should be observed the rigidity of the arms, on the eleventh day of the disease, which, in one of the foregoing cases, has been mentioned as a symptom almost uniformly fatal. Some amendment occurred, though not in all respects, on the twelfth and thirteenth days. There are few cases so bad, as not to present such a temporary ame- lioration. The increasing and great rapidity of the pulse ac- cords with my observation, not in all, but in many fatal cases. It seems not to have been so true, or else the pulse has not been so accurately noted, in the cases at la Pitie as here. In this case the rose pimples were seen on the ninth day; whether they had existed earlier is not known; sudamina were not seen at all; the abdomen did not become meteorized; there were no symptoms oS disease in the lungs, unless in the rapid and, at times, slightly labored respiration ; death occur- red on the fifteenth day, a period earlier than is usual. In the post mortem appearances, we may first notice the marked affection oS Peyer's glands and of the mesenteric glands, and the enlargement of the spleen. These, especially the disease in the elliptical patches, are described very Sully. The reporter had it in his mind, no doubt, to Surnish to M. Louis the evidence in detail, that our common continued Sever was the same as that oS Paris, in its anatomical characters, as well as in its symptoms. Among the anatomical changes, which M. Louis would re- gard as secondary, we have in this case; 1st. Some marks oS disease in the mucous membrane oS the stomach. As these were in the small curvature only, and there was very little liquid in the stomach, and as, too, the examination took place very soon aSter death, no one will suspect them to have been chemical changes only. 2d. The mucous membrane in 269 the lower half of the small intestines was more or less diseased; a circumstance not uncommon certainly ; but which, it should be distinctly noticed, does not always occur ; and is therefore to be regarded as a secondary affection. 3d. The mucous membrane of the large intestines was not entirely without marks of disease, though these were trifling in comparison with those in Case No. XII, and in many other instances. How far the profuse discharges from the bowels depended on the extensive disease in Peyer's glands, and how far on the secondary disease in the alimentary canal, it is not easy to de- cide positively. It is however most probable that the second- ary affection was of comparatively late date, while the diar- rhoea existed from the beginning of the disease. 4th. The lungs were much diseased on both sides; and it is quite re- markable to find the middle lobe on the right so much diseased, while the other lobes were so healthy as in this case. Inflam- mation in the thoracic viscera is so common in typhus, and especially in the fatal cases, that some are almost ready to re- gard it as much of an essential anatomical character, as the lesion of any other part. But this, at least, is to be remarked on this head, that, if some disease in the thorax is found in most fatal cases, there is not any one part, nor any one texture which is uniformly the seat of disease ; while in the abdomen it is otherwise, according to the observations of M. Louis, and, so far as I have been able to learn, according to the observa- tions made here for the last two years. It should be added, that the absence of symptoms in this case, indicating important disease in the lungs, may be accounted for, as M. Louis sug- gests in such cases, by the degree of stupor which was early manifested. Physical signs might, no doubt, have evinced the disease in the lungs on the last days of life; but, in a patient situated as this woman was, one does not Seel willing to seek 270 Sor these signs. It cannot be done thoroughly without annoy- ing and distressing the patient. 5th. Notwithstanding there were some grave symptoms, which might be reSerred to the nervous, or animal system, there was so little discovered with- in the cranium in the slightest degree morbid, that the most violent partisan would hardly contend that there was evidence that the disease had its seat within that cavity. It is not surprising that he, who has attended only to the symptoms of typhus, should suspect that its seat is in the brain ; but it is very much so that any one should maintain this opinion, who has attended fairly to the anatomical evidence derived Srom the victims oS the disease. CASE XIV. TYPHUS FEVER. Boston, Oct. 11, 1834. — I was invited by Dr. T. to at- tend the autopsy of J. P. T., aet. 19. This young man had had our autumnal, or typhus Sever, during two weeks, without much diarrhoea, under the care oS Dr. T. who stated the symptoms and course oS the disease. In the third week he appeared.to have nearly recovered, was up and even abroad Sor five or six days; though his pulse con- tinued to be frequent during this time. On the third and Sourth instant he had a little diarrhoea. On the fifth he was more ill, and kept his bed; but had not any alarming, nor even any grave symptoms till the ninth. On that morning he had ap- peared bright and comfortable ; when at eight o'clock, a. m., on making some motion, he was seized with a sudden and severe pain in the right iliac region, or near the anterior, superior spinous process of the ilium. This was soon followed by pain 271 over the whole abdomen. Dr. J. saw him at twelve o'clock, when there was great pain and tenderness over the whole ab- domen ; pain shooting up to the shoulder and down the thigh; no great tension, nor swelling of the abdomen ; pulse rapid and sinking; some nausea and vomiting with shrinking of the features. There had not been any chill; the intellect was perfect. Coldness soon followed, and he died at four, a. m., on the 10th. Autopsy Oct. 11, eleven, a.m. Thirty hours after death. Externally. Limbs very rigid; general surface pale ; no infiltration. Abdomen. Stomach of ordinary volume ; internal surface slightly red in some spots ; mucous membrane of natural con- sistence and thickness. Small intestines of ordinary volume, containing a light yel- low mucus; in the upper three-quarters mucous membrane of natural consistence and thickness ; in the lower quarter ten or fifteen large patches of Peyer's glands much swollen, some of them red and ulcerated at surface, others pale, with orifices very open and enlarged ; in all not only the mucous but sub- mucous membrane thickened ; the last, two inches long and nearly the same broad, enormously thickened. In the same part numerous solitary glands also, greatly enlarged ; and the mucous membrane thickened and softened. Mesenteric glands much enlarged, size of a chesnut-red, soft, friable, not containing pus. Large intestines, nothing peculiar except a perforation of the vermiform appendix by ulceration. In the extremity of this appendix was found a small, flat, oval gall-stone, and it was half an inch above this that was found the orifice produced by ulceration, about two lines in diameter. The mucous membrane of this appendix was thickened and slightly ulcer- 272 ated at some other spots, besides that which was perSorated. The appendix was Sound lying up against the caecum, and cov- ered by a Salse membrane, by which it adhered to the caecum. The peritoneum was greatly inflamed. The small and large intestines toward the right iliac region in the pelvis were red ex- ternally, and in many spots covered with a Salse membrane, and adherent; the peritoneum lining the anterior parietes was also oS a bright red, and had lost part of its polish. In the cavity one or two pints of turbid, purulent serum, with many flakes of lymph, but no feces. At first we were embarrassed to find the perforation, though its existence was shown so clearly by the history, and con- firmed by the state of the peritoneal cavity. The difficulty was, first, that there were no feces in the abdomen ; second, and principally, because pressure on the intestines did not cause any air to escape. The seat of the perforation and the subse- quent adhesion of the appendix, closing the orifice, afford a suf- ficient explanation of both circumstances. By the Editor. — I have thought it best to print this case, though so deficient in details, on account of its peculiar inter- est. It is an instance of perforation of the intestines and death in consequence of the peritonitis. That the disease was ty- phus fever, both my son and myself were Sully convinced at the time, not only Srom the opinion oS the very respectable physician, who attended the patient, but likewise Srom the evi- dence in detail which he gave us. Some of this evidence is contained in the statement of the case. I have not thought proper to add to what my son had written, though I knew that more was given. The disease was a mild one, and the patient seemed once to be convalescent. It is, however, in mild cases, or at least in those which are not peculiarly severe, that this perforation most frequently occurs. 273 I have known various instances, in which this accident has proved fatal in fever; but they were more frequent in the autumn of 1833, than usual, or else our attention to the sub- ject led us to notice them more than usual. Besides this case, which I saw after the accident, there were two others in the same season in this city, which I also saw. Of these, one only was examined after death, but the symptoms left not a shadow of doubt as to the other. This other was in a young gentle- man, who had been ill for more than thirty days, but not so severely as to be entirely confined to the bed more than a week. He had had some diarrhoea, great meteorism, and rose pimples. After having been more ill for a few days, he was somewhat convalescent on one day, and on the morning of the next, much more decidedly so. About noon, on this day, he was seized instantaneously with a severe pain in the lower part of the abdomen, which soon spread, and was followed in a few hours by soreness to the touch, and by increased distention. His pulse became extremely rapid, great prostration ensued, and he died in about twenty-four hours from the time of this attack. A Sourth case occurred in a lawyer in a neighboring town, the symptoms oS whose case were detailed to me and left no doubt of its nature. But I had afterwards the further evidence, from the post mortem examination, given me by an intelligent physician, who witnessed it. In the case of J. P., however, there is a peculiar interest, derived from the part in which the perforation occurred. In the cases given by M. Louis, and in all others, which I have known, the perforation has been in the small intestines. In this case it was in the vermiform appendix of the caecum. This is a part which is not probably examined in ordinary cases. 35 274 Whether it is common for ulceration to occur In this part is not probably known to any one. In one case of typhus in the last autumn, (1834,) I opened this part and found an ulcera- tion, not deep however. The two cases XIII. and XIV., are the only ones left by my son of fatal typhus in this country, which I have thought fit for publication. He had brief notes of others, and attended the examination of at least six, I believe more, in the four or five weeks before he was taken sick with the same disease him- self in October, 1833. In the course of that season there were fourteen undoubted cases of typhus examined by myself, or my Sriends, and in every one the phenomena accorded with the descriptions given us by M. Louis. CASE XV. PNEUMONITIS AND PLEURITIS. Hospital la Pitie. Ward St. Paul. Under the care of M. Louis. Jan. 26, 1833. — This man, aet. 65, entered the hospital yesterday. He was born in Savoy, and at 14 years oS age enlisted in the French army, where he remained till the age oS 28. From this time until 52, he was a pedlar, and since has had no regular employment, and has hardly done any work. His parents had no disease that he knew oS, were never palsied, nor asthmatic. He had twice gonorrhea while in Italy, never any other venereal disease. He does not re- member having had any severe diseases, except three, during his life, viz; 1st. Intermittent fever, while in Italy, at the age of 20, which lasted three months. 275 2d. Acute disease of the chest, two years since, causing stitch in the left side, cough, and fever ; was bled twice, and kept bed fifteen days. 3d. Five years ago had retention of urine, for which he entered the hospital Beaujou. While there, a catheter was retained in the bladder ninety days, it having been changed only once in fifteen days. At the end of these ninety days he left the hospital, sicker than at entrance; for he says that, beside the retention of urine, there was also a catarrh of the bladder and the urine was thick. During the five last years has never been able to pass urine except by means of a cathe- ter; and for eighteen months past has injected every day tepid water into bladder with relief. From the beginning of disease of the bladder, his health, which had been previously very good, has been always more or less bad, and he has been incapable of continued labor; the appetite has been sufficiently good, but he thinks he has not eaten more than half of what he used to eat; digestion sufficiently good ; but perhaps during one fifth part of the time he has been liable to diarrhoea, with griping; never more than six or seven dejections a day. Emaciation slight until pneumonic disease two years ago ; but since that period has been quite marked, and his strength also has much dimin- ished, having been somewhat so before. Previously to these two years, he had been rarely afflicted with colds, and had never had dyspnoea; but since, has always had cough and difficulty of breathing; never haemoptysis, nor palpitations. Present disease began three weeks ago. At its beginning he had chills and increase of cough ; expectoration white ; no pain in chest until about eight days ago, i. e. after having been sick a fortnight, when it seized him in the right side. It has increased since, and is felt even when patient does not 276 cough. The same day, or the day after, he was able to walk six miles out of Paris to Sevres, in three hours. ASter his arrival at the house of a Sriend in Sevres, the expectoration became red; pain in side increased, much oppression in breathing. He remained seven days at Sevres, where he employed no remedies, and took nothing save beef-tea and goat's milk. Yesterday, 25th, the seventh or eighth day of augmentation of disease, and twentieth from commencement, the patient returned again on foot to Paris, going at the rate of a mile an hour. Entered la Pitie the same day. Now, nine, a. m. —Eyes blue; hair gray ; constitution sanguine; pretty strong; height five feet and six inches; some veins on left leg varicose; these have been so since age of 27. Tongue villous, whitish, a little dry ; thirst; anorexy ; vomited a little green, bitter liquid yesterday and day before; no dejection for eight days ; pulse 100 ; cough frequent; res- piration labored, 44 after conversation; rather severe pain at right side, three inches above the border of false ribs; expec- toration rather copious, an ounce and a half, rusty, (brownish,) semi-transparent, containing very minute bubbles of air, slightly liquid. On percussion in front, sonorous at left, very obscure at right; respiration at right in front everywhere coarse, not exactly bronchial anywhere ; slight resonance of voice below right clavicle, none in other parts; behind, at right, crepitous rale in superior third of chest, on Sull inspiration; and below, throughout same side, sub-crepitous rale, alternating with a sound similar to sound of bass-viol; no bronchial respiration, nor broncophony. At left, respiration pure above, sub-crepi- tous rale below. (Syrup of violet flowers, with oxymel. Gum potion. Ve- nesection ad § xv. Aromatic potion with grs. viii of tart. ant. conditionally this evening.) 277 Four, p. m. —Face red ; lips oS slight violet hue ; dilatation of alae nasi; slight headache; no buzzing in ears ; no dizzi- ness now, nor at any previous period oS disease ; eyes heavy ; pupils round, equal, natural; tongue a little moist, pale-red, natural at point and edges, white at centre ; mouth bitter ; great thirst; likes warm drinks ; no soreness oS throat; de- glutition easy ; anorexy; abdomen supple ; slight meteorism at right, and slightly sensible to pressure there ; no dejection ; urine by catheter two and a halS hours ago; no flatness on percussion ; no tumor Selt in hypogastric region; p. 108, Seeble ; skin hot, dry not burning; resp. 40, with much op- pression ; a groan attends each expiration, which last is quite short; speech concise and broken ; auscultation as this morn- ing, except that I do not hear at all a vesicular expansion at right which is heard at left. Below right clavicle is heard a blowing, which sounds like bronchial respiration, although not heard in expiration ; sound like bass-viol heard both sides, behind, in expiration and inspiration. Jan. 27. — Venesection yesterday to eighteen ounces; blood covered by a buff, yellow, tough, and having five lines in thickness. Has not taken tart. ant. Strength more evi- dently diminished ; emaciation ; cheek bones red ; dilatation of alae nasi; tongue moist, brown in centre; abdomen supple, without pain; p. 120; heat moderate; resp. quicker, 40, ac- companied with a sonorous rale ; expectoration less abundant, some parts of a yellow-ochre color, others oS brown; which Sorm a mass, the greatest part oS which is somewhat Srothy ; the remainder containing very fine bubbles oS air; viscid, semi- transparent. Right side oS chest in Sront is painSul on per- cussion ; so is the leSt, but less so. At right, behind, the chest is sufficiently sonorous on percussion in the two lower thirds • in Sront it is as yesterday. Respiration throughout right side 278 is coarse, no where vesicular; sub-crepitous rale and almost gurgling below right clavicle ; and lower down is heard a kind oS crackling, like the noise produced by the sudden separation oS two pieces of moist leather. Behind, at summit, fine crepitous rale; below, it is sub-crepitous, alternating with a vibrating rale. Nothing remarkable at left. (Aromatic potion, with ant. tart. grs. viii, and syrup of white poppies | i. Sinapisms to chest immediately.) Five, p. m. — Diminution of strength more marked than yesterday. Pulse as in morning, very feeble. Resp. 42. Pure bronchial respiration immediately below right clavicle ; less marked lower down ; at this latter place very numerous and fine crepitations after cough, or strong inspiration ; reso- nance of voice in the whole Sront on same side. Has taken a spoonSul oS potion, which has caused neither vomiting, nor dejection. Jan. 28. — Potion all taken ; Sace less flushed ; emaciation ; tongue dry, brown as before in centre ; deglutition a little dif- ficult on account of dyspnoea ; voice feebler, speech difficult; no vomiting ; two dejections ; some expectoration, with large bubbles of air in it, gray color, none opake, nor yellowish. P. 112, not very feeble. Resp. 44. Percussion below right clavicle flatter than yesterday ; respiratory sounds the same as before. (Same prescription, only increasing ant. tart, to grs. xii.) Five, p. m. — Head raised ; lips violet; Sace sallow ; resp. 48, with rattle in throat; p. 120 ; skin hot; speech as beSore ; halS of potion taken without dejection, or vomiting, or nausea ; urine, twice. Death at one, a. m., 29th. Autopsy at nine, a. m., 30th, twenty hours after death. 279 Exterior of body. Yellow tint generally over body ; red- ness where sinapisms were applied to inside of thighs; — no livid spots; no stiffness of limbs ; pilous system much devel- oped upon abdomen and upon the thighs; emaciation, not very marked. Four lines of fat upon chest; two upon abdo- men ; muscles firm, red, natural. Abdomen. — Peritoneum, moist. Stomach pale externally, rather large ; on internal surface the veins are strongly marked along the great curvature and upon the anterior and posterior faces under the mucous membrane. In several parts the mu- cous membrane is injected, so as to present red points, and thus are Sormed many patches of a reddish-gray color. Along the small curvature are three or four longitudinal depressions, from one to three inches in length by four lines in breadth, filled with very red points. In cutting the mucous membrane at these depres- sions we find it evidently thinner than in the surrounding parts. The whole surface of the stomach is mamelonated, save a part of the cul-de-sac and the small curvature near the cardia. This appearance is most marked in the great curvature, and in the posterior face, and all the parts thus affected are covered by viscid mucus in great abundance. The mucous membrane gives strips from ten to twelve lines upon the small, seven to eight upon the large, curvature, and upon the anterior face, and very nearly the same length in the great cul-de-sac. This membrane is normal as to its consistence. Small intestines. Pale, slightly enlarged, and containing a very little mucus only; pale internally, except in the two or three first feet, in which there is a slight injection of the vessels in the sub-mucous tissue. Thirty-seven glands of Peyer, pale, thin, healthy ; isolated glands are only seen in last six inches, white, without central points; mucous membrane of usual thickness, — gives strips from five to six lines in first half; six 280 to seven afterwards, except in some parts of last third, where they are only Srom two to three. Mesenteric glands, small, gray, healthy. Large intestines, contain considerable quantity oS Secal matter: pultaceous at first; hard, moulded to Sorm of intestine afterward; mucous membrane, pale, of usual thickness, gives strips from two to five lines in first halS; Srom ten to twelve below ; glands of Brunner few in number. Liver, large; left lobe covers the spleen ; right lobe is red, mingled with yellow externally and internally, as if bile had been effused into its substance ; color somewhat like mustard; consistence natural. Left lobe, natural in color. Spleen, small, slightly friable, usual color. Kidneys, healthy, membrane covering them can be easily detached, is thin and transparent; at summit of each is a de- pression, six lines long, four in breadth, half deep; substance underneath healthy. In the bladder is a tumor situated at the left of the median line, very near the orifice oS the urethra, so that its right Sace rests very nearly upon this orifice. This tumor is oS an irreg- ular, oval form, in length one inch and a halS, in breadth one and a quarter, and in thickness two thirds oS an inch. Its Saces correspond to the anterior and posterior faces oS the blad- der. Externally its color is yellow, except at its posterior sur- Sace, where it is red. It is attached to the bladder by a pedi- cle, which is Sour lines in thickness; and although the substance is continuous with that oS the prostate, this latter does not appear in any respect morbid, neither as to volume, nor as to texture. The tumor is covered by the mucous membrane. It is hard, tough, shining on its cut surSace, and gives a sound under the scalpel. It is not homogeneous ; it is of a yellowish- white above, reddish below, and the substance oS the pedicle 281 is less firm and more vascular than the rest of the tumor. The bladder is larger by one half than it is usually, and its walls have three or four times their accustomed thickness, owing principally to a hypertrophy of the muscular fibres. Its internal surface is generally red, especially near the tumor; and about this last for the space of one and a half inches are seen, on the mucous membrane, a multitude of small points, half a line in diameter, elevated, confluent, or separated, and which can be easily raised by the back of the scalpel, and appear to be false membrane. Mucous membrane is in this part twice as thick as it is elsewhere; it is also less movable upon the subjacent parts. Chest. — Pericardium contains four ounces of a yellow se- rous fluid, with some few flocculi. The heart appears a little enlarged, and upon its anterior face is a white opake patch. The auricles, especially the right, the aorta and pulmonary artery contain large fibrinous clots. Substance of heart firm, color natural and cavities of usual size, with walls of natural thickness. Left lung has some slight adhesions at its posterior part, the two lower thirds and part of its base; at its apex and on its anterior edge are many greatly dilated vesicles, six or eight times larger than when in healthy state. The lower lobe contains a moderate quantity of blood, frothy as it runs after an incision. Owing to this blood the lung is heavier than usual; for its substance is not in the least granulated, nor hepatized, nor does it have the appearance of the spleen ; al- though it has a little less firmness of texture than is usual. The bronchia, especially at their divisions, are of a bright red color, but still continue polished ; those of the lower lobe con- tain as mall quantity of yellowish mucus. Right lung, throughout, is adherent. The adhesions are old, cellular at the superior portion ; recent below, where the false 36 282 membrane is yellow, easily broken, oS an unequal thickness, and infiltrated at its base. The lung is much enlarged, and very heavy. Upon its posterior part are seen the indentations of the ribs ; it is hard and firm everywhere, except at its ante- rior margin, where, over an extent oS two inches, the vesicles are much dilated; and at its base, over an extent oS an inch and a halS, it is soft and crepitating. Its color internally is va- rious ; it is yellow, or yellow mingled with red-gray, to the ex- tent oS two and a half inches Srom its apex ; more red below, but there also mixed with yellow. It is everywhere granulated, contains no air, very little liquid, and is easily penetrated by the finger; in other words, it is hepatized to the third degree at summit, and is between second and third degree below. In some of the bronchia oS this lung is a concrete, yellow, opake matter, which can be Sollowed into the small ramifications, always preserving their form, but having no evident adhesions to them. It is impossible to decide whether this matter is solid or hollow ; however, on making a transverse section of it there seems to be a slight orifice in it. Neck. — Trachea in lower three quarters is of a vivid red color, but not uniformly ; the mucous membrane preserves its polish, and is not evidently thickened ; the redness is entirely in the mucous membrane, Sor the sub-mucous is not injected in the least. Upon the posterior part oS Epiglottis, which is otherwise perfectly well, is a small elevation, one line thick, Sormed by a small cyst, which contains a substance, halS liquid, and clear as iS crystalized. Head. — Very slight effusion under arachnoid, and only in the convolutions ; pia mater slightly injected, easily raised Srom surface of brain; cerebral veins slightly distended with blood. Cortical substance is perhaps of a little deeper color than is usual; medullary substance somewhat pointed with red, 283 oS good consistence ; two drachms oS clear serous fluid in each oS the lateral ventricles. Cerebellum, a little marbled; oS its usual consistence. Annular protuberance and medulla oblongata are in a normal state. Remarks by the Reporter. — We have just read an observa- tion, relative to a person, previously ill, who died after eleven days of pneumonia. Let us make a few remarks upon this acute disease, after having brought to mind that it was the second attack of the same kind, within these last two years. 1st. We remark that the inflammation of the pulmonary tissue and pleura was preceded by a bronchitis of fifteen days' duration, and this latter commenced with chills and rather severe general symptoms. 2d. As to the seat of the pneumonia: the physical signs during life, and the appearances after death, prove that the inflammation began in the superior lobe of the right lung. This is an exception to an observation made a long time since, viz.: that pneumonia usually commences in the lower lobe. This affection of the upper lobes has been marked by M. An- dral as being oftener fatal, than pneumonia of the lower lobes. M. Louis, in seeking for the cause of this difference of mortal- ity, discovered that inflammation commences in the upper lobe much oStener in old persons, than in those who are in the prime oS liSe; Sor, of thirty-two cases oS pneumonia, which he has examined in reSerence to this point, he Sound that in eleven the disease commenced in the upper lobe; in twenty-one in the lower; oS these the mean age of the former was 61 years; oS the latter 38 years. I have examined also thirty-two cases, reported by Andrei in his Clinique Medicale, and, oS these, eleven began in the upper and twenty-one in the lower lobes. 284 Between these two classes, the same distinction in regard to age takes place, only it is not so marked as in the others. In the former, the mean age was 47 years; in the latter, 37 only. The law deduced by Louis from his cases appears confirmed by Andrei's, and it is for future time to decide the numbers more exactly. I will mention, at this time, another question relative to age, in cases oS pneumonia, which merits attention ; to wit, does the disease go oStener to the third degree in old persons, than in the young and middle aged. I have examined, in reSerence to this point, twenty cases given by Andral, and oS them thirteen arrived at the second degree; and their mean age was 37 years. Seven only had the disease in the third degree, and their mean age was 56. These cases are too Sew in number to justify any positive inSerences; but, in this number, the result is so striking, that it seems to me worthy of our attention. I have thought proper to introduce these remarks because our / patient is in precisely the circumstances mentioned. 3d. As to the phenomena which the patient presented dur- ing liSe, without doubt the most remarkable one is the preser- vation oS his strength, during the course of so grave a disease, until within three days of his death. A day at least after the pleurisy had commenced, he went from Paris to Sevres; and five or six days afterwards, unequivocal signs of pneumonia existed; for, at that time, when our first examination of the chest was made, a great portion of the upper lobe was hepatized. However, the patient took the same walk, the day beSore this examination ; though he spent twice as much time on the road as when he went. This circumstance is so extraordinary, and in Sact is so different Srom what we believe generally, that I cannot restrain myselS Srom adding some oS the details of another case, analogous in this respect to the Soregoing. 285 On entering la Pitie on the evening oS January 16th, I saw a man aged about 35 years, who, after remaining two hours at the hospital, had suddenly died. The nurse, in attendance, inform- ed me that this man had arrived at two, p. m., saying that he had come Srom the Bureau Central (three quarters oS a mile) on Soot, and that he had been sick only eight days, never hav- ing been sick beSore. He seated himselS near the stove, con- versed with the other patients, and finally laid himselS down upon his bed. He was observed at this time to have great dyspnoea; his Sace and hands were oS a violet hue and appear- ed swollen. In a short time aSter this he died. On percussion oSthe dead body, I Sound complete flatness Srom one inch below the clavicle, throughout the whole oSleft breast, Sront and side, even to the Salse ribs. On the morrow, at the autopsy, we Sound the body to be that of a man oS strong con- stitution, the muscles greatly developed, and in the leSt pleura was a large quart oS serous pus. The lung oS this side was hepatized and oS a gray color throughout, except two inches at the summit; i. e., the lung was yellow and so softened, that in several places there was a solution of continuity, and little cavities were commencing. These cavities were not lined by false membranes, but were covered by the remains of the pul- monary tissue, broken in filaments, which floated in water. It is much to be regretted that we have not this case in greater detail; but one point is well established, that a man having pneumonia, in the third degree, oS nearly a whole lung, was able to walk nearly a mile, two hours beSore his death. 4th. Let us now connect the dyspnoea which our patient had constantly experienced the two last years oS his life, with its organic cause, viz. partial emphysema of the two lungs; al- though the physical signs of this affection were not noticed, so far as we know, during life. 286 5th. The cancerous affection of the bladder, which appears to date five years back, ought not to be passed over in silence. Let us especially remark, that inflammation of the mucous membrane of the bladder was the consequence, not the cause of this affection; for the patient assured me that on leaving the hospital Beaujou (where, in consequence of a false diagnosis probably, a catheter had been retained in the bladder 90 days) he was more ill than beSore; the urine became thicker; and in short he had catarrh oS the bladder, which did not exist at his entrance. 1 am extremely sorry to be unable to answer the questions which could be suggested, in relation to the history oS this affection of the bladder, and especially that I cannot say whether there was hemorrhage in the commencement. Whilst the patient lived, in consequence of the treatment he had undergone, I supposed there was a stricture oS the urethra; and consequently did not make very minute Inquiries upon the subject. Remarks by Editor.— I add only two observations to those of the reporter. 1st. The bruit de frottement, or the sound which resembles that from the sudden separation of two pieces of wet leather, observed on the 27th on the lower part of the right back, is found at the autopsy to correspond with recent adhesions, with- out liquid effusion, in the lower part oS the right lung. 2d. The preservation oS the muscular strength to a late peri- od oS the disease was certainly uncommon, as has been stated; but it may be well to note that the muscular strength, and like- wise the integrity oS the mind, is much oStener maintained to the last moments oS liSe, in diseases oS the thorax, both acute and chronic, than in those of the abdomen. It is not rare to find patients, under pneumonitis and under phthisis, rising in bed 287 and even getting up out oS bed, in the Sull possession oS their minds, within the last hour oSliSe. It is in such cases that we often hear those calm and interesting discourses, upon their own situation and in regard to the affairs oS their Sriends, from patients, who are Sully aware how Sew are the minutes which remain Sor them in this world. CASE XVI. PNEUMONITIS AND PLEURITIS. Hospital La Pitie. Ward St. Charles, 11. Under the care of M. Louis. May 11, 1833.— K. L., seamstress, aged 50; eyes deep blue; chesnut hair; unmarried; has never had children; entered hospital this aSternoon. She was born at Paris; her Sather died at 40, oS pneumonic disease; (ill eight days only;) mother died aet. 38, ill fifteen days, disease unknown; neither oS them had had either asthma or palsy, but her maternal grandmother had the latter disease ; one brother living aged 49. She was nursed by her mother. In her inSancy she never had short breath ; until the age oS 12 was much subject to epistaxis; has never been peculiarly liable to take cold, and her colds have been oS unusually short duration. Menses at 11 Sor the first time, and the discharge has always been regular; not preceded nor accompanied by pain in head, loins or abdomen; never diarrhoea at these periods; until the age oS 30 they usually were abundant and continued six days, and after that time they diminished to the age of 46, when they ceased entirely. Never hemorrhage from uterus, nor leucorrhea at any time, except a short period after the cessation of the menses. Until age of 48, she was never sick with any grave disease, except variola at 6 years, and fevers, as she says, at ten. 288 During the five or six years preceding November, 1831, she was subject to pain in the pit of stomach occasionally after meals ; but generally the digestion has been sufficiently good ; and she never had dysphagia, nor anorexia, nor vomiting, nor emaciation, nor short breath until November, 1831. At this time she was seized with a most severe pain at the epigastrium; which was followed by vomiting; neither of these symptoms have again recurred, but she has always been ill, since. During the first three months appetite was lost, and has never been so strong since, as it was before the attack; digestion has been difficult. OSten eructation oS wind and oS food aSter eating; constipation rather than diarrhoea; never dysphagia; pains limited to the loins, limbs, hypochondrium, and right scapula; and these have not been constant. During all this time, she has been gradually becoming thin; she has however continued to work, and this even two nights in the week, as well as in the day. She has never had yellowness of skin, nor cough, nor oppression, nor hemoptysis, nor palpitations of the heart, during these eighteen months; but she has suffered much Srom pain in the head, and within eight or ten months past her legs have been a little swollen, although this was never the case with the thighs, nor the Seet. The disease, Sor which she enters the hospital, commenced the seventh of this month ; she went to bed on the night of the sixth as well as usual and arose on the morning of the seventh, wearied and fatigued, without as yet, any local symptom. She labored during the day, ate less than usual, and at seven, p. m., went to bed with pain in head and heart. The next morning she had pain in right side of the chest, oppression at breast, cough, white expectoration ; slight soreness of throat without dysphagia, and which soon ceased; anorexy, thirst, and heat, without previous chills. Besides these symptoms, she began 289 to become yellow, and this yellowness with the above-mention- ed symptoms have continued to increase until this time. She has always kept bed since the 7th, adhering to a strict diet, and having undergone no treatment except eight leeches to right side of chest. She has not had vomiting, nor diarrhoea; two or three dejections only, natural, since the 7th; no chill, nor sweat; urine was involuntary during the two first days of the disease, and has been very high colored these two last; no palpitations, nor epistaxis since commencement of attack. Now, Sour, p. m., 11th. — Lying with head and shoulders elevated; Sace and conjunctivae and skin, generally, quite yellow; expression oS anxiety ; cheeks oS a violet red; dilatation of alae nasi at each inspiration ; Sace showing emaciation ; intelligence and memory good. Tongue not thick, a little moist, covered with a white coat; bad taste; no pain in throat; deglutition easy; thirst; anorexy; no dejection to-day, one yesterday; abdomen well Sormed and not painful, soft except in right hypochondrium, toward epigastrium, where is felt a resistance over the space of three inches below ribs; and she is sensible to pressure on this spot. Cough rather infrequent; expecto- ration nearly nothing since entrance; pain in right side from mamma to border of cartilages of ribs, and extending behind; it is excited by motion, cough, or full inspiration; very great dyspnoea; speech difficult; resp. 28, high ; decubiture dorsal; lies easier on right side than left; chest rounded and very promi- nent in front. Percussion more sonorous, and respiration stronger at left than at right below clavicles, although it is pure in front on both sides. Behind, percussion sonorous and respiration natural, without expiration, at left; at right, percussion very obscure, nearly flat over the two lower thirds, where is heard a bronchial respiration, very marked in both expiration and inspi- ration, and mixed, especially below, with a crepitation rather 37 290 fine. In same parts a strongly marked bronchophony, partak- ing oS the character oS aegophony. The bronchial respiration, the crepitous rale and the bronchophony extend to the right side, but not in Sront. In the upper third oS the back respiration pretty good. Pulse 96, regular, vibrating, but neither hard, nor very large ; skin hot, but not very dry ; complains oS headache. May 12. — Little sleep in night; no sweat; one dejection, Secal matter, yellow; yellowness and pulmonic symptoms con- tinue to increase ; bronchial respiration very decided; crepita- tion gone; pain in right side a little more since yesterday; three sputa, yellowish; the others are white, but all are viscid, semi-transparent, and contain very fine bubbles oS air; objects do not appear yellow to patient. (Venesection to § xii. Gum potion. Strict diet.) Three, p. m. — HalS oS blood drawn is serum. Clot is less firm than usual, but it is covered at top with a buff which is yellow like the skin of patient, and has two lines of thickness at edge, less than one in centre and is very tough; very little relief since venesection ; auscultation as this morning, only now is heard an expiration at right in Sront; none at leSt; p. 96; resp. 20. May 13.—Bad night; resp. 32, more anxiety but less pain; cough more frequent; feebleness more marked; skin more yellow and more hot; p. 96. Nothing new from auscultation, except that the bronchophony behind has some- thing more aegophonic in it than before; tenesmus; no dejec- tion ; thirst greater. (Syrup of violet flowers with gum syrup. Aromatic potion with grs. vi of ant. tart, and § i of syrup white poppies. En- ema of flaxseed tea.) Four, p. m. — As this morning. Pain almost gone ; no nausea, nor vomiting, nor colics ; two yellow dejections, solid ; 291 many greenish-yellow sputa; others white, &c, as before ; same on auscultation behind ; throughout lower half right side, in front, the intercostal spaces are very slightly marked, and the part seems prominent. Percussion here very sonorous, and respiration feeble ; same at left, low down, but less marked. May 14.—Has taken all the potion; ten dejections; no vomiting ; feels worse; pain in side again ; more yellow and feeble; expectoration as yesterday p. m. ; no soreness of throat, no nausea. (Ant. tart. grs. viii.) Five, p. m. — More oppression and anxiety; resp. 36; speech very difficult; three or four dejections, without nausea, or vomiting; pain as yesterday ; sputa more liquid and less yellow, without green tinge ; expiration more prolonged below right clavicle than before ; p. 100. May 15. — Has been constantly having dejections during night; on percussion more flat below right clavicle, and res- piration coarse, where I found prolonged expiration yesterday evening; more yellow. (Tartarized antimony omitted. Blister to thighs.) Death at two, p. m. without agony, or convulsions. Autopsy ten, a. m. 17th, forty-four hours after death. Exterior. — Whole surface of skin yellow, without any livid spots ; stiffness of body ; fat four lines thick upon chest; muscles of a good color and consistence ; no infiltration of lower limbs. Abdomen. — Peritoneum moist, healthy. Pharynx and cesophagus covered throughout with healthy epithelium. Stomach covered almost entirely by liver, which descends towards the epigastric region. It is of moderate size and con- tains a moderate quantity of a grayish liquid, which flows easily; on its interior, it is nearly throughout gray, or white, 292 slightly red toward cul-de-sac and in small curvature ; the two Saces and great curvature are mamelonated, especially toward pylorus, but no where in a great degree. Mucous membrane has its usual thickness everywhere, and gives strips Srom Sour to five lines in cul-de-sac, where there is redness, owing to injection of the membrane ; from eight to ten upon great cur- vature and the two Saces, and a little longer upon small cur- vature. . Small intestines. — Usual size, thin, contain a small quan- tity oS a clear, yellow liquid, which flows Sreely, mingled with some mucosities. Mucous membrane pale, white through whole extent, except toward end of ileum, where it is a little red. It is thin everywhere, and has its usual appearance; yet, although not apparently softened, 1 cannot raise strips of more than two lines in any part. In three last feet, the glands of Brunner are a little more numerous and developed than usual. At two feet from end of ileum is a diverticulum three inches long, and sufficiently large to admit the middle finger; its structure is precisely that of the intestine. Mesenteric glands, small, healthy. Large intestines. — Moderate size, contain clear, thin, yellow fluid, with parcels of fecal matter, not moulded; mu- cous membrane pale, thin, white ; give everywhere strips from twelve to fifteen lines. Brunner's glands distinctly seen, but not larger than usual. Liver. — Partly covers the stomach, extending as it does, more than usual into epigastric region; in other parts it is oS its usual size, but in this part it is covered both anteriorly and posteriorly by Salse membrane, which is not in a continuous sheet, but presents the appearance oS many little elevations, which can be detached in strips. Underneath this membrane, especially towards the edge, are seen small irregular spots of 293 a brownish-yellow hue, which color enters the substance oS the organ ; and in this part the liver is much firmer than elsewhere, and it is only with much difficulty that the finger can be made to penetrate it. These yellow spots are not more granulated than other parts oS the organ, and in other parts there is the usual consistence and color. Gall-bladder oS usual size, con- tains a yellow fluid, rather clear and thin. Its duct appears not very much dilated, while the ductus communis choledochus is so very much enlarged, as nearly to admit the entrance oS the little finger. This dilatation extends to duodenum, into which can be passed a stilet oS two lines diameter. The dila- tation seems to be owing to a biliary calculus, which is situated in the duct itselS, and which has nearly twice the volume oS a pea ; is round and broken. In the liver the hepatic ducts have first three lines, then two, and one line in diameter, and in no part is there Sound any other calculus. Spleen, in color, size and consistence, as usual; it contains much blood, but is not very Sriable. Kidneys, oS a deep red, except tubular portion, which is a little pale. Cortical substance red, mixed with yellow ; oS usual firmness. External membrane easily detached, with- out tearing the substance oS organ ; it is thin, and semi-trans- parent. Bladder rather distended with urine; its mucous membrane pale, thin, and gives strips more than an inch long. Uterus small, natural. Mucous membrane healthy ; and has nothing remarkable about it, save a Solding upon itselS toward the upper angle at right side. This folding is red, half an inch long, and hangs freely in cavity oS the organ. Chest. — Larynx and trachea are pale, white, healthy ; strips Srom fifteen to twenty lines long from trachea. The lungs touch in front under sternum. 294 Right lung, adherent to diaphragm by means of a Salse membrane, which is yellow and friable. In cavity of pleura are eight to ten ounces of a yellow, serous fluid. The supe- rior lobe has no Salse membranes covering it; the middle is partly covered, especially towards its base, where it adheres to the inSerior, by a false membrane, as above described, yel- low, tearing easily, one third line thick; and the lower lobe is entirely covered by it. This lung is very heavy, owing to the weight oS the lower lobe, which is very large and firm, and does not crepitate in any part. This lower lobe has, nearly throughout, passed to the third stage oS inflammation, i. e. it is yellow, mingled with a little red in spots, is granulated, very Sriable, suffers the fingers to penetrate it easily; contains no air, but allows much purulent fluid to escape on slight pres- sure. Towards its base it is red for a small space, granulated, but less softened ; in some spots the color is of a brownish- yellow, but they have no gangrenous odour. A part of the two upper lobes, especially toward their posterior portion, is red, granulated, slightly Sriable, hepatized. Throughout they contain a rather large quantity oS yellowish-red and frothy liquid. Many vesicles in this lung towards anterior edge, and base oS middle lobe, are, perhaps, two or three times larger than usual. The bronchia are everywhere pale, smooth, not thickened, nor dilated. The only difference between those of the lower lobe and those of the two upper, is, that in the former is found a thin, yellowish, opake liquid; but nowhere is there any false membrane. Left lung is much smaller, and less heavy, than the right. The upper lobe has many dilated vesicles, towards its anterior edge, but fewer than at right. This lobe has very little liquid in it, and everywhere it crepitates, and the liquid, which flows from its cut surface, has not the same yellow color, as that of 295 the right upper lobe. The inferior lobe is partly granulated, solid, red and friable, but the greater portion contains air ; the bronchia of both lobes are pale, thin, smooth, healthy. Pericardium contains two or three ounces of a yellow, clear, serous fluid. The heart contains fibrinous clots; its consis- tence, volume, and color, are natural; valves free and healthy. Ascending vena cava, as also the iliacs are smooth, thin, and have in them a little clotted blood. Head. — Slight effusion under arachnoid; longitudinal sinus contains a small clot, fibrous and very thin ; glands of Pacchioni small; pia mater somewhat injected, easily raised. Cortical substance of ordinary gray color ; medullary substance white, slightly injected, presenting a faint lilac tinge, soon af- ter being cut. Consistence good everywhere. Lateral ven- tricles contain little serum, perhaps an ounce each. Central parts, corpus callosum, corpora striata, medulla oblongata, annular protuberance, cerebellum, all have their usual color and firmness. Pituitary gland very soft, of reddish-yellow color, partly liquid, partly pulpy in interior, firmer towards its periphery, as if it were enveloped in a membrane. Reflections by the Reporter. — We have just read the case of a woman sick during eighteen months, previous to entering hospital, and who died of a very severe pneumonia, which ran through all its periods, even to suppuration, and that through- out a large portion of the lung, in the space of eight days. The only remark we shall make in relation to the pneumonia is this; our patient had febrile symptoms during twenty-four hours previous to any evident local affection. We may consider the pneumonia as an accident which has enabled us to see a chronic lesion of the liver, which had made but little progress, and which had given rise to few symp- 296 toms. The patient had been ill eighteen months ; during this time progressive, through very great emaciation ; diminution of strength and appetite; pain, at intervals, in right hypochon- drium, below right scapula, and in the limbs ; and, at the last, yellowness in the skin and eyes; no other symptoms relative to the digestive organs, lungs or heart. After her entrance into the hospital we were able to add yet another circumstance, viz. a fulness and sensibility to pressure in the right hypochon- drium towards epigastrium. These were all the symptoms we were able to obtain, in reference to this chronic affection, which had caused emaciation, and diminution of strength dur- ing eighteen months. At the autopsy we found the lesion of the liver above de- scribed, and no other that could be called a chronic affection, and consequently would explain the symptoms. But what is the nature of this lesion ? what name shall we give to it ? where shall we put it in a pathological table ? For myself I know not how to answer either of these questions. It had some- what the appearance of what Laennec has described under the name of cirrhose, i. e. there were yellow granulations, which this author gives as characteristic of this lesion. But this observer does not tell us whether the organ is softened, or hardened in this disease. For want of this information we are embarrassed as to our decision in the case before us ; for one oS the circum- stances, the most marked, was a hardening of the tissue of the liver of our patient in the parts evidently diseased. Finally, in the actual state of our knowledge, all we can do, is to state the symptoms, and describe the lesion, and leave its nature and its relations to be decided hereaSter. But we have passed in silence another affection of the bili- ary apparatus, which will be thought of as much importance as that oS which we have just spoken ; I reSer to the biliary 297 calculus Sound in the ductus choledochus. This calculus ap- pears to have been the cause oS the yellowness, which existed during eight or nine days beSore the death of our patient; but the passage was not entirely obstructed. The bile passed always into the intestine, for the dejections were always yellow during life, and bile was found in the intestine after death. It may be asked how long this calculus had been in the duct and what relation it bore to the disease of the left extremity oS the great lobe oS the liver, as cause or effect. I do not see how we can answer these questions rigorously. We will only re- mark that the enormous dilatation oS the passage is by no means a prooS that the stone had been there a long while ; Sor we see this dilatation of membranous organs, take place in a very short time. We will not cite the hollow organs, which are formed for dilatation and contraction every day; we will mention the ureters only, together with the pelves of the kidneys, which dilate in the space oS one or two. days, to a much greater ex- tent, than the biliary passage, in the present case. An unnat- ural anomaly demands yet another moment oS our time, I mean the diverticulum, three inches in length, which was at- tached to the ilium, and which, terminating in a cul-de-sac, floated Sreely in the peritoneal cavity, like the vermiSorm ap- pendix oS the caecum ; but having, however, eight times the diameter oS this appendix. This anomaly is worthy oS remark, inasmuch as it sometimes occasions an internal hernia ; Sor by the adhesion oS its Sree extremity to a Sold oS the intestine, or to the walls of the abdomen, it may Sorm a band, capable oS producing strangulation of the intestine. Cases of this kind, presenting all the appearances of hernia, without any external tumor, may become very embarrassing as to the diagnosis. There are many such cases in the annals of science. I have 38 298 seen one in a young man aged eighteen, whose intestine had the same anomaly, as we have described in this case ; and, in consequence of his having all the signs oS strangulation of the intestine, he was suspected to have internal hernia, though its cause was unknown till aSter death. By the Editor. — To the remarks above, we may add, 1st. In addition to the signs, rational and physical, oS pneu- monitis, it is noted on the 11th and 13th, that the broncho- phony of the right back partakes of the character of aegoph- ony. On the autopsy we find effusion upon the pleura in this part, over the hepatized lung, showing the accuracy of this sign. 2d. On the 13th, we find noted that, in the lower half of the right breast, the intercostal spaces are somewhat filled out or prominent, and in the same part, the respiration is feeble, while the percussion gives a full sound. The same signs were noticed on the leSt, in Sront, but in a less degree. These signs belong to vesicular emphysema, and this is found in the corres- ponding parts oS the lungs after death. As some one, a stran- ger to the reporter, may suspect that his imagination aided him in describing these exact coincidences, it may be proper to state, that I have before me the original rough notes of the observations made beSore the death of the patient; and that I have also a copy of the case in French, drawn up by the re- porter, and read by him to the society of medical observation in Paris. As most of the members of this society must have seen the case, as well as himself, he could not have ventured to give any colored view of it in their presence. 3d. The hepatization of the left lung was not discovered during life. It might have been, with more care. Ferb;ins it took place in the last day or two; it may be said, however, 299 that we are apt to overlook the slighter affections in cases, in which we have discovered one grave disease, and this often leads to errors of no small importance. CASE XVII. PNEUMONITIS. Hospital la Pitie. Ward St. Paul, 9. Under the care of M. Louis. Jan. 10,1833. —This man entered on 13th ult.; complained then of pain in side, which had lasted three or four days; but he never appeared very ill, and his breathing was good. From the time of entrance until the present, I have often examined the left thorax, and have found flatness on percussion, absence of respiratory sound, no bronchial respiration, nor bronchopho- ny. Yesterday morning, a short time aSter visit, he had chill, and at same time, pain in nose, which on Seeling it appeared to him swollen; his thirst increased, no appetite; no nausea, nor pain in belly ; two dejections, no diarrhoea. No pain in neck yesterday, nor beSore; sleep pretty good. Now, (twenty- three hours aSter attack,) Sace not recognizable ; nose large, tender, red Srom tip to an inch above root on Sorehead, one inch on right side, and one and a halS at leSt; both eyelids affected, the leSt the most; lips natural; p. 112, Seeble, small, regular ; heat slight; tongue dry, its color natural, easily pro- truded ; no pain in abdomen ; respiration seems easy; voice rough, hoarse ; says throat Seels dry; no sweat in night, chest flat behind at leSt, auscultation as beSore. (Gr. i. ant. tart, in sweetened whey.) Four, p. m. — p. 108, skin hot, cutaneous affection extended three or Sour lines in every direction, except toward lips. Respiration, as he lies asleep, is 27. 300 Jan. 11.— Disease extended to hair on Sorehead, and to a line with external edge oS eyes, on cheeks ; epidermis raised on right cheek ; crusty eruption along both sides oS nose; p. 92, not large; two dejections. Antimony not taken. (Sweetened barley-water with gr. ii. of ant. tart.) Four and half, p. m. — p. 120, small; skin hot, dry ; resp. 36; high on left back, respiration bronchial on expiration; in front, both sides puerile ; thirst ; deglutition easy; slight pain under jaws, from swelling of glands; no headache. Jan. 12. — Disease has not extended ; skin of face and fore- head less tense, nose smaller ; little vesication on right cheek, and desquamation on forehead. Pulse as yesterday evening. Tongue reddish, not coated; four or five dejections ; intelli- gence good ; glands a little swollen. (Half a pint of flaxseed tea for enema. Three cups of beef tea.) Three, p.m. — p. 116, heat; respiration bronchial left back; about centre and lower third there is resonance of voice. Lit- tle scales beginning to appear over whole of diseased parts. Jan. 13. — Tension and swelling much diminished; crusts and desquamation increased ; slight oedema toward right angle of jaw without redness or pain ; some towards occiput, other symptoms as before. (Syrup of violet-flowers. Flaxseed enema. Three cups of beef tea.) From this time until five, p. m., 19th, slight records are made, and referring principally to disease of skin. Jan. 15th, left ear swollen, red, tense ; right, not so. — 16th, left ear less swollen, and right, attacked now as left was yesterday. On 17th, and 18th, right ear less swollen. 18th, left nearly nat- ural. On 19th, all redness and tension gone from head. (Edema of scalp is mentioned on the 18th, and had existed previously. 301 The pulse gradually diminished until 18th, when it was at 96; the skin became less hot, resp. 30, on 18th ; the tongue was slightly moist on 14th, yellow on 16th ; 19th, a. m., it was dry and red. Two dejections reported on 18th and 19th. On 14th, patient said he had no cough. By auscultation on 18th, a. m., sub-crepitous rale low down on left back. On 19th, a. m., crepi- tous rale at middle of right back; and bronchial respiration below. Treatment was until 18th, sweetened rice water with eight ounces of flaxseed tea for enema daily, sometimes mixed with decoction of poppy heads. On 15th, patient was allowed three and a half cups beef tea ; 16th, a small quantity of ver- micelli ; on 18th, gum potion with oxymel, was ordered, and three cups beef tea; 19th, plaster of Burgundy pitch to right side of chest. Jan. 19, p. m.—p. 132; resp. 44; says he has had much more cough for two days past; without chills, or increased dyspnoea, or pain in chest; no expectoration ; now, no pain in throat, deglutition easy ; no pain in abdomen ; has appetite; no diar- rhoea ; dejection daily. Tongue, rather dry, furrowed, brown- ish ; voice muffled (voilee), no headache ; countenance much emaciated ; — auscultation in front, good ; murmur stronger at left than right; percussion there good; behind, on the right bronchial, respiration and bronchophony at middle; crepitous rale as before, below; and flatness on percussion. Jan. 20. — Little sleep; no sweat; tongue moist, otherwise as yesterday; on percussion does not resound well at lower half of back on either side. (Aromatic potion with gr. vi tart, ant.) Three, p. m. — p. 160, very small, varying; resp. 52, with rattle in throat; features pinched ; eyes natural; no headache ; voice very Seeble; skin very hot; tongue dry, mamelonated, brown; not thickened, nor painSul; deglutition easy; belly 302 soft, bears pressure, contracted ; no colic, nor vomiting; but five or six liquid dejections since morning. Great emaciation within eight days. Jan. 21.—Repeat antimony. Five, p. m. — p. 144 ; resp. 56. Percussion good in both breasts; in Sront, at the right, lower part, crepitous rale rather large, disappearing after a short interval; tremor communi- cated to hand at right, none at left; respiratory murmur very low at left, too weak to allow of examination behind. Cough very frequent without expectoration. Jan. 22. — Death at one, a. m. Autopsy, Jan. 23, ten, a. m., thirty-three hours after death. Externally. — Surface pale, face covered with little scales, (desquamation oS the cuticle;) no violet spots, anteriorly nor laterally ; no oedema oS lower extremities; emaciation consid- erable ; a little more than a line of Sat over chest and abdo- men ; muscles sufficiently firm, not large. Head. — Dura mater natural; glands oS Pacchioni fully de- veloped at posterior part of longitudinal sinus; considerable effusion under arachnoid, which, however, is not very vascu- lar ; grey substance oS brain paler than usual; white substance, throughout, has very Sew red points, but oS good consistence and firm ; very little serosity in ventricles; cerebellum, me- dulla oblongata healthy. Neck. — Velum palati, and upper part of pharynx have on each side a thin, white opake membrane ; this is not continuous, but is at intervals only; does not extend into oesophagus, and is easily removed by the scalpel. Larynx and trachea, natural; the last somewhat red, con- taining two or three morsels oS matter like the contents of stomach, perhaps entered aSter death. Chest. — Pericardium contains about Sour ounces oS a red- 303 dish serosity ; white spot, one inch long, halS an inch broad, on the surSace oS heart. A large firm coagulum fills right auricle, extends into ventricle and vena cava; small clot in leSt auricle, but blood there less entirely coagulated. (Here the reporter makes a remark, that shows he meant to have ex- amined more minutely this organ, but was prevented Srom so doing.) Left lung, adherent by a very thick Salse membrane, be- tween pleurae in its upper two-thirds ; and in this membrane are numerous small tubercles; the lower third oS lung is cov- ered also by a Salse membrane, in which are many small ec- chymoses. This Salse membrane is separated Srom another on pleura costalis by a quantity oS serous fluid. By removing the pleura costalis, the pouch is well demonstrated. The upper lobe contains numerous gray, semi-transparent granula- tions, some becoming a little opake, none completely so; these Sound only within Sour inches oS apex, and with them one cre- taceous mass ; tissue around them is natural, crepitating well, is Sull oS air, though more red than the healthier part of lungs. (The bronchia, says the reporter, leading to this lobe were not examined, which was a great oversight.) Lower lobe anteri- orly healthy, crepitating, bronchia easily followed ; posteriorly and externally it is compressed, does not crepitate, is red, not granulated, but as if carnified, is hard, not easily penetrated by finger. Bronchia of this lobe traced with difficulty to peri- phery, are red, thickened, evidently of less diameter than those of the upper lobe same side. This lobe does not con- tain much fluid, and sinks in water. Right Lung,—considerably larger than left; is slightly adherent, by cellular membrane, to sternum and pericardium, elsewhere free ; thick, recent false membrane between lobes. Upper lobe, — anteriorly crepitates, is pale and is healthy, 304 save that it contains a few gray semi-transparent granulations; posteriorly, and especially at its lower part, is commencing in- flammation, which, below, is passing to hepatization, i. e. much red fluid Slows Srom incision in the upper part, but toward the lower part it becomes less in quantity and is less Srothy; also the substance is less crepitating, and is more easily penetrable to finger, than in health. Bronchia pale, thin, especially an- teriorly ; a little redder and not thickened below, and poste- riorly ; — lower lobe heavy, and of a light reddish-gray color, not crepitating, very Sriable, granulated, sinks in water, i. e. between red and gray hepatization. The bronchia oS this lobe, beginning at one inch Srom their origin, were filled to their minutest ramifications with a concrete, tubular (hollow) yellow substance, oS very considerable firmness, rather oS a fibrinous, than mucous consistence ; not evidently adherent to bronchia, but seeming to be a false membrane lining them. It could be traced to the minutest ramifications, without breaking, even to those smaller than a common pin ; it became white on arriving at these smaller bronchia. The branches oS this membrane were everywhere hollow and firm, retaining their Sorm, even after having been Solded on paper. The bronchia underneath were red, evidently thicker than those oS upper lobe, and I thought a little less polished. Abdomen. — Peritoneum moist. Organs generally pale. Stomach, — one half as large again as usual. Internally in three quarters oS the organ, nearest cardia, is of dark brown, al- most black color ; in many parts has bright red points, especial- ly in great cul-de-sac and anterior Sace; the part nearer pylorus is oS a pale white, with some spots oS equally vivid red. The large veins are very strongly marked, under mucous membrane, which last appeared to the reporter, soft in cardiac half, though oS its usual thickness. Organ contained a small 305 quantity of a dirty greyish fluid, with little morsels, like curd- ed milk, and some beans. Small Intestines. — Little yellow mucus in upper part, more consistent substance near caecum ; membranes generally pale, save in last two or three feet, where are some patches of rather a lively red ; strips three lines long here ; five above ; Peyer's glands natural; mesenteric glands small, grayish, healthy. Larg», Intestines. — First half is filled with a pultaceous, yellow matter ; caecum and six inches of colon are red inter- nally ; mucous membrane not thickened ; but not yielding strips of more than three or four lines ; while in some parts of colon, where it is pale, strips are raised twelve to fifteen lines long. Substance of the intestine easily torn. Liver, rather large ; not containing much blood; quite friable. Gall-bladder contains a quantity of yellow, stringy fluid ; its mucous membrane natural. Spleen, large, soft. Kidneys, — Left larger than right, and than usual; lobulated, and has a very small cyst, containing serous fluid, at its upper part, just under external membrane. Internal substance of both, soft and rather pale ; right kidney smaller, but has a cyst that is similar to the one above described, though larger. Bladder,—mucous membrane pale, gives strips of twelve to fifteen lines; muscular portions very distinct, thick, like columnae carneae of heart, leaving between them little depress- ions of two or three lines on posterior face of bladder. Notes by Reporter. — Since there were tubercles found in the false membrane about the upper lobe of the left lung; they must have been formed since the membrane ; perhaps, therefore, those of the lungs are equally recent. 39 306 Remarks by Henry 1. Bowditch, M. D. — The above case, though very deSective, presents many points worthy oS our careful attention. During its course we have examples given us, of three distinct diseases, each well marked by its appro- priate symptoms. Let us examine each. 1st. During the twenty-nine days, previous to the first notes taken by the reporter, the patient evidently was suffering from pleurisy. For, before entrance he had experienced, during three or four days, a pain in the side, without great dyspnoea, or apparently any grave disease. By means of auscultation, an absence oS respiratory murmur, without bronchophony or bronchial respiration was discovered. In addition to this, there was flatness on percussion, on the left part of the back of thorax. Though these details are very imperfect, still, what other disease than pleurisy could, at that time, have ex- isted ? No other than pneumonia can be thought of. But pneumonia, to have caused such physical signs, must have been very severe. Pneumonia would not have continued so long and severely, without having caused more general dis- turbance oS the system. Besides, there never was any crepi- tous rale, and there was perfect flatness on percussion. It is not rare to see a man in Paris hospitals, apparently not very ill, who is able to get up, and walk about, and yet, on examination, all the physical signs of a great effusion into the chest will be found. Pneumonia, it is true, in some very rare cases, does not prevent the patient from rising and walking; still, every one knows that it prostrates more than pleurisy. But the autopsy proved the diagnosis to be correct; for, on the left side is found an effusion into the cavity of the pleura. This was the principal disease, though the lung was altered, probably by compression, by the affection of the bronchia, and the usual changes that take place after death. 307 2d. The second disease was erysipelas of the face, and it lasted from Jan. 10th to Jan. 19th. It is interesting on account of the precision with which the commencement and termination are marked. But there are two important omissions in the history of the symptoms, viz.; no where is it stated whether the redness of the skin had well-defined limits, or whether the skin was hardened in the part affected. These signs are of very great importance in the diagnosis of erysipe- las. The disease began, as it generally does, on the nose, and afterwards spread to both sides oS Sace. On the 10th, it is stated that no pain had been Selt just under the lower jaw, either previously or on that day. This remark has reSerence to an opinion, given out recently by Chomel, that, in very many cases oS erysipelas oS the face, there is pain under the jaw the day previous to the commencement of the affection of the skin, owing, as he thinks, to some affection of the absorbents. How far this opinion is correct remains still sub judice. By the report, it appears that our patient did suffer on the after- noon of the 11th, from such pains; but in Chomel's cases the pain has been experienced before any evident local symp- tom, so that the professor has made it, at times, a means of early diagnosis. The present affection lasted nine days; the mean length, according to Louis, being eight. 3d. From the 19th, the day of the termination of erysipelas, until death, our patient suffered from his third disease, viz. pneumonia. It produced hepatization of the right lung. OS the truth oS this assertion the autopsy leaves no doubt. Be- sides, the crepitous rale, and bronchophony, &c, proved it during liSe. On the 19th, we find it reported that the cough has been worse, and the pulse and respiration are quicker than they were beSore. These symptoms mark increase oS disease, 308 but I doubt much whether any one unaccustomed to the use oS auscultation and percussion, would have discovered the exis- tence oSthe pneumonia beSore death. For there was no ex- pectoration, and there was nothing, so Sar as I can see, to prove the existence oS pneumonitis, save physical signs. This absence oS pneumonitic sputa, even in advanced cases of the disease, is quite singular, though Andral; in his Clinique Med- icale, gives one case in which the expectoration disappeared after the first day, and also two in which there was none at all. While considering this point, I cannot refrain from alluding to a case recently in the Massachusetts General Hospital, in this city. The patient was an individual who, from good circumstances, had fallen into the depths of poverty. He had been sick four days before his entrance, with what was supposed to be se- vere pleurisy, because he had severe pain in the left side of thorax, cough, fever, and no expectoration. On reading the his- tory of the symptoms, as obtained by the House Physician, we were led to think that there was either pleurisy, or pericarditis. On percussion about the region of the heart, the sound was not remarkably flat, and the sounds of the heart were heard with nothing unnatural about them. Hence the idea of peri- carditis was excluded. On percussion low down on back of chest, the sound was, in a small degree, less clear at left than on the other side. The respiratory murmur here was less full and good than on the other corresponding parts ; still there was nothing distinctly morbid about it. There was no resonance of the voice, no oegophony; hence, according to physical signs, there was no pleurisy. On further examination over the upper part of the left cavity of the thorax, we found a solution of our difficulty. The upper lobe of the left lung ap- 309 peared to be in an inflamed state ; for, both behind, near the spine of scapula, and top of shoulder, and in front from below clavicle, there was much less sonoriety over left part of chest than over the right. Crepitous rale when the patient coughed, and bronchophony were heard under clavicle. Bronchopho- ny at top of shoulder behind. Here there was pneumonia, if any trust could be held in the results of our examination. Repeated examinations only tended to confirm the diagnosis, by showing an increase of all the signs. Still, during the whole period that the patient lived, (nine days,) there was but once any expectoration at all. Once during examination, the exertion of sitting up in bed caused severer cough than usual, and two minute portions of rusty expectoration were spit upon his handkerchief. At the post mortem examination, we found the upper part of both lungs hepatized, and in some parts the affection was pass- ing into the purulent stage. It may be asked why, if ausculta- tion and percussion told always the truth, the inflamed state of the right lung was not discovered. Simply, because after the first day the part was very slightly, if at all, examined; inasmuch as previously, great disease was discovered in the left. There was carelessness on our part, but no argument can be brought against auscultation, from such a result. We are too apt to satisfy ourselves with the discovery, during life, of one serious affection, without constantly remembering that another, either similar or different, very commonly ensues to complicate the original affection. Having thus examined the different diseases, let us touch upon a few symptoms, which seem worthy of notice. 1st. Voice. It is mentioned (10th) as rough and hoarse, and the throat at the same time is dry. Again, on the after- noon of 19th we find it muffled or " veiled" (voilee.) 310 Query ;— If this alteration of the voice be not dependent upon the affection of the velum palati, and upper part oS pharynx, which caused a Salse membrane to be Sormed there ? 2d. Auscultatory phenomena. At the afternoon visit, Jan. 11th, the respiration was bronchial on expiration, high up on left part of back. The existence of tubercles would seem sufficient to explain this expiratory sound. The auscultatory phenomena offered by the right lung are interesting, for there are two points, viz. 1, their accord- ance with the symptoms and autopsy. For example, the crepitous rale appeared first on the back, and gradually extend- ed to the front. 2. We find in the last report, that the crepi- tous rale was heard at the first part of the examination, but it disappeared afterwards. It is important to know this. A crepitation is also at times not heard when the patient breathes calmly, or even when he draws a full inspiration. Then we must make the patient cough ; and no one has a right to say that crepitous rale cannot be heard in a certain portion of lung, until he has made his patient do so, without exciting it. In order to decide accurately, the examiner must have his ear always, during the act oS coughing, placed upon the stethe- scope, or what is better, upon the chest itself. 4th. On 21st is reported, tremor oS hand when it is placed on the right breast, none on left. The reporter meant not to say there was no tremor at left, but merely that there was much more of it at right than at the left. There is a tremor felt over every man's chest when he speaks, and this varies according to the state of the lungs or pleura. In this case, the hepatized lung was the cause. This tremor is often very marked under the clavicles of tuberculous patients, and at times, marks as clearly the apex that is most diseased, as auscultation and percussion do. 311 5th. At the autopsy, a partial pericarditis was discovered, which was latent during life. Only one symptom seems to have reference to this affection, viz. the extraordinary rapidi- ity, and the irregularity of the pulse. 6th. The false membrane lining the bronchia is very curi- ous, and has lately been pointed out as very common in pneu- monia. We are unable to see it, in consequence of being ac- customed to open the lungs by making long incisions through the hepatized portion, instead of following the course of the bronchia, and thus exposing all the tissues without injuring any of them. 7th. The inflammation of the caecum and colon, as marked by redness, and shortness of the strips raised, correspond well with the symptoms to be referred to the alimentary canal; for, before the patient began to take antimony, the dejections were frequent. CASE XVIII. PNEUMONITIS. Hospital la Pitie. Ward St. Paul, 13. Under the care of M. Louis. Jan. 9, 1833. — L. M., journeyman baker, aet. 66. This man knows nothing about the health of his parents, except that they were never palsied. He himself has been well nour- ished, has been accustomed to drink freely, and is of a strong constitution ; though he has been subject to cough, without dyspnoea, for twenty or thirty years. He has generally had good digestion and appetite ; bowels regular; not subject to diarrhoea; never any venereal disease. Five years ago, he was in this ward, with a disease resembling the present; fever, cough, without bloody sputa, and pain in left side of thorax; re- 312 mained in hospital five weeks, during which time had venesec- tion performed, eighty leeches applied to chest, blisters to legs, &c. This was in April. Last year, about this time, was at la Charite four weeks, with same symptoms and pain in right side, to which was applied a blister, without any other treatment. Left there on January 16th, and since then has been strong and fat as ever. Thinks both attacks more severe than present one. Present disease began on 5th, though patient had had six days before this, coryza, with dizziness, but without headache; also diminished appetite, increase of his accustomed cough, with some oppression, and some chills and thirst. On 5th, worked during day; and in night, after an hour's sleep, having gone to bed fatigued and somewhat intoxicated, he awoke, and immediately had severe chill, increase of cough, and great fee- bleness, and had very little more sleep during remainder of the night. In the morning dyspnoea was much increased, and he has kept bed since ; has had much thirst; deglutition easy; no pain in throat; anorexy; little pain in abdomen first days of attack, none since; no diarrhoea ; one dejection daily ; urine has been very abundant, red and burning; has never had pain in chest at any time since attack; never bloody spu- ta ; no headache, but bad dreams and troubled sleep ; has had much pain in limbs ; has had much heat, without sweat; has been growing always worse and worse until now; has not used any remedy, except simple infusions ; has not been bled. Now, tongue has a thick, brownish-white coat, moist; ab- domen of natural form, without meteorism ; a few whitish sputa in spit cup; pulse 108, small, regular; respiration 28, not very high ; little sleep in night, no sweat; sub-crepitous rale in right back at lower half, becoming larger toward the base; no crepitation in front, and percussion there good. 313 (Syrup oS violet flowers with oxymel. Gum potion. Ve- nesection to § xv. Aromatic potion, with grs. vi ant. tart. conditionally, i. e. if much worse at night.) One, p. m. — Has been bled § viii, or x ; thinks respiration easier since venesection ; resp. 26 ; auscultation as this morn- ing. Left chest, behind, evidently smaller than right; less prominent. Color of his face more yellow, than natural; decidedly more so than that of patients about him. Five, p. m. — p. 104, small; respiration as before; has been again bled to § x. Jan. 10. — Buff on the blood first drawn not so thick as that on the second ; this latter is three lines thick, opake, yellow, not cupped. Feels Seebler; Sace flushed ; heat moderate ; tremor oS muscles oS Sace and lips, without sensation oS cold; motion oS alae nasi; pains in ears, tinnitus aurium ; no head- ache ; tongue moist, white; thirst; throat and abdomen as beSore; two dejections; pulse Suller than yesterday, but not than natural, 108, not hard, nor very Seeble ; resp. 28, rather high ; pain at right side on cough, none at leSt; dyspnoea not great; sputa somewhat viscid, none rusty, some grayish, semi- transparent, others yellow and opake. On percussion oS upper halS oS right back, decidedly less sonorous than left in corres- ponding part; crepitous rale in every part of right back, fine, mixed with great bubbles above. Crepitous rale very fine at left, in its two upper thirds. No bronchial respiration any- where ; no evident resonance of voice at right back. In front, respiration is pure two inches from right clavicle, but below there is some crackling, rather fine. At left, in corresponding part, is mucous rale. (Antimony not taken yesterday. Take antimony. Fif- teen leeches to right side.) 40 314 Half past three, p.m.—Asleep; resp. 30; Sace pale; more yellow than yesterday ; more emaciated; countenance pinched ; p. 108; is disposed to sleep, even when one is by him; and when asleep, cheeks are protruded at each expira- tion, (as in smoking,) especially left. Jan. 11. — Some good sleep this morning ; six dejections ; pulse as yesterday, except Seeble ; sputa are like a solution oS glue, viscid, Srothy, somewhat opake ; he feels lighter than yesterday. On percussion, very sonorous in front; in both breasts respiration pure. Behind, at left, respiration and per- cussion good everywhere ; at right, on percussion, obscure sound in two lower thirds ; respiration obscure at middle, and there it is mixed with crepitous and sub-crepitous rale; sub- crepitous rale below. (Add syrup of white poppies § i to gum potion. Other- wise same prescription.) Three, p. m. — No difference from usual afternoon reports. Jan. 12. — Head a little elevated ; p. 112, regular; resp. 28; tongue moist, yellowish at centre ; sputa white, frothy, not viscid, nor rusty. On percussion at lower third of back, right side, obscure sound ; respiration scarcely heard there, but some crepitous rale, larger and less continuous than yes- terday ; slight resonance of voice at same part. On upper half, large crackling, almost gargouillement; only a little vi- bratory rale at left; no resonance of voice ; anteriorly, percus- sion and respiration everywhere good. (Grs. x antimony. One and a half cups beef tea.) Three, p. m. — Asleep ; resp. 28, on back; cheeks often protruded during respiration, (twelve times per minute); hiccough, with great elevation of abdominal parietes; alae nasi dilated, though not greatly ; countenance much altered since entrance ; emaciation ; cheeks sunken, pinched ; little mucous 315 secretion about eyes, which during sleep he opens occasionally for a moment; deeper yellow color oS skin ; mind not clear ; apparently wandering ; moves with ease Srom back to right side, and remains asleep ; hiccoughing while in this latter position. From this time until the 17th, the morning on which his death was reported, his organs and Sunctions were as follows: On the night oS his death he had some delirium, but other- wise the brain was not remarkably affected; but, as before, he was inclined to sleep, even during visit, and made no com- plaints. The alimentary canal had no unusual symptoms ; the tongue was moist and white on 14th; never any vomiting; generally two dejections a day. The respiration varied be- tween 24 and 30; hiccough, puffing of cheeks occasionally until death; the expectoration was of a mucous character, mingled with saliva, towards end of life becoming greenish, opake, never viscid, generally rather abundant. Auscultation and percussion in front gave always good results, though res- piration in left breast was louder than in right; behind, on the left, the percussion was always clear throughout, and respiration was heard, louder than in right, and pure, save on 15th, when sub-crepitous rale was heard in lower half. On 13th, percus- sion at upper half of right back was completely flat, and flatter than previously in lower part. Respiration was very bronchial, and broncophony existed in upper half; below, it was very obscure and mixed with sub-crepitous rale. On 14th, same, generally, except that broncophony and bronchial respiration were not so extensive in morning, but in p. m. more so than on the day before. This continued until death, with the addition of sub-crepitous rale heard over whole of right back, even gargouillement at upper part on 16th. The pulse varied from 104 to 120, but generally it was about 108 to 316 112. On 16th, p. m. its character was as at previous reports. Skin on 15th and 16th was said to be natural, without heat; face was flushed at times ; his strength on 13th and 14th was quite good ; could rise in bed. The treatment was continued—on 13th, eight grs. anti- mony; on 14th, ten grs.; 15th and 16th, six grs.; on 13th, a blister was applied to right side of chest; on 15th, a weak infusion oS polygala was ordered, and he was allowed an egg in addition to his beeStea. On 17th, he died during morning visit. Autopsy, Jan. 19, at ten, a. m. Externally. — Emaciation moderate ; Sour lines of Sat over chest; muscles well; surSace of body pale, without livid spots, on front, or sides ; no oedema oS legs. Chest. — Pericardium contains only a Sew drops oS serous fluid, and surSace seems dry. Heart of middling size ; base and right edge surrounded by considerable fat; in right ventricle a small yellow coagulum ; pulmonary artery healthy ; sigmoid valves of aorta a little thickened and have yellow opake spots, most towards their base and one at free edge ; in other parts nothing remarkable. No serous fluid in either pleura. Left lung. — Adherent by cellular membrane, not very strongly, in two-thirds of its outer portion; lung large, collaps- ing slightly at anterior edge, where the vesicles are much dilated, especially for two or three inches oS its middle; less dilated at apex; same dilatation of vesicles of diaphrag- matic portion of lower lobe, though less than in the upper; this lobe heavier than upper, contains a moderate quantity of red frothy fluid, is crepitating, yields more easy to finger than healthy organ does; and offers to view many little black spots, which do not disappear under pressure. The bronchia of 317 lower lobe contain a small quantity oS whitish, opake, milky mucus; this same liquid is in the bronchia oS the upper lobes, where it is especially abundant near their division; the mucous membrane has its usual polish, and is so thin that it can hardly be perceived over cartilages. Toward the base the bronchia have two and a halS lines in diameter but are thin and trans- parent ; those going toward the anterior edge, where the vesicles are most dilated, are oS moderate size and transparent, but have no mucus. Right lung, heavy, large; adheres Srom apex to base in Sront and behind, partly by old, cellular and firm, partly by recent and soft adhesions. The vesicles are dilated near free edge of lung, though less than at left. This edge, from three to four inches from apex downward, is light, soft, crepitating and healthy, except the emphysema. Bronchia here are pale and contain the same mucus as at left. Two and a half inches of lower part oS upper lobe is hard, firm and grayish internally. It has many black spots, when cut surSace is seen, except near periphery, where it is uniSormly red; on incision there flows a little reddish fluid, not Srothy; the cut surSace is granulated, is more firm and less Sriable than hepatized lungs usually are, and the portion thus described sinks in water. Middle lobe very small and healthy. Whole oS lower lobe, red, firm, granu- lated, Sriable, does not crepitate, contains no air; its bronchiaare little larger than those oS left lung and contain similar fluid ; mucous membrane is thin and polished. Abdomen. — Peritoneum rather dry; Sat in omentum and parietes oS abdomen. Liver rather pale, ordinary size, easily penetrated by finger. Gall-bladder distended with thick, yellow bile, and con- taining many flocculi, which are easily broken down; mucous membrane normal. 318 Stomach, one third less in size than usual, contains two ounces of a light yellow, rather fluid liquid ; internal Sace gen- erally pale, but pointed with red Sor an inch about cardiac orifice and a little on anterior Sace. In two-fiSths of organ towards pylorus, especially on the part most remote Srom this opening, the mucous membrane is mamelonated; on small curvature Sor an inch in breadth it is less so; strips three or four lines in cul-de-sac, eight to ten small curvature, seven to eight great curvature; and it is no where thicker than usual, even where mamelonated. Small intestines, oS moderate size, without any redness ex- ternally ; contain in first and last third a quantity oS yellow liquid mingled with mucus; in middle third a little whitish mucus only. Mucous membrane pale, very thin, not oS usual aspect; but has numerous brilliant points, as if sanded, and does not allow of strips being raised on account of the laxity of cellular membrane beneath it. Large intestines, of moderate size; contain pretty large quantity of yellow matter, like pea-soup, becoming thick and fecal at the lower part. Internal surface pale, yellowish; mucous membrane thin; gives strips from ten to twelve lines long, except in ten first inches; no crypts discovered. Neck. — (Esophagus. The epidermis is well throughout, except in last five inches, where are numerous ulcers; some round, one to two lines in diameter; others irregular, six to seven lines in length and one to three broad; edges yellow, as are also their surfaces, and in some the muscular fibres are exposed. Pharynx; in lower two-third oSthis part are many patches oS an opake, yellowish, white color; some ulcerated, some not; some also near base oS tongue, and on sides oS epiglottis; one of these at left side is circular, covered with a little detritus, 319 which is easily removed; and around this detritus, at some points, is seen a little furrow, separating it from the surround- ing tissue, and at other points it joins or rather is continuous with the mucous membrane, which is apparently healthy, is thin and of its natural consistence; this patch is a quarter of a line thick; at the side of it, in front of the epiglottis, is an evident ulcer, which is oval, four lines in longest diameter; at the right of this last is another, irregular in shape, one inch long, two or three lines in breadth and corresponding to patch first spoken of, it has an unequal surface, and elevated edges. On the same side is another very irregularly formed patch, one inch long, somewhat destroyed in some points, entirely so in others. On left side of pharynx are several oval ulcers, of same aspect as above described, and about which the epithe- lium is thickened and opake. Epiglottis pale, but nearly of double the usual thickness; it is evidently ulcerated on its lateral edge which is more than a line thick. Lateral liga- ments a little cedematous. Two little ulcers similar to others on lower part of vocal chords. Mucus rather abundant in trachea, the sub-mucous tissue of which is a little injected. Head. — Effusion very abundant under arachnoid mem- brane ; itself not so transparent as usual, over the furrows be- tween the convolutions. On the front of right anterior lobe is a destruction of the gray substance of brain for the space of an inch and a half— half millimetre in depth. Partial destruc- tion near middle lobe to the extent of a line or two ; same ap- pearance, more rarely, over prominent portions oS several oS the convolutions, at the back part on same side. On the left, the anterior lobe only is affected, and this less so than on the right. Both ventricles contain five or six spoonSuls oS serous fluid. Septum lucidum, cerebellum, medulla oblongata all well. Substance oS brain firm, not injected. 320 Remarks by the Reporter.— 1st. The upper part oS right lung being harder than the lower, and its gray central aspect are prooSs oS its having been longer inflamed. 2d. This case is an apparent exception to the law that the oesophagus is found ulcerated in typhus Sever only ; but in ty- phus, a gangrenous affection is not, as in this case, the cause oS ulceration. 3d. When Louis wrote on typhus Sever, he had never seen a case similar to this in pneumonia. Remarks by Henry I. Bowditch, M. D. — On reviewing this interesting case, we find the Sollowing points worthy oS notice. 1st. Cough, without dyspnoea, Sor twenty or thirty years. To what was it owing ? At the autopsy, emphysema was Sound in both lungs. This affection was probably the cause of the long cough. The symptoms, or rather the want of serious symptoms, ought to have led us to this diagnosis before death. No organic affection, such as tubercles or disease oS the heart, could have lasted so long without producing greater trouble in the economy than a slight cough. 2d. The two previous attacks of thoracic disease are to be noted, Sor this reason, viz.; some pathologists say that a man who has once had pneumonia, iS attacked anew, is more likely to recover than one attacked Sor the first time; true. Now the history oS our patient, and the autopsy prove that, at Sormer periods he had suffered Srom severe pleurisy oS both sides; and Srom the symptoms as related by him, we have every reason to believe that pneumonia existed also at these times. 3d. On entrance at the hospital, there was no doubt oS the existence oS pneumonia combined with pleurisy. The 321 acute symptoms, and the physical signs proved their existence, though the expectoration had few characteristic marks. 4th. To what was the yellowness oS the skin to be attri- buted ? The autopsy does not tell us. 5th. Andral says the mucous membrane oS the bronchia, near a hepatized portion oS lung, is always inflamed. This case proves his assertion to be incorrect. In Sact the mem- brane was remarkably thin and transparent. 6th. The affection oS the pharynx and parts connected with it, I well remember, astonished us all. There was no doubt oS the ulcers having a gangrenous origin, because some of the spots were nearly separated Srom the healthy parts ad- jacent, in the same way that a gangrened part is thrown off Srom any portion oS the body. At first sight, it appeared to us that the affection was an exception to the law established by Louis in his work on typhus Sever. This law is thus ex- pressed by Louis. " Out oS seventy cases oS persons dying oS other acute diseases than Sever, I have not Sound a single example of ulceration oS this part, (pharynx). IS these Sacts be not sufficiently numerous to allow us to affirm that ulcera- tion oS the pharynx takes place only in the course oS affec- tions oS the nature oS those, concerning which we are now treating, still they render the Sact very probable, and make these ulcerations very important lesions, and, as we shall see hereafter, one of the secondary anatomical characteristics oS this disease." In the case beSore us there was no real excep- tion to the rule, because Louis, in using the term ulceration, did not mean to include gangrenous destruction oS the mucous membrane. But while upon this subject, I will allude to the exceptions to the law oS ulceration oS the small intestines, which makes 41 322 that affection peculiar to typhus Sever and phthisis. Not long since a young man who had been supercargo to the East In- dies, entered the Massachusetts General Hospital, suffering from chronic diarrhoea. He had been suffering for a long time, and while with us his only complaint was this constant diar- rhoea;— he was extremely emaciated. On the autopsy being made, extensive ulceration, with some cicatrices, were found in the small intestines, and not the least appearance of tubercle in any part of the body ; all the cavities having been opened, and the lungs in particular cut into most minute portions, for the special object of deciding the point. This man had the diarrhoea which those physicians, who reside in sea-port towns, see oSten in seamen who return Srom a sojourn in tropical cli- mates. Again, I have seen cases of small-pox, and have notes oS one of them, in which ulcers were Sound in the intestines. There were no tubercles in the lungs, which were hepatized and gangrenous ; though I conSess I did not examine the different organs, especially with reSerence to tubercles, as in the Sormer case. 7th. Ought we not to have expected an alteration oS the voice Srom the ulceration oS the vocal chords ? We all know that in phthisis continued hoarseness, sometimes complete aphony is produced by ulceration oS the larynx. Again. Is not the Sact oS the ulceration of the vocal chords being oS the same nature, as those oS the pharynx and oesoph- agus, another proof against the idea of the former ulcers being caused by antimony taken into the mouth ? Could a solution of antimony have entered the larynx without causing very great distress ? IS there were any, no note is made of it. 8th. The affection oS the convolutions oS the brain was singular. Andral describes it in his pathological anatomy. In 323 this case I cannot find any peculiar symptom which can be connected with it, though there were symptoms marking an affection oSthe brain. Lallemand, P. de Chatelet and Martinet I have consulted, without finding in their respective works upon the brain and its membranes any analogous, cases. CASE XIX. PNEUMONITIS. Hospital la Pitie. Ward St. Paul, 46. Under the care of M. Louis. May 22, 1833. — Coulomb, Sarrier, aet. 45. This man was born at St. Denis and has always been there; never a soldier; his Sather is now living, aet. 74, is well and is not subject to disease oS chest, has not had asthma nor palsy. Mother died aged 66, after a sickness oS a month ; asthmatic Srom age of 36, but never palsied; one sister, well, aet. 49, never asthmatic. His breath was not short in inSancy; could run as well as his companions; never epistaxis; had chancre and bubo at 18, during fifty days; once a slight gonorrhea; married at 21; had six sons; two dead, one at 4 years, the other at 6 months. He has never had any acute disease, except at the age of 23, when he had a partial palsy of all his limbs preventing work during six weeks; but the account he gives of this affec- tion is very indefinite ; no acute disease since; no cholera; is very subject to catarrh, and it lasts only two or three days; never haemoptysis; has been well this winter; has been accus- tomed to intoxication from wine at least once a week; eyes brown; hair dark brown; strong large limbs; generally rather pale than red; is five feet four inches high. Present disease. During five or six days previous to 18th, 324 had less appetite than usual, and had a little cough; no local or other general symptoms; no chills, heat nor thirst, no vom- iting nor diarrhoea. On 18th, appetite entirely gone; 19th, cough more marked with a little expectoration; worked with sufficient strength this day, and w7as somewhat intoxicated, and while in this state received a blow in left breast, which he has felt since. On 20th, cough, and expectoration of a reddish- yellow color, with great thirst; pain along trachea; no difficulty of deglutition, nor nausea, nor vomiting; no pain in abdomen, nor diarrhoea; but has had much oppression and pain in both sides of chest about mammae, most at left; headache, heat with sweats, no chill, no palpitation. Since 20th has kept bed, has had little sleep since ; cough and oppression at chest have in- creased ; headache not violent except under severe cough; urine red and burning since 20th; has taken no food and under- gone no treatment; has had a kind of numbness of limbs for three past days; went in carriage to " Bureau Central," and walked here Srom that place in halS an hour (about a mile.) Now, countenance pale, Satigued, anxious; head elevated; memory and intelligence good ; a little dilatation oS alae nasi; tongue white, moist, thick, not painful; no pain in throat; deglutition easy; thirst, no appetite ; no pain in abdomen, which is soSt, well formed, without meteorism and without pain under pressure; one dejection to-day, black, not liquid ; voice (to reporter) seems a little hoarse, though patient says it is not so; pain quite severe about left mamma, less about right; cough frequent, increasing pain in side; sputa mostly liquid and of a dirty reddish color; scanty, with some frothy saliva, having a very unpleasant, though not exactly a gangrenous odour; after long examination, one sputum yellow, semi-trans- parent, viscid, containing air. P. 108, full, hard ; when lying, drowsy; respiration under similar circumstances 36, abdominal; 325 skin hot; urine as before. On percussion, not very sonorous anywhere; perhaps rather more so under right than left clavicle ; an expiration is heard under both, but it is longer and resonance of voice is louder under right than left; but generally, in front, vesicular expansion is good and full throughout. In upper third, or half of left back and around to side are bronchial respiration and bronchophony; the former heard both in inspi- ration and expiration. Elsewhere, behind, respiration is very obscure, except at right summit. At left, where there is bron- chial respiration, a crepitous rale is also heard at times; and a sub-crepitous rale is heard in lower half of both ; but ausculta- tion not satisfactory from inability of patient to breathe properly. Impulse of heart moderate; its sound not heard under right clavicle. May 23. — No treatment as yet; sleep pretty good last night, no delirium. Tongue, expectoration, respiration, and pulse as yesterday; pain at left side less; breath not fetid; some headache, without dizziness, this morning; two very small liquid yellow dejections, without pain. Bronchial respiration has extended around side and to mamma in Sront; not very marked above mamma, except perhaps Sor halS an inch. Behind, at left, more crepitation and more distinct than last evening; none at all at right. (Syrup of Violet flowTers. Venesection to § xv. Gum potion. Sprinkling of solution oS chloride oS lime.) Four, p. m.— p. 104 ; resp. 42 ; blood flowed well and is now in a large clot, with a buff upon it halS line in thickness, firm. Since bleeding pain relieved, but Seels Seeble ; nausea after drinking; auscultation as this morning, except that there is no rale ; he perceives no odour in his sputa; other symptoms the same as before. 326 May 24. — (Venesection again. Prescription the same.) Three, p. m. — p. 116; resp. 32, with very slight motion of chest, much of abdomen ; skin quite warm, moist, sweat in drops on face; was bled this morning g xv, and feels as yes- terday,— relieved but feebler since ; blood buffed, not cupped; clot as large as the vessel containing it, firm and with very little serum in it; has felt a little dizzy since bleeding; tongue as before; a little pain in swallowing; no dejection ; much urine; little pain on pressing abdomen; pain still in chest, slight, about left mamma; cough often, not increasing pain; two sputa, white, frothy with yellow tint; restlessness ; bron- chial respiration distinct in left breast. In left back crepitation most marked at middle. Some crackling at right back occa- sionally. The patient died at three, a. m., of the 27th, and the following is the state of his symptoms as they appeared on the mornings of 25th and 26th. At the visits his mind was always clear, though he was inclined to fall asleep ; this latter inclination in- creased so as to be very great the day before death ; delirium on night of 25th and 26th; was changing his position continu- ally ; the tongue changed Srom yellow to brown and was cover- ed with a thick, gluey coat; as were also the teeth on 26th ; thirst as beSore; green matter vomited on 26th ; diarrhoea on both days; three dejections on 25th ; five on 26th beSore morning visit, with relieS to pectoral symptoms; urine as beSore. The pulse was always at 124, and respiration at 44 ; skin hot, sweat about head; cough always great; expectoration always had a peculiar odour, though not gangrenous; it was a little Srothy, floated on water; the strength remained pretty good, could get out oS bed to go to stool on both days. Auscultation and percussion gave the same general results as previously. The 327 treatment is not mentioned save on 26th, when venesection to § vi, and grs. v, oS ant. tart, were ordered. On 27th, at three, a. m., having passed the previous day tranquilly, he arose Srom his bed in delirium, and threw him- selS upon one adjacent to him, and soon after expired. Autopsy, May 27th, nine, a. m. Exterior.— Pale ; no oedema. Abdomen. — Stomach, three times as large as usual; con- tains a little clear, watery fluid ; its internal surSace is oS a grayish-white, generally, except in a Sew spots, where it is a little red ; a little emphysema under coats; mamelonated ap- pearance Sor the space oS three inches in diameter on anterior Sace ; strips everywhere oS natural thickness, except, perhaps, where it is mamelonated; there, perhaps, a little thicker than natural. Small intestines, oS a good volume, contain a little light- yellow liquid ; pale through almost whole oSits extent; but in some rare spots slight sub-mucous injection; everywhere membrane is thin, and gives strips oS three to Sour lines above, six below ; Brunner's glands Sew, below, natural; mesenteric glands small, oS natural pink hue. Large intestines, oS small size ; contain a yellow liquid ; mucous membrane pale, thin; giving strips Srom twelve to fifteen lines long. Liver, large, especially in its great lobe; of a pale-yellow color; of natural consistence ; the two substances very dis- tinct, and in equal proportions ; not much granulated ; contains little blood. Gall-bladder small, containing dark, greenish, not very viscid bile. Spleen, natural color; moderate size; texture rather soft. Kidneys. — External membrane easily detached ; thin and natural; surface of organ polished and natural; cortical sub- 328 stance composed of two colors, running in lines from the sur- face to the centre, one red, the other slightly yellowish-white, alternating with each other; in central parts, the substance is likewise marked by the same colors, but in dots ; both kidneys large. Bladder, moderate size; mucous ~ubstance a little injected ; strips from twelve to sixteen lines long. Chest.—Left lung adherent at upper part, posteriorly and laterally, by a membrane that is very thin and recent. The lung itself is heavy ; its upper lobe is in the third stage of inflammation, throughout its whole extent, except three or Sour inches space from anterior edge, along front oSlung. Behind, this lobe is yellow, softened, granulated ; contains no air, but much pus; some three or four lobules are not so far advanced, but have a red hue. Lower lobe partly like upper; yellow ; greater portion of it in first, or second stage of inflammation ; bronchia everywhere in upper lobe filled with pus ; they are thin, pale and smooth ; in lower lobe bronchia filled with pus; but this lobe has less fluid than the upper. No portion oS lungs has gangrenous odour or aspect. Right lung, partially adherent; upper part of upper lobe is between first and second stage oS inflammation; lower part is yellow, but less advanced in suppuration than the other lung in same part. The lower lobe, as is the greater part oSthis lung, is much lighter than the other, crepitates, and contains a quan- tity oSred, Srothy fluid. Bronchia same as in the other lung. Pericardium contains four or five ounces clear serous fluid. Heart natural in color and consistence. Neck. — Larynx and trachea somewhat red ; strips Srom sixteen to eighteen lines long. Epiglottis looks as iS mamel- onated ; little elevations, without orifices. Head. — Pia mater moderately injected, easily detached from brain, effusion under it very slight; gray substance of 329 brain has three lines oS thickness ; in some parts distinguished with difficulty ; medullary substance moderately injected, with points oS a lilac color after exposure ; oSgood firmness; as are also the remainder oS central parts. Ventricles contain scarce a drop oS liquid. Medulla oblongata, annular protuberance, oS good color and consistence. By the Editor. — This case is less accurately reported than some oS the others ; but there will be Sound a general accord- ance between the physical signs and the state oS the lungs, as ascertained aSter death. The blow, which the patient re- ceived on the 19th, does not seem to have had any important effect on the disease. The disease had evidently begun be- Sore that. The left lung was more diseased than the right, and the blow was on the left breast. But the disease was worse on the posterior, than on the anterior part of the lung, and the blow was on the front. CASE XX. PNEUMONITIS. Hospital la Pitie. Ward St. Paul, 8. Under the care of M. Louis. April 3, 1833. — N. P., a mason, aet. 23 ; fair complexion ; hair clear brown ; eyes gray; rather large than small frame ; not much flesh. Born at Oulon,in Department of laCreuse ; has been in Paris only since the 31st March. From infancy has been subject to epistaxis several times every year. At the age of 10 he had a tertian intermittent fever, which lasted a year, and has never had any grave disease since ; not been sub- 42 330 ject to colds. The 1st of March, i. e. four weeks before quitting his part of the country, he took cold, had cough and expec- toration without any pain in side, dyspnoea, diminution of ap- petite, or emaciation. The 26th March he quited Oulon for Paris, and went a hundred leagues on Soot; and at his depar- ture his health was entirely good, except that he had the cough above-mentioned; his appetite and strength were as usual. On the 27th, he Selt a slight pain in left side of chest, accompanied by oppression, and then the appetite began to diminish ; the 28th, pain in side and oppression increased ; then the anorexy was complete, and he had great thirst. On lying down in the evening there occurred chills, followed by heat, with pain in head and loins ; cough had diminished since pain in side occurred. All these symptoms continued during the following day, and on 29th, the sputa were yellowish and reddish in color. The pain in side and dyspnoea increased progressively until the 1st of April; after that day pain was gone, but oppression remained. On the 28th and three fol- lowing days, he bled from nose twice, daily. From the be- ginning he has never had sore throat, nausea, vomiting, pain in abdomen, nor diarrhoea ; no dejection Sor three days. Urine red and burning Srom the 29th. On the 27th and 28th he walked Sourteen leagues a day ; on 29th, ten leagues only ; on 30th, after walking three in the morning, he took the diligence and arrived at Paris on the morning of the 31st. From that time his weakness has in- creased, and he has kept the bed; and to-day he was brought upon a litter to the hospital, being unable to walk ; emacia- tion from 27th, and from this time, having no appetite, he has hardly eaten anything; but during the four days' journey he had much thirst, and drank much water, and nearly two bot- tles, or a bottle and a halS oS wine daily ; a halS bottle at each 331 repast; his companions being wont to eat three or Sour times a day. Has undergone no treatment. Now, Sour, p.m., April 3d. — Face slightly flushed; ex- pression natural, intelligence sufficient, although slow ; mem- ory good; dilatation oS alae nasi at each inspiration ; a little blood adhering about nose ; herpetic eruption about upper lip, which he says has existed six days ; lips a little dry, tongue a little redder than lips, a little dry, and with a white coat; no soreness oS throat; thirst; deglutition easy; no appetite; no nausea; no dejection Sor three days; abdomen well Sormed, rather Sull than otherwise, not very sonorous, without pain, except in right iliac region, where it is a little sensible to pres- sure ; it is supple, except in leSt hypochondrium, where Sor some space is Selt a tumor, whose edge is two inches below the cartilages oS ribs ; it has the Sorm oS the spleen enlarged ; there are neither spots on body, nor gurgling in bowels. Cough rare, not once during hour past; expectoration nothing since entrance ; oppression; respiration abdominal, and 32 per min- ute. On percussion, very obscure sound behind at leSt; in the middle three fifths are heard bronchial respiration, and bronchophony, and, from time to time, a crepitous and sub-crepi- tous rale : decubitus upon the back most of the time, but easier at right than left. Headache ; no dizziness ; no buzzing in ears, although he has had some within two or three days. Urine red and burning. Pulse 112, regular, a little hard ; skin warm, dry ; sweat proSuse yesterday, so as to require the change oS shirt; this Sor the first time. April 4th. —Being interrogated by M. Louis, he gives the same answers as to me yesterday, in relation to his health previous to the Sour weeks of cough, and declares still, the ab- sence oS all local symptoms during that time. Little sleep during night, pulse less Srequent than last evening. M. Louis 332 having decided upon the existence oS pneumonia, with only slight Sebrile symptoms, ordered venesection conditionally in evening, and the Sollowing prescription. (Syrup oS violet flowers mixed with gum syrup. Gum po- tion. Burgundy pitch plaster upon left side.) Four, p. m. — Venesection not perSormed; tongue, thirst, anorexy, abdomen, as yesterday; no dejection; cough as be- beSore ; expectoration small in quantity, yellowish, or reddish, with very little air in it; resp. 32 ; percussion less sonorous at leSt than at right, in Sront. Behind, at left, bronchial respi- ration less marked and less in extent, although still marked at lower angle of scapula, where it is unequivocal, and accom- panied by a very distinct bronchophony ; crepitous and sub- crepitous rale more numerous in two lower thirds, and extend laterally, and even in front to mamma. P. 84; skin warm, face covered with sweat; headache. (Same prescription. Strict diet.) April 5, five, p. m. —Sweat last night so as to wet two shirts. P. 60, resp. 24 ; no dilatation of alae nasi; less thirst and oppression ; appetite begins to return; skin less hot; no headache ; tongue cleaner ; bronchial respiration at left in spot mentioned yesterday, and is mixed with crepitation ; the bron- chophony is also less marked. April 6. — Progressive improvement in general and local symptoms ; no sweat in night; appetite increased. Pulse as yesterday; resp. 20. Vesicular expansion begins to be heard at left behind, mingled with a rale which becomes more moist; expectoration nearly two ounces in last twenty-four hours, like gruel, with some sputa, yellowish and opake. (Three cups beef tea.) April 7. — Same state. In the evening, while examining the right side of chest with more attention than before, I find 333 that the right post-clavicular region is a little more depressed than the left, and is a little less sonorous. Below right clavi- cle the vesicular expansion is not so perfect, and there is an expiration evidently more prolonged than below the left ; it has also a little of the character of bronchial respiration ; a slight resonance of the voice at the summit of right shoul- der behind, and there inspiration coarse, expiration bronchial and lengthened ; bronchophony much more marked at this summit than at left. No rale in front nor on back. The days following until the 12th, when he left the hos- pital, the convalescence continued to go on ; his appetite and strength increased ; on 8th, he took soup, and afterwards bread; he walked in the garden on the 10th. Pulse on 9th, at evening, 90; no longer sweats at night; always a little sub- crepitous rale at lower angle of left scapula ; cough continued, though less; phenomena of auscultation, already indicated as existing at summit of right lung, were observed several times by myself and others, and remained always the same. He went out convalescent 12th, contrary to the advice of M. Louis, and before he had fully recovered his strength. Remarks by the Reporter. — This case appears to me to be interesting under many points of view. 1st. We see an acute pneumonia which lasted fifteen days, and cured itself, without any treatment; and this cure was ac- complished in spite of two circumstances, which we are wont to consider very hurtful in acute diseases, viz; violent and long continued physical exercise; and the use of alcoholic liquors, during the first four days. Our patient walked ten to fourteen leagues a day, during three days, and three leagues the fourth ; and during this time, he drank nearly two bottles of wine a day; the general and local symptoms being from 334 the first so well marked, as to leave no doubt as to the nature of the disease at this early period. Now there are two points to be noticed, viz. his remarkable preservation of strength, not- withstanding he was affected with so grave a malady ; and the small effect, which exercise and stimulating drinks appear to have had upon the march and termination of the disease. 2d. There is another point of view, under which this pa- tient is still more interesting, viz. he seems to be tuberculous. This circumstance should be particularly noted ; and in order to render it still more worthy of examination, I will give rapid sketches of two other similar cases, of which I have detailed accounts, and in this way we may see the march of pneumo- nia, as sometimes exhibited in tuberculous cases. I shall give details only sufficient to prove that these patients were phthisical, and that they had pneumonia, terminated by recovery. Observation II. — A day-laborer, aet. 49, entered la Pitie, Dec. 3d, 1832, saying he had been sick eight days. Cough, oppression, obscurity of sound on percussion, behind, at left in lower half oS the chest, where is heard a fine crepitous rattle; no expectoration ; no Sever; was bled, and rales became less numerous and smaller. Our patient, after some time, becomes convalescent, but remains in hospital and begins to eat. But on Jan. 15th, he is again seized with pneumonia, and this was more severe than the other. My attention was thus again led to him ; he had previously, for two or three weeks, been eating three quarters of a large loaf of bread a day. But to recommence his history. It appears that in the month of Jan., 1832, the patient had begun to cough without ex- pectoration, and at the same time his appetite diminished, as well as his strength and flesh. These symptoms continued to 335 increase, without hoemoptysis, or pain in chest, or sensible dyspnoea, until the month of August. At this period he entered la Pitie, in the wards of M. Piorry, with headache, vomiting and diarrhoea, without cramps ; having also, pain in right side, increase of cough, and much oppression. After having re- mained under care of M. Piorry nearly two months, he left, having been able to eat three quarters of a loaf, for some time previous. Some weeks after this period, he entered the wards of M. Louis, and was in the state described, at the beginning of the observation ; and after twenty days of convalescence, during which the cough was always more or less troublesome, and the breath always embarrassed, he was taken again with symptoms, such as I shall now indicate. On the evening of the 13th January, chill followed by heat, thirst, anorexia, acceleration of the pulse, pain in right side of chest, increase of cough and of dyspnoea. Was bled that evening, and again on the following morning, and after the latter he felt a little relieved. On 16th, expec- toration in part white, frothy ; partly the color of barley-candy, more viscid, and semi-transparent. It preserved this appear- ance until 19th, after which it was always opake, yellowish, and not abundant. On auscultation crepitous rale fine, abundant through whole of right breast; which was soon followed by bron- chial respiration, especially in expiration, and by bronchophony, well marked through the space of four inches below the right cla- vicle, and a prolonged expiration under the mamma and in lateral region on the same side. On the back, same side, same phe- nomena less marked, and less extensive. At left, was heard always a sub-crepitous rale behind. Pulse from 15th to 18th, was 120 ; from 18th to 28th, from 106 to 96; the first of Feb. 72, and it did not rise afterwards beyond 84, even in the evening. 336 The respiration was in the beginning very much troubled, and accelerated ; 36, the first three days ; afterward 30, and finally 24, and even 20. Heat oS skin very great at first, diminished aSterwards. The patient recovered his strength very slowly, and in March quitted the hospital, having been able to eat three quarters oS a loaf of bread per day, during two or three weeks. The cough and dyspnoea continued always, and, when he left, the chest was in the following state. At right, below the clavicle, and at summit behind of the same side, there was a bronchial inspiration and expira- tion, with bronchophony, well marked. At left in correspond- ing parts, were the same phenomena, only much less marked. The crepitous rale had disappeared from the Sront, save in the lower quarter oS right side; but there was an expiration some- what prolonged through the whole right breast; the same was heard only below the clavicle at the leSt. Behind were sub- crepitous and crepitous rales on both sides. Here are, I think, the prooSs oS a very severe and extensive pneumonia, Sollowed by a cure, in a tuberculous patient. Observation III. — A house-keeper, aet. 68, entered la Pitie, April 7,1833. She told us that during a year previous she had been emaciating, but this emaciation had not been accompanied by cough, nor hoemoptysis, nor expectoration, nor by chills, nor heat, nor diminution oS appetite; but Sor three or Sour months she had suffered Srom dyspnoea and pains between the shoulders, without pain in sides of chest. On 29th and 30th oS March, she experienced a general uneasiness, with a slight loss oS ap- petite, without pain, or any local symptom. On evening oS 31st, pain in leSt side, cough, without expectoration, oppres- sion at chest, heat, pain in head and limbs, thirst and .complete anorexy. These symptoms increased, notwithstanding a small 337 bleeding, and the application oS fiSteen leeches on the 6th, and she entered the hospital in a very weak state on 7th. On the Sollowing morning she was as Sollows. Appearance oS great Seebleness; voice broken; very marked oppression at chest; tongue not moist, color oS coffee ; complete anorexy ; very intense thirst; one or two liquid dejections daily, without pain ; cough without expectoration; pain in left side; resp. 36. Right post-clavicular region more depressed than leSt; left side of chest in front appears more prominent than the other. On percussion, the left breast very flat throughout its whole extent; as is also the left post-clavicular region. At right this region is less flat, although it is not very sonorous. Left axilla entirely flat. Below left clavicle, the vesicular ex- pansion, or proper murmur of respiration, is almost nothing, and the expiratory sound is prolonged and nearly bronchial; and a little lower both inspiration and expiration are evidently bronchial; and through the whole of this breast is heard a crepitous rale, not very copious, and only after coughing at upper part; but without cough, and more copious at the lower part. Bronchophony, most marked, is heard a little below left mamma. In axilla of this side no vesicular expansion is heard, and expiration is very bronchial, with bronchophony, almost pectoriloquy. At the left summit, behind, are the same phe- nomena, with a little crepitous rale after cough. Below, on left back, respiration vesicular and good. In the right breast, towards top, for the space of two inches, expansion evidently less strong and less perfect than below; and at the same place, the expiratory sound is loud and prolonged, and a little reso- nance of the voice is heard there. At the right summit, be- hind, expansion very imperfect, expiration prolonged and bronchial; strong resonance of voice; impulse of heart moderately strong, heard below right clavicle, and also, very 43 338 strong in left axilla. P. 96 ; sometimes intermittent. She took antimony from four to six grs. daily during eight days. April 9. — P. at 72, and it always, with very few exceptions, remained the same, until the patient left the hospital. Resp. on 9th, was 27, then 24, afterward 20 ; the oppression and heat of skin diminished gradually ; pain in side remained until 13th, and then ceased ; cough diminished. Even after all the ra- tional, local symptoms, had much diminished, andlhe Sever had abated ; and the patient had begun to recover strength and ap- petite, the phenomena of auscultation remained the same very nearly ; the percussion, however, becoming less flat anteriorly at left; and bronchial respiration mingled with a crepitation much more abundant than beSore. This amelioration oS the physical signs, on this side, gradually progressed, although slowly, while auscultation and percussion always gave the same results at right summit, as they did the first day. The patient went down into the garden on 22d, and the succeed- ing days; and on 25th, having Sor three or four days previous taken only the eighth oS a loaf, she went out convalescent, although by no means entirely cured oS the pneumonia, which brought her to the hospital. We have just read three cases of pneumonia, all oS which have pursued their wonted courses, and have been cured, and every one was tuberculous. Such cases are not rare. MM. Louis and Andral have already, in their respective works, in- dicated that pneumonia is cured easily in phthisical patients. But they have given no examples oS it, and, consequently, we do not know in detail, what are the special characters, iS there be such, oS these cases. M. Andral has, it is true, given two observations oSpneumonia in tubercular patients; but they differ much Srom ours : 1st, in that the disease was already Sar ad- vanced ; 2d, that the pneumonia is not described as having 339 passed through all its usual periods ; 3d, it was Satal in both. It is precisely the contrary oS the above, that makes these three cases peculiarly interesting. Let us observe some oS the circumstances, which appear to connect themselves with pneumonia, occurring in patients oS this kind; or, at least, those which seem common to our patients. 1st. Seat oS the inflammation. In all three, the upper lobe was chiefly affected. In addition to this we find in the two last, the auscultatory phenomena were more marked, and in one (III.) they were Sound almost exclusively, in the anterior part oS the lung. It was then at the anterior and superior part oS the lung that pneumonia existed; which is rarely the case in common pneumonia, in which the physical signs are most marked at the base and posterior portion oS organs. And not only were the parts, mentioned above, the principal seat oS in- flammation during its acute stage ; but after the convalescence, when the auscultatory signs had disappeared or greatly dimin- ished in other parts, it was at the summit, in all three cases, that the marks of disease still remained; so that when the patients went out from the hospital, there was in each case a respiration more or less bronchial, and a bronchophony more or less marked in the upper part of the chest. So that here we find the phy- sical signs differing from those commonly observed in subjects, otherwise sound, who have been affected with pneumonia; for in them the physical signs, which so often remain for a long time, after convalescence has been manifested in other respects, are foun d at the lower part of the back, instead of the regions about the clavicles and above the scapula. 2d. Physical signs. There seems not to be any difference as to those signs, in cases of pneumonia occurring in a healthy subject and those occurring in tuberculous patients, during the course oS the disease. But at its termination, when con- valescence is well established, there is one distinction which 340 appears to me worthy of being remarked upon. In conva- lescence Srom pneumonia, in a healthy man, we hear the crep- itous and sub-crepitous rale, but the bronchial respiration and bronchophony disappear soon, and vesicular expansion comes on. In the tuberculous it is precisely these bronchial charac- ters, which remain in a space more or less marked; and it was these that still existed at the time, when two of our patients (II, III.) left the hospital. 3d. There is another distinction to be made, which is not uninteresting by any means, between the physical signs of hepatization of the summit of one lung, and the same signs at the summit of the other, where we presume tubercles to exist, without pneumonia. It is especially in the first and third of our observations, that these signs can be distinguished the most easily. First, some of these signs were the same at the summit oS both lungs; Sor we have stated that the vesicular expansion was imperfect, or, absolutely nothing; that the expiratory sound was bronchial or prolonged ; and that the voice resounded more or less to the ear. But, secondly, at the summit affected with pneumonia, there was another sign which did not exist at the tuberculous apex. This sign was the crepitous rale, which either existed at the entrance oS the patient, or after convalescence began. Thirdly, and this is of the highest importance, while the physical signs varied in the part affected with pneumonia, during Sour or five days, those observed in the other lung remained always the same. But setting aside these distinctions, I wish to draw your atten- tion to the signs which existed in both sides, and especially at one oS them, to wit, the expiration ; which was sometimes very bronchial, at others, only what I call prolonged. And upon this point, perhaps, it will be permitted me to give the result oS what I have observed, during some time past. About fiSteen months ago, when I began to give much atten- 341 tion to auscultation, 1 perceived that very often, at an early stage of tubercles, the sound of expiration at the summit of the lungs was more or less prolonged on the side, which other physical signs showed to be most affected. Soon, this sign became, for me, one of the first which struck my ear in similar cases ; and I tried to analyze in each case the respiration, i. e. 1 tried, while listening with much attention, to gain a clear and distinct idea of inspiration and expiration, on both sides. Af- ter a short time I observed, that nearly always, when I analyzed the sound, which M. Louis calls coarse, (rude) below one or both clavicles, the vesicular expansion was more or less imper- fect. By this expression I mean, that it finished more quickly and suddenly, and often with less noise than is usual in healthy respiration, or what is still better, than in other portions of the lung, that were healthy. In addition to this change in the expansion, I heard a pro- longed expiration, which had more or less of the bronchial character. I thought from this that expiration may become bronchial, before inspiration does. Since the period above al- luded to, I have paid much attention to this subject, and every thing I have seen confirms me in the belief that my opinion is correct. It will be sufficient for me to say, that I have exam- ined my notes relative to thirty-one patients, who were tuberculous, as proved by autopsy, or by the diagnosis of Louis, and whose histories I have more or less in detail, these being all in which I have noted this expiratory sound ; and this prolonged expiration, in a part proved to be diseased by other signs, has been found in every one of them. I will add in relation to ten or twelve other patients, who are not very evidently tuberculous,.perhaps because the disease is not sufficiently advanced, this phenomenon, (i. e. prolonged expiration,) accompanied by others very slight and delicate, exists under one of the clavicles ; and exists even in a degree 342 more marked, than in some of the thirty-one patients already spoken of, in whom we found small, semi-transparent, grey granulations, more or less agglomerated together. This sign I have also remarked in pneumonia, before hepatization was sufficiently advanced to produce bronchial inspiration ; so also in dilatation of the bronchia, the existence of which has been proved by autopsy. Finally, let me state what appears to me to be the value of this sign, what it appears to indicate, and what appears to constitute its importance. First, when the pulmonary tissue begins to grow solid, from infiltration oS mat- ter into its substance, one of the first alterations of the respi- ratory murmur is a prolongation of the expiratory sound, and, at the same time, this begins to be bronchial, even before the inspiration becomes in the least so. This fact once proved, it seems to me possible to give a simple explanation oS it, and one which agrees with Sacts. What is there in hepatization, and in advanced hardening from tubercles, which makes the respiration bronchial? I think no one will doubt that it is owing to a solidification oSthe parts adjacent to the bronchia; but air passing through bron- chia that are healthy, as well as those that are diseased, ought to produce vibrations. Why are not these vibrations always transmitted to our ear ? Simply because the pulmonary tis- sue intervening is too soft*, too spongy, too light, to transmit Sreely these vibrations. But after a tuberculous or inflammatory action, a more solid matter is deposited in the substance, and, consequently, it is reasonable to expect that those vibrations, caused by the pass- age of air, should be transmitted to the ear; and hence it * The healthy vesicles of the lungs will not transmit the sound from the bronchia, while the condensed substance, under disease, will do it. See Williams on diseases of the lungs, &c. See also letter of March 20th — 24th, 1832, page 129 of this work. 343 only remains Sor us to explain, why these vibrations are trans- mitted in expiration, in a less advanced stage oS disease, than they are in inspiration. This appears to me very explicable ; Sor at the beginning oS disease, on the deposition oS solid matter, when there Is already sufficient to transmit the vibrations produced in the bronchia, there are still many vesicles entirely Sree, the expansion oS which causes a certain quantity oS sound at each inspiration. But when do these vesicles dilate; when do they make this noise ? Precisely at the moment when the air is traversing the bronchia in inspiration; so that the sound produced by this passage oS air, and which ought to be transmitted to the ear by means oS the solid matter recently deposited, is destroyed by the greater sound oS the expansion oS the vesicles. On the other hand, in expiration, this bronchial sound continues while there is no vesicular expansion to destroy it by Its superior Sorce ; consequently we hear it. This explanation is confirmed by the Sact, which I have oSten remarked, namely, that in emphysematous patients, the expiratory sound is nearly nothing ; at least, iS there be not in some part oS the lungs bronchia more or less dilated. But, still, it may be asked, oSwhat use is this phenomenon, as we have others which indicate the same state oS parts ? First, it is useSul as a new sign to add to others. Again, it exists ; and that is sufficient Sor us, who study every thing that exists, and not that which we think beSorehand will be useSul. Further, this phenomenon is, perhaps, more marked, more capable oS being exactly measured, than others which we have in similar cases. Finally, there is a difficulty in auscultation, which every one who has seriously attended to this subject must have Selt; viz. a difficulty, at times, oS distinguishing a vesicular respiration Srom a bronchial one. For 344 myselS, I well know I have made many mistakes upon this point, and I have seen others make them also, especially among children. Now I know oS no phenomenon which can aid us in this distinction, so much as the study oS the expira- tion ; Sor in all cases, with some very rare exceptions, I have Sound a prolonged expiration, where the respiration was evi- dently bronchia]; and, in Sact, my attention, very often, has been fixed upon this respiration, by the Sact of the existence of a prolonged expiration, which first struck my ear ; in a doubt- ful case oS this sort, thereSore, I should be decided by the character of the expiration. Remarks by Henry 1. Bowditch, M. D. — We may remark that the whole oS these observations are very interesting, as the reporter has pointed out to the Society. (We well remember the discussion which took place at the meeting oS the Societe Medicale d' Observation, when these notes were read.) No one, so Sar as we know, has shown so well the differences be- tween pneumonia in healthy persons and in tuberculous ones. But we wish to reSer to the prominent topic treated oS in the reporter's notes, viz. the prolonged expiration. He was much interested on this point, for many months previous to making known his researches to the society, and when he did so, it was thought too important to be passed over, and caused a very animated discussion. There was one circumstance which the reporter mentioned, which all were inclined to dispute, viz. that in healthy respi- ration there is no expiration at all, or, at least, it is very slight, and not more marked in one lung, than in the corresponding part of the other. Consequently, if the assertion of the re- porter was true, if any one in ausculting a patient, who had presented some of the symptoms difficult to explain, except 345 on the supposition of grave disease, should discover a pro- longed expiration under either clavicle, or at the top of the shoulder behind, he might be led to anticipate tuberculous disease in that part. Many were very sanguine that Jackson had made one of the most important discoveries in ausculta- tion since the time of Laennec; a discovery which would teach us the spot where tubercles were just beginning to develope themselves, and before they could be, by common observers, recognized. But every one could decide whether there existed a lengthened expiration, when he could not tell whether it was bronchial or not. Louis was along while in co- inciding with Jackson, but eventually he was led to think favor- ably of the sign, and many a time, during the winter succeeding that at which Jackson first made known the point in question, did his master mention, in my presence, this sign, as very im- portant, and gave the credit of it to Jackson. But there are still some who doubt, and I think the subject is still " sub ju- dice," and I allude to it in order to draw the attention of prac- titioners to the necessity of analyzing the respiration more thoroughly than we do. A question has lately been raised in relation to this interesting subject, of this nature, viz., v/hether there be not often a prolonged expiration at the top of the right shoulder, and none at the left, and this without any dis- ease ? I do not know that this has been proved, and there is a great difference between opinion and proof. At any rate, the subject is too important not to excite every one who de- sires our knowledge of the early stages of phthisis to be advanced ; for it is in these early stages that we must hope to be able to do something towards preventing its rapid progress. I shall make but one more remark, viz. one in relation to the tumor of the spleen, observed at the first examination of the first patient; was it the remains of his intermittent, which 44 346 he suffered from, at the age oS eleven years ? We cannot decide in this case, because no report is made in relation to it after the first visit. CASE XXT. PNEUMONITIS AND PLEURITIS. Hospital la Pitie. Ward St. Paul, 13. Under the care of M. Louis. June 17, 1833. —G. J., aet. 31, shoemaker, from the age of 15 ; hair black ; eyes and complexion deep brown ; flesh in sufficient quantity ; five and a halS Seet tall. This man was born in the department oS La Meuse. His Sather was killed in battle, aet. 34, and patient knows nothing of his previous health ; his mother died, aet. 47, after a disease which lasted one month; she was never asthmatic, nor palsied; two of his brothers are living, aet. 33 and 38, and are well; one other died when a few months old ; one sister died, aet. 17. This patient was nursed by his mother ; his health has gen- erally been pretty good ; he has never had any grave disease, except the small-pox, when two and a halS years old; since then has never kept his bed for illness; did not have short breath during childhood ; could run as easily as his compan- ions ; but has been often subject to colds, with a slight hoars- ness, lasting about fifteen days, yet not such as to oblige him to quit his usual occupations; he has never had haemoptysis nor haematemesis, and never dejections nor urine that were bloody. He had epistaxis and frequent attacks of hemicrania until the age of 15, sometimes accompanied by vomiting; none of either since 15. Had gonorrhea at age of 24, for six weeks ; has been at Paris since four years of age ; he has 347 no children ; during the last two months he has worked at Longjumeau, four and a half leagues from Paris. Present disease, which he dates from the 9th, was preced- ed during three days, by coryza, without any other symptom. On the evening of the 9th, after having drank two bottles of bad wine, without, however, being intoxicated, he was sud- denly seized by a severe chill, causing him to tremble. This continued more or less during the night, together with thirst, and a little cough, and with white expectoration ; no pain in any part, but sleep disturbed. On morning of the 10th, on rising from bed, severe pain in head came on, together with a stitch in the right side of chest, so acute as to cause tears ; cough increased; expectoration still white, and it continued so until toward evening, when it became rusty, and has been so ever since; also oppression and anorexia. During the night of 10th and on 11th, dizziness, and all the above-men- tioned symptoms, and they have continued until present time. The stitch in the side has abated a little this morning, but not before ; sleep bad ; frequent dreams; no delirium ; no epis- taxis ; no buzzing in ears ; never nausea, nor vomiting, nor sore throat, nor dysphagia, except from oppression at chest; never pains in bowels ; dejections only from enemata; has not eaten anything, and has constantly been in bed since the 10th. On that day had ten leeches applied to the right side of chest; venesection and blister on 15th, without the least relief to any symptom, except to the headache. He rode to Paris this morning from the country, and has felt better since his arrival ; pain in head and side, and the oppression having lessened; expectoration less copious and much easier. He has walked this morning from the palace of the Luxembourg to the Pavilion, and thence to this place, (about one and a quarter miles.) During this walk, he 348 felt once a transient pain in left side, near lower margin of the ribs. Now, four, p. m. — Face tolerably natural; intelligence and memory good ; slight cephalalgia; no dilatation oSalae nasi; tongue a little thickened, covered with a light, white coat, sufficiently moist; mouth pasty, but not bitter; thirst; ano- rexy ; no dysphagia; no nausea; abdomen soft, not painful even underpressure ; one dejection liquid, without enema, and without pain, this morning ; voice good, strong; but respira- tion quickened while conversing ; cough frequent; expecto- ration sufficiently copious, and more easy than heretofore, partly white, partly rusty, containing very small bubbles of air, and semi-transparent, slightly viscid ; resp. 28 after this exam- ination ; pain in right side of chest when raising himself in bed, and during cough, from mamma down to cartilages of lower ribs ; strength moderate ; not prostrated. On percussion the chest resounds very well throughout, both before and be- hind, except on the right, in the two lower thirds behind, where it is very obscure, although not flat; vesicular expan- sion, without expiration, except in the above-mentioned space, and extending as Sar on the side as a vertical line let Sail Srom the axilla; here, (i. e. from this line to the vertebrae) is heard a very minute crepitous rale, mingled at times with the sub- crepitous and mucous; no resonance of voice except in this part; the sound of the heart is heard, not very loud, the two sounds distinct; p. 108, skin very hot and dry. June 18.— Very little sleep; still slight pain in sides, right and left; none during cough ; one dejection this morn- ing ; urine red ; p. 90, regular, hard, rather small; great heat of skin; little sweat in night. Resp. 28, rather high; tremor, when the hand is applied to chest, is felt rather more at right side in front, than at left; respiration less free, and 349 percussion less clear in Sormer; on percussion, the right is nearly flat Srom mamma to liver, and in this space are heard a little sub-crepitous rale, bronchial inspiration, and expiration, and bronchophony. (Venesection, § xvi.) Five, p. m.—A little relieved since bleeding; but Seels weaker, and appears more emaciated ; p. 104, small, hard ; great heat; no vomiting ; no dejections ; expectoration more viscid, otherwise the same ; blood taken this morning has a pretty firm, yellow, and thin buff, with very little serum. Less crepitous rale behind at right; bronchial respiration and bronchophony well marked, especially at middle third ; a lit- tle bronchial respiration in a limited spot below, and a little outside oS right mamma. June 19. — Sleep good; night better than any since first attack ; no sweat; Seels better now ; expectoration as yester- day. Resp. 24 ; p. 84, aSter sitting up in bed. Crepitous rale begins immediately below the spine oS the right scapula, and two inches lower the respiration becomes bronchial, min- gled with a fine crepitous, and, at lowest part, with sub-crepi- tous and sonorous rale. In Sront at right, the respiration is less bronchial than yesterday below mamma. Sound on percus- sion more clear, especially below mamma ; but on the back, complete flatness in the inSerior third, and sound very dull in middle third. (Syrup oS violet flowers with oxymel. Gum potion. En- ema of flaxseed tea. Strict diet.) Five, p. m. — q. 84, hard, full; skin as before ; tongue as usual; expectoration less viscid; no dejection ; complains much of the parts about the spot where venesection was per- formed ; they are swollen, and very tender to pressure, caus- ing pain to shoot up and down from the opening of vein ; no 350 hard cords felt in course oS vein. Complained, not long since, oS a pain that had seized him below left mamma, but it ceased almost immediately. The respiration and results of percus- sion are natural throughout left part of chest, front and back; at right, same as this morning, except crepitous and sub-crepi- tous rale below and outside of mamma. From this time until the 22d, the symptoms were as fol- lows:— all the results of auscultation and percussion were nearly the same, except that the marks of hepatization of the lung, viz. bronchial respiration, bronchophony, and flatness on percussion were more extended, and on 21st, the two lower thirds of right side of chest gave scarcely any sound on per- cussion. Pain in right side of chest very severe, prevent- ing cough and easy respiration on 21st, p. m. No pain in left. The resp. was 22 on the morning oS 20th; it was 36 and " higher" at five, p. m., oSsame day ; the next morn- ing it was 42; expectoration same as before, but viscid, less transparent; on 20th, patient said he could lie, Sor the first time, on either side. The pulse on 20th, 84; at five, p. m., 100; on 21st, 84; at five, p. m. 108, hard. Chill, with trembling of body on 20th, a. m. and p. m. Heat oS skin generally as beSore ; no sweat; thirst intense. One dejec- tion on 20th, six on 21st, and two vomitings after three grains of antimony. Arm a little more swollen. Emaciation more marked. On 21st, the Sollowing prescription. (Antispasmodic potion with grs. vi, tart. ant. and syrup oS white poppies § i.) June 22.— No sleep on account oS pain in right side. Now much dyspnoea, pain severe in the inSerior and lateral parts oS right thorax; is much Satigued by it and it prevents easy cough. Expectoration slightly rusty and very viscid. Resp. 28; p. 98; heat purgent; more than twenty dejections; no nausea at 351 present. Bronchial respiration and bronchophony very indis- tinct ; no evident crepitous rale; in lower halS right back very little sound oS any kind by auscultation; otherwise chest the same behind. In Sront percussion more sonorous at right than left, and intercostal spaces are more marked at right. There is a little tumor on left forearm, over which the skin is pale. (Same prescription of antimony. Syrup oS violet flowers with oxymel. Eight leeches to right side.) Five, p. m. — Complains much of side. P. 120; resp. 40; no relief since leeches; no expectoration; cannot cough; speech obstructed ; thirst not so intense; has just taken a little beef tea; no dejection; skin very hot; more depression of strength; great vibration produced on hands placed on right breast. From this day until the day oS death, the 27th, the symptoms were as Sollows: — The respiration at right, behind, was always bronchial, save one day when none was heard and no rale; which last usually was heard on back and below mamma in Sront; not a fine crepitous but large and unequal cracklings. Bronchophony and flatness on percussion continued behind. On the 23d there was an expiration below the right clavicle, and the vesicular expansion was less strong than below left. On this same day the respiration below mamma was purer than it had been previously. On 25th there were heard loud cracklings, and an expiration in this latter spot. Expectoration, varying slightly from day to day, was always more or less vis- cid, yellow or red, and contained air; the viscidity increased toward end of life ; respiration varied from 36 to 54, but gene- rally was 40 or 44; pain in right side noticed until 26th, though diminished much on 24th ; oppression at chest on 23d. The pulse at the first three reports was at 116, the last three at 120 ; at the one intervening it was 108, hard; skin always 352 hot; no sweat except once a little about the head. Sleep, none on 23d and 24th ; delirium with great drowsiness, even so as to fall asleep during examination, on 26th and 27th; tongue dry, slightly coated ; dejections seldom, sometimes none at all until 26th, when he had six with colic; and on 27th, Sour. Tumor on left arm diminished on 23d; complained of pain in legs on 24th, but no swelling, nor redness of them was discerned. Emaciation and diminution of strength daily; on the 23d, it was reported that patient did not take the antimony ordered the day previous. A Burgundy pitch plaster to chest, and same prescription was ordered, substituting for the antimony, syrup of gum. No other prescription is mentioned in the original notes, except that on 25th, three grains of antimony were ordered. On 27th, one, p. m., death took place without agony, delirium having preceded it. Autopsy. June 29th, at eight, a. m., forty-three hours aSter death. Exterior. No stiffness oS limbs, abdominal parietes of a greenish hue ; veins easily traced throughout surSace by their livid color; leftside of chest anteriorly seems larger than right; intercostal spaces less marked in Sormer; flatness over praecor- dial region more extended than usual. No oedema oS lower extremities ; veins oS leSt arm entirely natural; no swelling at elbow. Fat about one line in thickness upon the chest; a small abscess in abdominal parietes at right side, near edge oS ribs ; muscles generally firm and oS a good color. Abdomen. — Stomach distended with gas, is a little larger than usual; has no viscid mucus and very little liquid in it. The internal surSace is nearly throughout oS a livid brown, or red color, except near pylorus where it is pale; the reddened part occupies the two thirds oS the small curvature nearest the 353 cardia and one and a halS inches on each side; the mucous membrane here is raised, and much infiltrated with a reddish serous fluid. In the great cul-de-sac and upon the two Saces, through nearly halS the organ, the brownish color is interrupted here and there by spaces oS a halS inch to an inch in diameter, and in these spots the color is white, but the mucous membrane is entirely destroyed. In the other parts, oS the extent above marked out, the membrane is very thin and soSt, like mucus in some parts, giving strips oS only one or two lines in some others. Toward the pylorus, in the great curvature and the adjoining parts oS the two Saces, the membrane yields strips Srom seven to nine lines; upon the small curvature the tissue is so infiltrated that no strips can be raised. Small intestines, common size, contain a little yellowish- green liquid, with more or less oS mucus; internal surface of a pale-white mixed with a yellow, green, brown or red; these colors being equally seen in every part; only the last third is quite pale; Brunner's glands were to be seen, small and pale, in the last three Seet. The mucous membrane gives strips with much difficulty, but in certain spots some are from two to Sour lines long; in others the membrane is thin and of a brownish color, very similar to the cardiac halSoS the'stomach; these spots are rare, and generally the membrane has its usual thickness. Mesenteric glands, oSa pale rose, or gray color, small. Large intestines, ordinary size; contain a little yellow, clear liquid, without any moulded fecal matter; internal surSace, pale- white throughout, except in a small spot in transverse colon ; strips everywhere Srom ten to twelve lines; thickness oS mem- brane natural; Brunner's glands pale and small. Liver large, pale, adherent by a small cellular band, oS an inch long, to the anterior walls of abdomen ; contains the usual 45 354 quantity oS blood; soft, easily penetrated by Singer; the two substances distinct; the white the most abundant. Gall-bladder small; has a moderate quantity oS clear, yel- lowish-green bile; its mucous membrane natural. Spleen very large ; six inches by three and a halS; very soSt; almost diffluent; has the color oS wine-dregs. Kidneys large; easily torn; red; membrane easily raised Srom their surSaces, which are smooth. Urinary bladder rather small; mucous membrane slightly injected, giving strips Srom fiSteen to eighteen lines long. Neck. — Pharynx and oesophagus well and covered with their epithelium everywhere. Larynx and trachea a little red, without swelling, or Salse membrane. Mucous membrane of trachea thin, giving strips oS fiSteen lines. Chest. — Between the sternum and mediastinum, or rather in the superficial tissue of this latter, which is red, deeply in- jected and infiltrated, are seen some small collections oS pus. The two lungs adhere to the pericardium by the lower part oS their anterior edges. Right lung adherent laterally, and a little on its front and to diaphragm, by means of false membranes, which are thin and easily torn. On this side, the thorax contains fifteen or sixteen ounces of a sero-purulent liquid ; costal pleura thickened and ex- tremely red and injected; much more than in ordinary cases of pleurisy. This lung is rather large; moderately heavy; superior lobe and anterior face crepitate and are pale; lower lobe with part oS middle, and especially posteriorly, red, not crepitating, and compact, although flaccid throughout. The pale and cre- pitating portion contains much air and little liquid ; the other parts contain much reddish serous fluid, and very little air, and in these the cut surSaces are not maniSestly granulated, but the organ in these parts is easily penetrated by the finger, and sinks 355 to the bottom of water. Bronchial tubes red, as the trachea; those of lower lobes appear a little enlarged, but they contain very little liquid; and everywhere they are thin, transparent and smooth. Vesicles of lungs no where dilated. Left lung, free from adhesions nearly everywhere; less large, less heavy than the other; pale and crepitating; con- tains very little fluid anywhere ; bronchia like those of right, red, but smooth, thin, &c.; no dilatation of vesicles; at the sur- face of this lung are three masses about the size of small nuts, firm, hard, compact. Two of these masses are in the upper lobe, one or two inches from the apex ; on the surface of these two there are cicatrices, i. e. there are small depressions radi- ating from the masses as a centre, producing a puckered ap- pearance of the lung ; the third, which is situated at the sum- mit and upon the border of the lower lobe, is covered on both sides by a cartilaginous tissue, with a smooth surface, nearly a line thick ; all three are composed of a cretaceous substance, which is contained in a cyst, rather thin, and cartilaginous, surrounded by a hardened, dark matter. I traced one of the bronchial tubes to one of these masses, where it terminated suddenly in a cul-de-sac, having, even to its extremity, its nat- ural thickness and transparency. Pericardium, much distended, contains twelve or fifteen ouncesof a semi-opake, reddish-brown liquid,not clear; and con- taining numerous little flocculi. Surface of the pericardium is smooth and pale, or slightly injected, and has no false membranes upon it. Upon the surface of the heart are here and there some very small, and very thin false membranes, which float a little upon the water ; also some white spots, from which no false membrane could be detached. Head. — Arachnoid, a little infiltrated underneath, poste- riorly, by a clear serous fluid ; pia mater slightly injected ; 356 easily detached Srom the substance oS brain. Gray substance oS brain not more injected than usual; white substance has a few red dots, though not a great quantity, and is oS good con- sistence everywhere. Lateral ventricles contain two or three ounces oS a clear serous fluid ; central parts, septum lucidum, &c, oS a good consistence. Corpora striata, annular protu- berance, medulla oblongata, cerebellum, all well as to color, Sorm and consistence. By the Editor. —The rational symptoms oS inflammation in the lungs and pleurisy were distinctly marked in this case, within the first twenty-Sour hours of severe disease, which began on the evening oS the 9th oS June. We have, however, a new instance of the maintenance oS the muscular strength Sor many days, since the patient on the 17th, aSter a ride Srom the country, was able to walk more than a mile to the hospital. The pain determined the seat oS the pleurisy, at least, to be in the right side. The physical signs Sully con- firmed, what was otherwise probable, that the pneumony was on the same side, and showed that it was there limited to the lower two thirds of the lung and its posterior halS. On the Sollowing morning the percussion and auscultation dis- covered that the disease in the lung had extended to the front, except at the upper part; and, at evening, that a large part oS the lung was passing into the state of hepatization. Next day, the 19th, the disease seemed rather mitigated in the morning, but at afternoon there was a pain about the region of the heart, which was transient. This was noted, but would seem to have been lost sight of afterwards. It was, no doubt, at this moment that the pericarditis supervened, which was discovered after death, and probably contributed much to the Satal issue of the case. There were chills on the 20th ; and 357 on the 22d the percussion was less sonorous in Sront, at the leSt than at the right, and the intercostal spaces were less mark- ed at the Sormer than at the latter. Here we have signs oS pericarditis. In confirmation it was only necessary that the respiration should have been Sound deficient in a large space around the region oS the heart, in correspondence with the physical signs last mentioned, while the rest oS the left thorax should have exhibited all the phenomena of health and soundness. That this last was true, the notes give sufficient assurance, but the neglect to state the respiratory phenomena in the left breast seems to show that the question, as to pericar- ditis, was not brought into view. Such an oversight is com- mitted every day, but is more remarkable in M. Louis than in any other man, as will be acknowledged by those who are conversant with his writings, and his accuracy in studying indi- vidual cases. It is also remarkable in the reporter, who was peculiarly alive to every sign of this very disease, pericarditis; and who was, very early, in his studies under M. Louis, greatly delighted by the discovery of its true signs. It may, however, be true that the only oversight was in not writing down the observations actually made on this subject; and so far as re- gards M. Louis, it would be unjust to admit any other conclu- sion. We at least may learn from this case, what many others accurately observed will confirm, that a chill in an advanced stage of an acute disease, should always lead us to look for some new, secondary affection; and that a pain about the re- gion of the heart, although transient, should direct our inqui- ries to both the rational and physical signs of disease in that organ, or its envelope. I shall abstain from other remarks, which the accompanying circumstances might authorize, willing to fix the attention on what has been already stated on this point. The state of the right lung and its pleura was found, after 358 death, to be in accordance with the physical signs during life. The precise influence oS the effusion in the cavity oSthe pleura, and of the disease of the lung, respectively, in producing those signs, may not perhaps be accurately determined. The state of the lung was undoubtedly modified by the pressure of the fluid around it. I presume that the lung had a wrinkled aspect, and seemed as if somewhat shrivelled ; such at least is the appear- ance I have noted in analogous cases, and the description, at least, does not contradict this presumption. The flatness over the region of the heart, when the dead body was percussed, is an accordance with the effusion into the pericardium. The disease in the anterior mediastinum could not, under the circumstances, have been easily recognized during life; nor do I know that any certain signs will enable us, in any case, to dis- cover an inflammation in this part. In some instances, indeed, the evidence may be sufficiently obvious of such an affection, when it exists alone. Must we not regard the cretaceous deposits in the left lung, as equivalent to tubercles, as being in fact the result of tuber- cles in those spots, and therefore as throwing light on the pa- tient's constitution ? The disease in the mucous membrane of the stomach, if it was disease and not a cadaveric change, was not indicated by any signs during life. It might be the subject of much dis- cussion. But I prefer to leave all that to those, who have studied, and who are now studying this dark subject, not doubt- ing that a few more years will elucidate the questions, which relate to it. My young friend, Dr. Bowditch, has made some useful observations in regard to it, and I hope he will prosecute his inquiries still farther, and give the result to the public. 359 CASE XXII. PNEUMONITIS AND PLEURITIS. Hospital la Pitie. Ward St. Paul, 13. Under the care of M. Louis. Feb. 11, 1833. — H. J., aet. 36, limbs and chest well devel- oped ; middle stature ; mason; born at Passy, but has lived at Paris since age of 23. Father, aet. 72, living and well, so far as he knows ; has rarely seen him, and not once for last seven- teen years. Mother, aet. 68, alive and well three years ago. One brother died, aet. 3 months; two sisters alive, aet. 35, and 21, he believes both to be well. During infancy he was strong, robust, not prone to be short-breathed; but for twenty years has been frequently affected with colds in winter, lasting three or four weeks. At 8 years of age, had variola ; at 9, measles; and at 17, a severe fever at Reunes, during a fatal epidemic, by which all his family were attacked; in that fever his skin was red, he had soreness of throat, and desquamation of the cuticle afterwards ; also had vomiting and diarrhoea, and was abed fifteen days; does not think he was so ill as now. At Lyons, aet. 26, had intermittent fever, (quotidian,) for fifteen months ; most of the time was in hospital; was several times cured with quinine, and had relapses when at work again. Came to Paris during this, and has remained here since, in the same profession. At age oS 29, had gonor- rhea and buboes. Since at Paris, has had no other disease except as Sollows, first, jaundice, which began Jan. 1, 1830, and ceased in autumn of 1832, — was at Hotel Dieu, seven- teen days for it, but aSterward worked and ate as usual, with- out emaciation ; in this disease his bowels were regular; de- jections yellow, and his face was the only part oS body that was colored ; mouth tasted badly. Second, at end oS August 1832, having worked at the Thuilleries, was exposed to cold 360 wind, and had severe chill, Sollowed by heat; kept abed all next day, and a day aSterwards had pain in left side and cough, with white, clear expectoration. ASter three or Sour days got to work again, but had great dyspnoea and cough, which lasted until the last month. At first could not walk without being almost suffocated, and having pain in side ; sputa at last be- came thicker ; decubitus easy, both sides ; five or six first weeks appetite entirely gone ; had emaciation and thirst; no coryza at any time; slight Sebrile symptoms at evening; had no treatment; always worked after first few days though Seeble. This disease was more severe and lasted longer than any oS his previous diseases. Had been well about fifteen days, when present disease began ; cough had ceased; flesh and strength returned. Has generally led a regular liSe, though at times he drinks freely. Present disease, by report oS his wife and himself, com- menced thus. Feb. 9th, was first taken, after having worked harder than usual during the six previous days, in which, how- ever, he had enjoyed daily twelve hours of rest. During 9th, he worked as usual, had some thirst, but appetite was good and dined heartily at seven, p. m. At ten, p. m., had chill and took a pint of wine to overcome it. On 10th, fever, redness of integuments, delirium, headache during whole day, also cough with two or three bloody sputa ; took foot-bath. On 11th, headache and delirium continued, and he had pain also in left side of chest and more bloody sputa ; had fiSteen leeches to anus. He then entered here, being brought in a litter. Has not had diarrhoea, nor vomiting, has had little or no sleep. Now, five, p. m. — P. 115, hard ; skin hot and very moist; Sace flushed, with a little yellowish tinge ; tongue dry, lobu- lated, brown at centre, white at edges ; deglutition a little painSul, some pain in throat; heat Srom thyroid cartilage to 361 sternum ; thirst, desires warm drinks; no pain in belly, except a little at epigastrium ; no nausea, nor vomiting ; no dejection to-day ; has cough, pain in left side of chest; several rusty colored, semi-transparent, viscid sputa, containing small bubbles of air. Resp. 44, abdominal; headache ; tinnitus aurium ; dizziness when sitting up in bed ; pain in loins and legs. On auscultation, on the back respiration good at right, and also at left, in upper part; at beginning of the middle third of left back, bronchial inspiration and expiration with resonance of voice, — aegophony; a little crepitous rale around this part; respiration coarse down to edge of ribs; no expiration else- where ; some crepitous rale, and respiration very feeble on left lateral portion of chest. Percussion more sonorous at left, than at right in front and especially at side ; whereas, the res- piration on right, at the side, is much louder and freer than on left. Percussion behind at left is flat, and very slightly sono- rous at right. (Venesection § x. Tartarized antimony.) Feb. 12. — The blood has a thin and soft buff. P. 120, rather full, regular, resisting : resp. 36, not very high; speech rather short ; sputa not very abundant, hardly covering bottom of spit cup, all containing very small bubbles of air, semi-trans- parent, some whitish, but most of apricot color, moderately viscid ; less oppression at chest than last night; face less red ; good sleep in night; a little tendency to sleep now; does not remember having seen us yesterday; tongue dry, cracked ; no dejection; less pain in side than last night; pain in head and limbs ; but Seels better than yesterday. Has taken six grains oS antimony without nausea, or vomiting. Anteriorly, chest much more sonorous at right than left, Srom clavicle to mamma; behind, percussion sonorous at right; in the two 46 362 lower thirds of the left back, percussion less good, growing flatter from the upper part to the base, three inches from which there is perSect flatness. Respiration good at right back ; at leSt, in upper third behind, respiration very conSused, distin- guished with difficulty, but without evident rale; below this, inspiration and expiration bronchial, of which the maximum of intensity is at the middle; and at intervals there is a slight sub-crepitous rale and gurgling, after, or during cough. There is bronchophony, not oegophony, where bronchial respiration is heard. In front respiration is good, nearly equal in the two breasts ; it is very clear upon sides, especially at left. (Syrup of violet flowers. Gum potion. Venesection § xx. Aromatic potion with tart. ant. grs. viii, conditionally, at four, p. m., with syrup of white poppies, § i. Liquid farina- ceous diet.) Four, p. m. — P. 110; resp. 36; respiration becoming bronchial below left clavicle ; expiration there now, which was not there last evening. Feb. 13.— P. 108; resp. 34 to 38, with heat of skin; sputa less colored ; face somewhat yellow ; features a little pinched ; a small dejection in bed. In Sront, on percussion, more sonorous at right than at left; respiration pure at right, coarse at left. Behind, at left, percussion everywhere less sonorous than at right, and flatter below scapula than yesterday; bron- chial respiration at left through whole of back, save the three upper inches, with gurgling and sub-crepitous rale ; broncoph- ony, to a line let fall from axilla; respiration at top less clear than at right. Clot of blood, drawn yesterday, easily bro- ken, covered with a greenish buff. A little nausea in night, and has taken three quarters of the antimony. (Oxymel. Antimony grs. x. Two blisters to thighs, if great weakness towards night.) 363 Five, p. m. — Very feeble ; countenance more yellow ; in- clined to sleep ; skin hot; p. 108, small, hard; resp. 30; no vomiting, nor dejection. On the left back, auscultation as this morning, with a slight crackling near its summit; bronchial expiration throughout left back, and also below left clavicle, though not quite so distinct as last evening. Below right clavicle, in a limited spot, an expiration is heard from time to time ; none anywhere else in right thorax; resonance of voice below same clavicle at the same limited spot. Feb. 14.—P. 104; resp. 30 ; attitude of great depression of strength ; sputa more viscid, more red colored than yester- day ; tongue dry, cracked ; speech as before ; thirst; no nau- sea, nor dejection ; percussion equally sonorous below clavicles, but not very sonorous below either ; no difference in respiration below them, but perhaps coarse below both. Behind, auscul- tation and percussion gave less morbid results than before; respiration pure in leSt axilla. (Antimony grs. xii. Two blisters in Sront oS chest.) From this time until the day of his leaving the hospital, March 14th, there was, generally speaking, a gradual amend- ment, as will be seen by the following concise account of symptoms, which are given in great detail in the original notes, till Feb. 20th, though aSterwards the principal symp- toms alone are spoken of, Head. — His mind was not very clear until the aSternoon of 16th; he was inclined to sleep, even when examined. Af- ter 16th, his appearance was always calm, mind clear, and he was less inclined to sleep; never any complaint of pain in head; face had a yellow tinge during some days, aSterwards was red. Alimentary Canal. — Tongue was always mamelonated. It was yellow at centre until 19th, afterward whitish until 24th, 364 when it is described as more natural. It was rather dry until this time. On 15th, patient complained of having had a sore throat during three days, and that it had been increasing ; but on that day nothing could be discerned in pharynx and parts adjacent, which were all moist. This soreness of throat was complained of until 18th ; it was accompanied by difficulty in swallowing, causing cough and suffocation on first attempting to drink; also pain along larynx, when taking short breath. The pharynx was always well in appearance, excepting on 16th, when it was a little redder than natural; but the uvula was very red, without being swollen, and on its surface had two or three little white specks ; these continued, with very slight changes until 21st, after which no report is made of them. This trouble in throat was during two or three days, 16th to 19th, the principal complaint from the patient, and the voice was altered. He had vomiting in slight quantity on 15th, but otherwise alimentary canal was always as previously reported. No pain in abdomen. Chest. — Cough never very troublesome, never any com- plaint oSpain in chest. Expectoration, from being red and viscid, became, on 16th, of a brown color, and less viscid, and on 18th, it was a clear liquid, surmounted by a frothy fluid, like beaten saliva, without any color; on 19th, yellow, opake mucus, not adhesive, not containing air; 20th, green, opake ; and Srom this time it continued more or less opake, and varied in color Srom yellow to green, and sometimes white, never viscid. Respiration was at 36, at five, p. m., on 15th ; dimin- ished gradually, and on 20th, was at 28. It was usually di- minished in the morning, but was always accelerated in the afternoon. The results of auscultation and percussion corres- ponded with the general symptoms. In front, the respiration at left clavicle was always less than below right; it was more 365 superficial below the latter. Nothing is said of the front after- ward, until March 14th, when percussion is recorded as being sonorous below left clavicle, but respiration still a little stronger at right. Behind, at right, auscultation and percussion always good. On 15th, at left, bronchial respiration more extended, mingled with sub-crepitous rale after cough, and flatness as high as lower angle of scapula ; no broncophony at top, but respiration a little coarse there. On 16th, percussion good, and respiration also below left axilla ; sub-crepitous rale, al- most gurgling, in lower third of back; bronchial respiration, also, through whole of left back. On 17th, decided change for the better. Nowhere flat on left back ; respiration feebler than at right, but not bronchial, except when coughing. Such continued to be the signs throughout the remainder of his stay in the hospital; only there was a diminution, which was slow, but always progressive, of each one of them. On 21st, per- cussion very clear in middle third of left part of back; obscure below ; and, in this latter part, some crepitous rale, with bronchial respiration and broncophony. Finally, at the last reports on 14th March, the day of departure, there was coarse- ness of respiration, but not bronchial, on left back ; slight re- sonance but not perfect broncophony in same part. On 27th February, was remarked a diminution in the prom- inence of left side of thorax, both laterally and posteriorly ; left mamma lower than right; but patient said he had observed the same thing for many years past. The pulse, like the res- piration, diminished very rapidly, viz., to 72 and 64 ; the skin was sometimes hot, and on Feb. 20th reported as sweating, for the first time, during the previous night. The strength and flesh increased meanwhile ; on 21st, he began to take vermi- celli ; on 23d, egg and bread, and, before he left, he took three quarters of a loaf of bread a day, with two cups of wine. 366 Treatment was as follows : — Antimony was omitted on 15th, and oxymel of squills substituted; and this, with the rest of the previous prescription, was continued until 18th, after which no record is made of medicine, (as patient had become conva- lescent,) except on 22d, when four grains of Dover's powder and four grains oS digitalis were prescribed. Remarks by Editor. — In regard to this patient we notice ; 1st. That his frame was strong, and no doubt his constitution was so originally, and that he was in the vigor of manhood. 2d. His health had suffered from repeated and protracted diseases, previous to the one here recorded. 3d. ASter a short interval oS health, he was attacked in a very Sormal man- ner, with constitutional symptoms, indicative oS grave, local dis- ease. 4th. On the following day, the signs of the local dis- ease, cough and bloody sputa first appeared, and on the third day, pain in leSt side was added. 5th. The first examination for physical signs was made on the forty-sixth hour from the at- tack oS the disease. Then it was Sound that hepatization was already effected in the middle of the left lung, on its back part. 6th. At the first exploration oS the chest, we find signs of em- physema oS the left lung in front, and especially on the side; though subsequently some doubt was thrown on this matter. 7th. In the fourth and fifth days, we find the disease abated in violence, as manifested by rational signs; but the physical signs show that the local affection was extending its limits, and had reached the front part of the upper leSt lobe. 8th. On the fifth day there is first noticed an expiration, with resonance of voice in a limited spot below the right clavicle. Before that time no physical sign of disease in this region had been noted; and this observation appears to have been made by the reporter. On the following day, the reporter expresses a doubt 367 (for himself) whether the respiration be not rather coarse, and whether the percussion be sufficiently sonorous below the two clavicles. These observations may, perhaps, be regarded as some evidence, that the patient was tuberculous, and then we can understand the protracted cough, he., through the autumn and first halS oS the winter. On the other hand, iS this be a just view, the convalescence oS the patient under the acute disease, was more perSect and more rapid than would usually happen in cases apparently similar. 9th. From the seventh day there was a regular amendment, as regarded the disease in the lungs, so that on the ninth day, there was a great abatement maniSested in the physical signs. By a note in brackets in- troduced in the original notes, the reporter seems to have at- tributed much relieSto the venesection, which on the 12th Feb. especially, was comparatively copious. There was, however, an interruption in the patient's convalescence by a new disease in the throat, which began about the fifth, and was his most annoying complaint from the eighth to the eleventh day. 10th. If the evidence of the existence of tubercles in this case be regarded as satisfactory, the case is to be added to those mentioned in Case XX, as instances of recovery from pneu- monitis in tuberculous subjects. CASE XXIII. GANGRENE OF THE LUNGS. Hospital La Pitie. Ward St. Charles, 25. Under the care of M. Louis. Jan. 19, 1833. — H. H., aet. 34. This woman was born of healthy parents. Father died at 77, disease unknown, she says, old age; mother died at 44, in child-bed ; neither of them 368 having been asthmatic, nor palsied ; — one brother aet. 50, and one sister aet. 40, both well. She has good health generally ; twelve years since, she was sick six weeks, in her bed eight days, having pain in leSt side, a little dyspnoea and cough, but not any Sever, as she thinks. She has been in Paris Sour years, and every winter has had catarrhal cough, but never so as to keep abed. For two years she has been miserably poor; never, or very rarely, getting any animal Sood; but has been apt to drink too much wine. Has had five children, oS whom three are living ; she was nursing one, six months old, when she entered the hospital. She was healthy until the injury to be described. Breath not habitually short. She was injured January 1st, in an affray, at a time when she and her husband, by his account, were both intoxicated. The husband and another man were fighting; she attempted to separate them, and was kicked in the abdomen and elsewhere, but not on the chest. She was knocked down, and suffered extremely; lost her consciousness, and was brought to the hospital on the 2d, and placed under care oS the surgeon. While under his care, she had pain low in the leSt side, and was cupped there with entire relief. A cough coming on, she was transferred to the physician's care on the 6th inst. From that time she has had cough and slight fever; but noth- ing has been discovered by auscultation. To-day it was found that she had fetid sputa, and was more ill. Now, prostration and the appearance of fatigue, which have been noticed in some measure, together with sighing, on pre- ceding days ; no headache ; senses and memory good; eyes natural, but complexion yellowish and pale since yesterday ; tongue soft, pale at edges; great thirst; dejections fre- quent, involuntary ; abdomen soft, supple and without pain, except that on the right, a tumor is felt; this goes from the 369 edge of the ribs toward the flank, does not approach nearer than an inch and a half to the median line, and has its narrow- est point below, for it seems to be triangular. P. 124, regu- lar, rather small, not weak ; breath very offensive, cough very frequent, though not so just now ; expectoration of a dirty gray color, without air, extremely fetid, very liquid, and about half a pint; dyspnoea very manifest; speech interrupted, short and difficult; constant sighing and moaning, much exhausted, in despair; rises to her seat with extreme difficulty. On the back resounds well on percussion, and respiration good ; the same below left clavicle ; but below the right, respiration coarse, though percussion good. No sleep since entrance. She was bled once while under care of the surgeon, and twice since she was transferred. (Rice water, sweetened. Gum water with ten grains of extract of cinchona, and one ounce of syrup of orange-peel. Chlorate water to be put on compresses of linen, from which she should be made to breathe frequently. Fumigations of chlorine.) Three, p. m. — Asleep; resp. 30; p. 80. Tongue has a thick, light-brown coat on the lobes, white at edges, moist; no bad taste in mouth, except when sputa pass; these taste to her, or rather smell, like feces; deglutition easy; no vomiting since entrance ; but nausea and retching from the fetid odour, which she first noticed on the 17th inst. Now, respiration not strong behind, and a slight rale on both sides of back. Jan. 20. — P. 104, regular; cough the same; one dejec- tion, not involuntary. On the back, at the left, a mixture of gargouillement and crepitous rale at lower part, but no resonance of voice; above, respiration good; something similar, but less marked at the right. 47 370 (Sulphate of quinine xii grains. Chlorate water as yester- day, and fumigations.) Two, p.m. — P. 132; skin hot; face yellow and flushed; sputa as before; very feeble from her entrance into the hospi- tal, never having walked since, but much more Seeble now; anxiety, sighing. Respiration bronchial, or cavernous, with gargouillement very maniSest in the middle, or a little below it, on the back, at the leSt. Jan. 21. — Now lies on her back and says she cannot move; heretoSore has lain on either side. No sleep; Srequent, involun- tary dejections through the night, which she does not perceive; tongue moist, blackish on lobes, not red at edges, nor thickly coated; no pain in throat, nor dysphagia; no nausea, nor vom- iting, nor pain in bowels ; Seels no worse, but even a little better at stomach; urine sufficient and not passed without notice; p. 108, small and feeble ; sputa less abundant, one ounce only, equally fetid as well as the breath, but less liquid, mostly of determined form; resp. 36; voice feeble, short; cough as Srequent, but often dry; no headache; countenance less yellow and less prostrated; a little deaf, as she thinks. On the leSt back sonorous and whistling rales only, with a slight resonance of voice. (Sulphate of quinine xv grains. Continue the other pre- scriptions.) Five, p. m. — P. 106; skin not very hot; resp. 36; lying on right side; auscultation as this morning; on the left side expansion more free, pure, (without rale,) than on the back. Jan. 22. — Sputa much less abundant, their odour less gan- grenous, quite distinct from each other, color light-brown; tongue dry, brownish at centre; p. 96, regular; resp. 32; more prostrated, on her back; dejections involuntary; same tumor in abdomen ; this not painful on pressure. On percus- 371 sion on the right in front resonance evidently better; behind, the resonance is a little better at the middle third on the right than on the left, though there is a little difference only. In the same part oS back at the right the respiration is Seeble, without resonance oS voice, while on the left the respiration is coarse, with a little resonance of voice, but without crepitous rale, or gargouillement. (Rice water sweetened with lemon-juice. Sulphate of quinine gr. xx. Vermicelli. A glass of wine. Enema.) Three, p.m. — p. 130; resp. 40; sputa about two ounces, more confluent and darker than ever, the odour most com- pletely gangrenous ; on her right side ; face flushed, hot, moist; drowsy; greatly prostrated ; Srequent cough, groans, and rattling in throat; deglutition easy; no pain in leSt side. Respiration much less pure and complete on leSt side than yesterday; nothing new on the back, but exploration very imperSect. Jan. 23. — Sputa long, ragged, dark, more gangrenous, floating in water; much cough ; great prostration; one dejec- tion, involuntary ; p. 132, small, Seeble, regular; cheeks much flushed; tongue, lips, teeth dry ; skin a little yellow; anxiety and moaning, but without suffering anywhere, as she says; voice embarrassed ; recollection very imperSect. On the back, at the leSt, midway, a little resonance of voice, and the respi- ration is sometimes a little bronchial; sometimes a little crack- ling and a littie rale there. (Same prescriptions. Laudanum grs. xxx, in Enema. Sin- apisms to thighs.) Two, p. m. — Face pale, yellow; heat; p. 120 ; resp. 48. Jan. 24. — Seven or eight sputa, whitish, opaque, not finely aerated, not fetid; breath scarcely fetid ; p. 124, Seeble, regu- lar; resp. 36, high ; great prostration; countenance expressive 372 of astonishment; answers short; pupils rather small; tongue soSt, grayish, not red ; abdomen meteorized, without pain. (Sulphate oS quinine gr. xxv. Enema with rhatania and forty-five drops oS laudanum.) Jan. 25. — On her back, excessively feeble ; p. 128, regu- lar, rather Sull; resp. 40, high, with a noise ; cough frequent yesterday, without expectoration ; tongue crusted, dry; con- sciousness imperfect; has taken liquid nourishment very freely, and asks Sor solid Sood. (Prescriptions the same. Sinapisms to legs.) Five, p. m,!—On her back, with mouth open; resp. 48, with a rattle in throat; does not speak, but has not entirely lost consciousness ; no sputa; breath fetid; no diarrhoea; skin warm and moist. Died in the night Sollowing. Autopsy, Jan. 27, ten, a. m. Externally. — No infiltration oS lower extremities ; no lividity, unless a little on the legs ; no cadaveric rigidity ; Sat five or six lines over thorax, three or four over abdomen. Head. — Infiltration under the arachnoid very moderate ; cineritious substance rather pale ; medullary slightly marbled ; two drachms oS serous fluid in each ventricle ; consistence of all the organs natural. Chest. — Larynx, trachea, bronchia, pale, natural. Heart. — Pericardium distended, as if with air, contains about half an ounce of reddish serous fluid. Heart itself oS ordinary size; extremely flaccid, changing form with every change oS position, and flattening Srom its own weight; a white patch on its anterior surface, an inch in diameter; left ventricle a little thinner than usual; the cavity rather large and of a pale red internally ; containing a pretty firm, reddish, fibrinous 373 coagulum ; right ventricle very thin, half a line, quite easily torn, of same color internally as the left. Right lung, large, light, not collapsing, but preserving its form most remarkably; passing nearly an inch to the left of the median line; with some adhesions, not firm, over a small space laterally and posteriorly, a little below apex, but none anteriorly, nor at base ; vesicles dilated over the whole surface to two or three times their common size ; bronchia not mani- festly dilated; slight engorgement at base, but crepitation there, and on incision a flow oS reddish, Srothy, liquid; not granulated at this part; penetrated by the finger a little more easily than usual. Left lung, universally, though not very firmly adherent to the surrounding parts, except to the diaphragm and vertebrae; the two lobes also adhere to each other; on removing the Salse membrane Srom the upper lobe, the pleura is seen polish- ed, though not perSectly; over the lower lobe the Salse mem- brane is infiltrated with a considerable quantity oS reddish se- rous fluid; in detaching this membrane Srom the vertebrae and diaphragm, a cavity about to be described is laid open, and Srom it flow about eight ounces of a dirty, gray, gangrenous liquid. The left lung smaller than the right; the vesicles di- lated over a considerable portion of the upper lobe, though less than in right lung ; otherwise this lobe is healthy, crepi- tating ; its bronchia pale, thin and transparent, containing a small quantity of an opake, white fluid. In lower lobe, follow- ing the bronchial tube, which leads to the lower part, at about two inches from its origin, we open into a cavity, where this tube is cut short; and the same happens to two others. The cavity is about as large as a fist; its parietes are of a dark gray color internally, having an unequal or rough surface, while the cavity has numerous partial divisions formed by the 374 intersection oS imperSect membranes; the internal surSace is lined by myriads oS little filaments, whose loose ends are seen to float like moss, when the parts are immersed under water; these filaments vary in size, and to several oS them portions oS fetid, yellowish, pulmonary substance is attached; the cavity is not lined by any Salse membrane. At the lower part the cavity seems to be bounded almost immediately upon the di- aphragm, to which indeed the diseased part extends. The parts surrounding the cavity, and indeed all the rest of this lower lobe, is oS a livid red color, not crepitating, not floating in water, almost destitute oS air ; yielding by pressure a red- dish fluid, which is oS a livid, not scarlet color; not granulated, nor very Sriable ; neither like spleen, nor like liver in aspect; while all the bronchia are pale and natural, even those leading to the cavity. Abdomen. — Pharynx and oesophagus natural. Stomach larger by two thirds than usual; containing a little thin, yellow liquid, and scarcely any mucus ; posterior Sace oS same color as the fluid contained, the anterior grayish ; mucous membrane very slightly mamelonated over an extent oS two inches near pylorus; strips on the great cul-de-sac two to three lines, on the anterior Sace six to ten lines, on the small curvature twelve to fiSteen ; this membrane thicker on the anterior Sace than at larger curvature, but generally may be called healthy. In Sront of the vertical portion oS the duodenum is found a tumor, which is bounded as Sollows, besides the duodenum, viz.; above by the colon, just at the angle oS the ascending and transverse portions oS this intestine, below by the crista ilii, on the back by the vertebrae, and, in Sront oS these, by the vena cava at the leSt. The tumor measures from above down- wards three and a halS inches, and in breadth Sour or five. Its contents are ten or twelve ounces oS blood, mostly liquid, but 375 partly in coagula. Its internal surSace is a little unequal, and of a livid red color. It is not lined by any distinct membrane ; parietes two to three lines in thickness ; the cellular tissue sur- rounding is blackish and blue, Srom infiltration oS blood, though without coagula ; this color extends to the mesentery, meso- colon, parietes oS the intestines, he. Small intestines, a little larger than usual; contain not more than three ounces oS a yellow liquid, and a very little mu- cus ; the internal surSace oS a deep yellow color in the first third, the rest white and pale ; mucous membrane oS ordinary thickness, giving strips oS two to three lines in the first half, five to six lines in the last halS; thirteen patches of Peyer's glands discovered, the first at the eighth Soot Srom duodenum ; these are quite pale, and the first six or seven are seen only upon close inspection ; Brunner's glands are first seen just be- low the middle oS the intestine, but are not very distinct, ex- cept in the last Sour Seet; here, especially at the last part, they are rather numerous and large; in the last six inches many have black, central points. Mesenteric glands corresponding to upper parts oS a whitish gray, and small; those correspond- ing to the last Soot redder, and decidedly larger. The whole mesentery marked by small black spots, like ecchymoses. Large intestines contain a small quantity of pultaceous Seces; mucous membrane pale, oS ordinary thickness; strips Sour to five lines in caecum, ten to twelve in the rest; Brun- ner's glands not seen in great numbers throughout, least in the middle, most near to the extremities, with black central points, not enlarged. Liver contains very little blood, pale; or oS a pearl aspect, like putty; rather easily penetrated by the finger; extending up to fifth rib ; of good size. Gall-bladder contains considerable quantity of yellow bile. 376 Spleen, larger than common by one third; at upper extrem- ity a yellow, gray, opake spot, of one inch in diameter, and a little cavity, as big as a pea, containing a greyish, pultaceous, gangrenous matter. A small supernumerary spleen of the size of a marble. Pancreas, in the upper part a little abscess as big as a pea. Kidney,-^-left, membrane thin, diaphonous throughout, and not peculiarly adherent; texture of the organ rather pale, of ordinary consistence ; at the surface, upon external edge, two patches, each half an inch in length, one third in breadth, and two lines in depth, of a yellow, solid, firm, not shining matter, resembling in aspect some forms of cartilage, but too hard for that; no peculiar adhesion of membrane at these spots; tex- ture immediately surrounding them of same aspect as in the rest of the organ. Bladder, natural. Vagina contains a considerable quantity of white, opake, not very liquid fluid; internal membrane redder, but less wrinkled than usual. Uterus, ovaries, nothing peculiar. After boiling, the epi- thelium is seen extending up to the neck of the uterus ; it is decidedly thinner than that of mouth and oesophagus. By the Editor. — The striking circumstances, when this case is first introduced to us on the 19th of Jan., are the great and wretched prostration, Srequent pulse, dyspnoea, cough and Setid sputa. All these symptoms, except the fetid sputa, might exist without the gangrene of the lungs. On the other hand, the gangrene may occasion fetid sputa without inducing extreme prostration. It appears that in this patient great feeble- ness followed the injury of the 1st of Jan., and that the strength declined from that time, though the prostration was not extreme 377 till gangrene occurred. The patient's previous habits had, no doubt, much to do with this miserable termination. In regard to physical signs of disease in the lungs, on the 19th of Jan. we get none except below the right clavicle, and there only a coarse respiration. This, at least, was all which was observed in the morning; but, probably, the exhausted state of the patient prevented an accurate and full exploration of the chest. At evening there was a deficiency of respira- tory murmur, and a slight rale on both sides of the back. The next day (20th,) there was a mixture of gurgling and crepitous rale on the left side of the back, below the scapula. On the subsequent days the physical signs varied greatly ; at one time a cavity, containing a liquid and admitting air from the bronchia, with parietes in different stages of inflammation, was indicated by the gurgling, crepitous rale, bronchial respi- ration and resonance of voice; at another the subsidence of the worst signs, and diminution of others, seemed to show a real amendment and a return of the organs to a more healthy state. But this last conclusion could not be adopted, while the rational signs showed, so plainly, that the disease was tend- ing to a fatal termination. Even on the 24th, when the sputa ceased to be fetid, and the breath was scarcely so, no good hopes were justified. By attending to the appearances post mortem, we may obtain an explanation of these seeming incon- sistencies. In the right lung we find only a vesicular emphysema, probably not recent, and some want of the natural consistence in the texture of the lungs, which may be referred to the great diminution of vital power in the last few days oS liSe. It is in the lower lobe of the left lung that we find the great disease. In this lobe, at its lowest part, is a cavity, Sormed by 48 378 the breaking down oS the gangenous lung. This was in com- munication with one oS the bronchia; but it is not difficult to understand why the contents of this cavity, in the midst of a mass of halS dead lung, were not expelled, when the patient was under a state of extreme exhaustion. At an earlier pe- riod, when the gangrene was less extensive, and life not so far gone, a portion oS its contents were expectorated. But the tension oS the parts was subsequently destroyed ; and in order to continue the expectoration, greater efforts for the evacua- tion must have been made at a time, when the power to make them was lessened. The tumor in the abdomen might well have been thought to be some organ, enlarged in consequence of the injury inflict- ed on that part. But the dissection discovers a remarkable effusion oS blood, which possibly might have been removed by the efforts of nature in a healthy subject. The appearance oS gangrene in the spleen, could not have been anticipated. Nothing is said oS the diaphragm over the spleen; but one is tempted to suspect that the gangrene may have extended Srom the lung above to the spleen. It is highly probable that the little abscess in the pancreas had its origin in the external violence, to which the patient had been subjected. case xxiv. PHTHISIS. Hospital la Pitie. Ward St. Charles, 30. Under the care of M. Louis. Feb. 3, 1833. — Bretean, a woman, aet. 30. Hair black, eyes dark brown; born at Paris, and nursed at her mother's breast; father died, aet. 49, his disease not known to her; 379 mother, 63, alive, has often "vomited blood," and has had a cough Sor the last six years, otherwise well; had one sister, who died at 30, having " vomited blood, coughed, and become consumptive;" — had one child at23, who died at 11 months oS a "cerebral Sever," as the physician said. She began to menstruate at 12, and was always regular till August last; did not suffer much at monthly periods, most commonly had a diarrhoea preceding them, and Srom 20th year almost constant leucorrhoea in intervals; breath short Srom inSancy, could not run as well as others in childhood; subject to catarrh since her 15th year, but this never severe; had no swelling in throat, nor elsewhere in her youth; never seriously ill, even Sor a week, until her accouchment; Srom this she did not get up well; the lochia stopped prematurely,she had severe diarrhoea for fiSteen days, though no pain in abdomen, nor vomiting; she had however some dyspnoea, but without pain in the chest and without cough. Since 14th year she has worked in pearls. In June last she began to cough and expectorate; grew worse in August, and then leSt work, and since that month no men- struation. She had not had catarrh the last winter. Though the cough was not severe in June and July, the sputa were thicker than now. In August, her cough produced pain in chest and then she expectorated some fillets oS blood. Since August, has had sweats about the chest, which have not been increasing. BeSore her illness ate three quarters oS a common allowance, since then not more than one quarter. Thirst in the autumn more severe than now. Has emaciated Srom June; in her catarrhs Sormerly, never emaciated, though they usually continued six weeks. Lies best on her right side, Sormerly as well on one, as on the other. Does not Seel the air enter unequally at the two sides. No diarrhoea; Sor the last two months pain low in abdomen. 380 Now, skin pale, as always, she says; intellect and memory good ; some greenish sputa, irregularly round, but not properly ragged, mingled with some white, Srothy liquid, like saliva. Below right clavicle percussion decidedly more sonorous than below leSt; here it is somewhat flat, and it becomes more so in descending to the leSt mamma, where it is perSectly flat. Also, below left clavicle, on percussion, there is the sound of a cracked jar, (bruit de pot Sele.) Here also is a sub-crepitous rale, but not evident gargouillement; at four or five inches below the clavicle, over the mamma, there is gargouillement, and the same under axilla, and, two inches below this, expiration very slight. On the back, below the scapula, percussion clear on both sides; a littie obscure at the left, two inches above the lower angle of the scapula. On the right, behind, for two inches from the summit, respiration tracheal without any rale; also bronchophony there, though not pectoriloquy; below, near vertebrae, a little sub-crepitous rale, or a blowing, (sifflante.) On the leSt, behind, the same, except that the tracheal respi- ration is less maniSest, and there is a sub-crepitous rale, in its place. Below the right clavicle respiration coarse, bronchial; and, lower down, a little mucous rale. About the left clavicle, above and below it, more hollowness, or depression, than about the right. In the right hypochondrium, in the region of the liver, over an extent of two inches, some resistance on pressure, not very perfectly marked, and in the same part some sensibility on pressure. Voice natural. Tongue a little red, but moist; thirst acute in August and September, now very little; appetite and digestion pretty good; no diarrhoea; p. 88, small, feeble, regular, though examined after exploring the chest; no palpi- tations ; no headache; no sore throat; deglutition easy. (Infusion of marsh-mallows, sweetened. Gum potion. A quarter of a loaSoS bread daily.) 381 Feb. 5. — Pain in middle oS breast and back, none on side. Can now lie on leSt side. Some resistance in right hypo- chondrium. Feb. 6.—Percussion a little flat over the leSt scapula; at the leSt summit bronchial respiration, and resonance oS voice, but no gurgling. On the right a little gurgling above the spine oS the scapula; above this a littie crackling (craquement;) and at the very summit respiration almost cavernous ; at the same point pectoriloquy, or nearly this. Percussion in Sront, sono- rous at the right, flat at the leSt, more so in going Srom above downwards. Diarrhoea yesterday. (Gum potion with half a grain of watery extract of opium.) Feb. 7. — More cough ; no sleep; expectoration difficult; no dejection. (Extract of opium increased to one grain in same potion. Enema.) Feb. 8. — Expectoration more difficult and less abundant; gums painful and somewhat swollen. Scarcely any sleep; no sweat; p. 96; resp. 36. On the left breast the sound of a cracked jar is not heard on percussion ; no rale there ; perSect pectoriloquy at right summit behind, with tracheal respiration. Expiration heard nearly to the lowest part, on both sides, behind. From this time to the 20th of March, when she died, the cough was urgent and the expectoration difficult; the sputa were opake, and somewhat indistinct, ragged, firm masses, and seldom, iS ever, copious; she had pain in the breast and through to the back, but not in the side ; the right hypochondrium lost the Seeling oS resistance on pressure, and became supple; on the 14th oS February there was first noticed an embarrassment in the throat affecting her voice; this embarrassment increased so as to render deglutition difficult, and on the 6th March, on 382 attempting to drink, the liquid passed out of her nose; at this time nothing seen in fauces ; diarrhoea at times increased, but without much pain ; and night sweats sometimes occurred; yet the pulse grew less Srequent, so that Srom being 96, on the 8th, they were 90 on the 18th; 84 on the 19th oS February; and on the 4th oS March, 7S; and were marked, as not accelerated, within two days beSore death. As to physical signs, gurgling was heard, successively, at the summit oSthe chest behind and in Sront on the right side ; also on the leSt, over a large space at the summit behind, two inches below the clavicle, and in the axilla; in this last region was also heard cavernous inspiration and ex- piration and pectoriloquy; and expiration was heard everywhere, but more at the right than the left, on the lower half of the back; and the sound of a cracked jar was perceived at times, slightly, below the right clavicle. (Prescriptions various; anodynes, leeches once on neck, &c.) March 20, in the morning, pain in the right side; coun- tenance extremely changed, pale, bloodless; several littie caseiform deposites on the tongue; six dejections; excessive suffering. On percussion very sonorous on the right back; on the same, at lowest part, bruit de frottement; on the right side respiration audible. At one, p. m., this day, she died after a horrible agony. Autopsy, March 21, ten, a. m., twenty-one hours after death. Exterior. — Body perfectly cold; marasmus in the last de- gree ; no discolorations, nor oedema of the lower extremities. Chest. —Heart of moderate size ; no trace oS Salse mem- brane externally; three ounces of yellow serous fluid in the pericardium, with some little flakes; large coagulum oS fibrin in the right auricle. Left lung, adhering in every part to the pleura costalis; the lung firm, hard in its whole extent, scarcely exhibiting a point 383 healthy. Upper lobe, at the summit behind, has little exca- vations, oS an inch and less, which communicate with others below ; in some oS these excavations a commencing Salse mem- brane, in most oS them none ; the bronchia open into most oS them ; some oS these bronchia are dilated, their mucous mem- brane red and thickened, one oSthem ulcerated, and, to the ex- tent oS two lines, entirely destroyed, so as to show the parenchy- matous substance Sor the base oS the ulcer; the rest oSthe apex occupied by little cavities, and opake, yellow tubercles, with some small, semi-transparent tubercles, and, at the centre, some large tubercles, more or less opake; these tubercles are some oS them confluent, or congregated in masses, others separated by small portions of a healthy tissue ; in the lower part of this lobe is a narrow cavity, three inches long one, to one and a halS deep ; the lower part oS this cavity is lined by a matter alternately gray and yellow, opake, rather firm, in many parts two to three lines in thickness, oS a dull aspect, and not crying under the scalpel; this matter is subjacent to the pleura, and they are separated Srom each other by matter oS a firm, red- dish texture. Lower lobe has, Sor two inches Srom its summit, yellow, opake tubercles, and a multitude oS little, irregular cavities, without any Salse membrane ; Sor two and a halSinches below this portion, it has a great number oS semi-transparent granulations ; these cease two inches Srom the base, and in this portion there is a little hepatization. Right lung, adhering except in the lower quarter; being removed with the costal pleura, there is seen a little opening, or hole, at the upper part, communicating with a large cavity in the upper and posterior part oS the lung, more than two inches Srom top to bottom ; in this cavity a quantity oS reddish liquid ; its walls constitute a sort oS cup, one to two lines in thickness, and, in some spots behind, covered by pulmonary 384 texture, not more than half a line in thickness; several bron- chia communicate with this cavity; in Sront oS this cavity are several small ones ; the large cavity is lined with a grayish matter, (detritus,) which is so Sriable that it cannot be removed, in the Sorm oS a membrane; beneath this is an unequal, pol- ished, grayish, thin membrane; the rest oS the upper lobe is transSormed into a tuberculous, grey matter, separated by an infiltrated, gray, semi-transparent matter, the whole matter being harder than a hepatized lung ; pressure on this portion of the lung produces a very little air, which seems to come from little cavities. Lower lobe, to the extent of an inch and a half from its summit, is in the same state as the lower part of the upper lobe, just described, which is contiguous to it;* these morbid changes stop suddenly, and the lower part of this lobe is comparatively healthy, for four inches from the base ; It is, however, engorged, red, less coherent than a healthy lung, contains a few semi-transparent granulations, and one or two opake masses. Neck. — Pharynx presents laterally, and behind the os hyoides, an oval depression ; this is two lines in length, and one and a half in breadth, is encircled by a little red line, within which the epithelium is wanting. Epiglottis pale and thin ; and, on the right inferior corner, Is a little, button-like elevation; this is fleshy, pale, destitute of polish and of mucus. Larynx healthy. Trachea red ; this redness is in the mucous and sub-mucous textures ; the mucous membrane not thick- ened, giving strips of twelve to fifteen lines ; little crypts seen beneath It. * The middle lobe is not mentioned. Perhaps this was closely adherent to the upper lobe, and, being examined from behind, it was not thought of, and was confounded with the upper lobe. Such an oversight easily takes place under the circumstances here supposed. 385 Abdomen. — The peritoneal cavity contains about two pints of liquid, clear and slightly yellow. Stomach contains a moderate quantity of liquid, in which there are small flakes, and some of these adhere near the pylorus; internal surface generally pale, but has a little redness within two inches of the pylorus ; this redness is not continued, but is in points or dots, and similar dots are scattered slightly over other parts; a por- tion, about three inches in length, about the middle of the anterior face, mamelonated unequally, and, in this part, the mucous membrane thicker than elsewhere; mucous membrane everywhere softened, except at the anterior face, where the strips are from two to four lines, and in the small curvature, where the strips are from five to six lines ; the longitudinal muscular coat is prominent, or raised in some points, and near the pylorus, for two inches, it is from one to two lines in thick- ness. Small intestines of moderate volume ; in the first half some yellow mucus, in the last quarter pulpy greenish matter, in the interval gas only ; the mucous membrane pale through- out, normal as to thickness and consistence ; in the last two feet, three patches of Peyer's glands, which have each twelve to fifteen tubercles, of the size of a pea, ulcerated at summit; mesenteric glands a little more voluminous than common, some of them red. Large intestines very small; caecum contain- ino- matter, some of it green, (above) some whitish, (below) ; except the caecum, these intestines are of a more or less vivid red throughout, and the parietes thicker than common; in the first foot, the mucous membrane oS normal thickness; below this two or three times thicker ; in the first eighteen inches, the strips Srom two to Sour lines, in advancing toward rectum they grow less, and at last there is mucus only ; five ulcers in the caecum, irregular, halS an inch, grayish, with gray, semi- 49 386 transparent granulations at their centre; in the next ten inches Sour oval ulcers, each five or six lines in length; in middle oS colon eight or ten more, at the bottom oS which is some gray, semi-transparent matter ; also one or two ulcers near sigmoid flexure ; the subjacent cellular tissue thick and white; the muscular coat also much thickened. Liver rather large, some- what of a chesnut color ; at two inches from the free edge a depression, which corresponds with the edge of the ribs, and is two and a half inches in length by one in depth ; more gran- ular than natural; alternately yellow and brown. Gall-blad- der contains a liquid of the consistence of molasses, and of a deep green color. Spleen natural. Kidneys small, pale, otherwise natural. Bladder healthy, almost empty. Uterus small, eighteen lines in length ; contains considerable quantity of viscid, transparent mucus, some of it projecting from the mouth ; internal surface pale, healthy. Head. — Little arachnoid infiltration. Pia mater not much injected. Gray substance of a little deeper color than common, and corpora striata the same. Half an ounce oS serous fluid in each ventricle. Cerebellum, medulla oblon- gata, &rc, healthy. [To this case the following remarks are annexed. I pre- sume that they must, in substance, be derived Srom M. Louis; but I do not feel authorized to attribute them to him. —Editor.,] In this case there was never any pain in the sides, still ad- hesions existed. Pain is ordinarily noted in such instances, so that this is an exception. Are we to attribute the pain in phthisis to tubercles, or to pleurisy ? Unquestionably to pleu- risy ; for there are cases, in which there is a tuberculous cavity 387 on one side without pain, and pain on the opposite side, where no tubercles are Sound, but adhesion is Sound. Was the tuber- culous deposit in this case distributed in the ordinary manner ? It was in the upper part oS both lungs ; but the great cavity on the leSt side, in the lower part oS the upper lobe, was extra- ordinary. For prooSs that the semi-transparent granulations and tubercles are the same, see Louis on phthisis. What are these granulations ? They have been thought to be vesicles transSormed. But this opinion cannot be supported, for they are Sound, exactly the same, in other organs besides the lungs; as, in this case, on an ulcerated surSace of the intestines, and frequently on the peritoneum. What is the gray matter, in which these bodies exist, as in a matrix ? It has been regarded as tuberculous ; but this has, by no means, been proved. Does the advanced state of the tuberculous matter in the in- Serior part of the upper left lobe show, that the tuberculous deposit commenced first in that part ? No ; for there is also Sound a large cavity at the summit oS the right lung, and that is in a more advanced state than the cavity in the left lung. In regard to the epiglottis, although the disease in it is slight, yet this disease caused the dysphagia. This will be more evi- dent if we remember that a part of the swelling and redness, which exist during life, disappears in the dead body. In small organs, especially, a slight difference of this sort is important in explaining to us the mechanical, or other obstacle to the use of the part. When did the redness and softening of the mucous membrane of the large intestines commence ? This cannot be decided ; but, very possibly, it was within a day, or day and a half before death. We must keep in mind the ex- treme rapidity with which inflammation proceeds in enfeebled subjects. 388 By the Editor. —To the remarks above I have only to add, that a comparison of the post mortem appearances with the physical signs of disease in the lungs, shows the value of these signs. The unusual size of the cavity in the lower part of the left upper lobe was detected at a very early period. CASE XXV. PHTHISIS AND EMPHYSEMA OF THE LUNGS. Hospital la Pitie. Ward St. Charles, 38. Under the care of M. Louis. Jan. 8, 1833. —M., aet. 38, widow, of a disposition most peculiarly ugly. Entered hospital Nov. 13, 1832, for chronic headache. This commenced three years since after her ac- couchment and has never been decidedly relieved at any mo- ment. It succeeded a strong moral emotion. It has never been accompanied by any failure in the functions of the intel- lect, of sensation, or of motion. Previous to its occurrence the catamenia were always regular, accompanied by slight pains. Since April, 1832, neither catamenia, nor the premon- itory pains, nor leucorrhoea; though this had sometimes oc- curred before. Did not have cholera during the epidemic last spring. Seldom has had catarrh, and not at all for a long time. Always feeble, she has become more so under the headache. Different means had been employed before her entrance here, such as leeches often to the ears, sometimes to the anus, venesection in arm, never in foot, and cautery a little before her entrance ; but all without success. Appetite has been lessened since the headache. Five or six days after her entrance here there was prescribed venesection in the foot without relief; then she had pills of 389 hyoscyamus with oxide oS zinc, with a little relieS, as she thought; then a blister to the head, (Dec. 11,) since which she has had no headache. Ten days since she had severe diarrhoea with colic. Jan. 8. — On evening oS the 6th, slight hemoptysis ; this lasted somewhat during night and increased on the morning oS the 7th, then amounting to six or eight ounces. She was bled at the arm, ten ounces, and Srom twelve to Sour o'clock was relieved. The blood Srom the arm was covered with a firm, yellowish buff, three lines in thickness. In the night oS 7th, she spit again five or six ounces oS blood ; hemoptysis always with cough. On the morning oS the 7th, there was a sub-crep- itous, a mucous and a sonorous rale, below the right clavicle. She was not examined any Sarther. Now, p. 112, regular ; countenance natural, rather colored; voice clear ; respiration not greatly accelerated ; feels no pain, but excessive Satigue ; no cough during examination. Tongue moist, a little white ; no pain in bowels ; constipated Sor two or three days. On percussion and auscultation nothing unnatural discovered; but there is so much agitation and pal- pitation, that the exploration is necessarily imperSect. (Rice emulsion, one mug. Gum potion. Ten leeches on upper part oS thighs. Enema, to be repeated iS necessary.) At halS past three, p. m. — Has spit a little blood since morning; p. 124, small; skin not very hot; Sace paler than this morning. For a Sew days aSter this the sputa were colored more or less with blood, but never much ; cough not very urgent; p. about 120 ; undue heat at night by her report. On the 13th, percussion on, above and below left clavicle more sonorous than at right in some points ; also respiration louder and more 390 pure below the left clavicle. Elsewhere, respiration and sound on percussion healthy. (On 13th, gum potion with two drachms oS syr. oS white poppies. On 14th, milk.) Jan. 15. — Hemoptysis last night, three or Sour ounces. This had nearly ceased on 16th. (Sulphuric acid. Rhatania.) Jan. 26. —On percussion about the clavicles the difference not so decided as on 13th, but yet a little. Respiration quite pure below the left, but mingled with a sub-crepitous rale on the right from the clavicle to the mamma. Behind, on the right, upper part, sub-crepitous, and at some points a crepitous rale. Respiration a little rude, or coarse, at the root of bron- chia, especially on the right. Pulse moderately accelerated. A dejection once in two or three days. Abdomen soft and without pain. Complexion pale, yellow. (Enema. Milk.) Jan. 28. —Sub-crepitous rale behind at left and right, but at the left through the whole inspiration, at the right only at its commencement. The sputa white, glairy, and a little froth on the top. Feb. 1. —Two or three inches below right clavicle, sub- crepitous rale ; directly below clavicle, respiration coarse; less so below the left. Percussion more sonorous below right than below left clavicle. Behind, at the left summit, respiration pure ; at the right coarse and seems farther from the ear ; voice so feeble that it is impossible to decide as to its resonance ; in the lower two thirds, on both sides, there is a fine crepitous rale ; but the percussion behind is more sonorous at the left, than at the right. (Gum potion with oxymel and four grains of Kermes min- eral.) Feb. 3.— Almost a gargouillement below the right clavicle, and from this to the region oS liver, in Sront, a sub-crepitous 391 rale ; the same rale on the left Srom the clavicle downwards. Percussion clear below clavicles, perhaps a little more below right than left. Oppression great; tongue very white at cen- tre ; no dejections. (Opiate. Blisters on Sront oS chest. Sinapisms to thighs.) Feb. 4. — Very much sunk in the morning. Death aSter- wards. Autopsy, Feb. 5, at 10, a. m. Externally. — Emaciation considerable ; two lines oS Sat on the chest, one on abdomen. No redness, no lividity. Very little rigidity. Head. — Nothing remarkable on outer surSace oS dura ma- ter. Traces oS arachnoid infiltration behind only; arachnoid itselS natural. Pia mater very little, and very partially inject- ed. Cortical substance natural. One drachm oS serous fluid in each lateral ventricle. The whole mass oS cerebrum oS good consistence; so little injected that drops oS blood appear only on pressure and at intervals. An extremely delicate lilac color in centrum ovale. Other parts within the cranium quite natural. Neck. — Larynx, pharynx, oesophagus, natural. Chest. — Right lung, some cellular adhesions at the base, and at the side and back, midway, over one third the lung; the Sormer firm ; no adhesions on the upper part. The whole lung two or three times heavier than usual, especially the up- per lobe ; hard in portions, with intervening portions not so ; projections where there is no hardness, and in these projections the vesicles are two, three, and even Sour times as large as natural; the lower lobe less heavy than the upper, and oS a livid rose color, while the upper is oS a pale gray ; some Sew vesicles dilated in the lower lobe; at the summit in Sront, sev- eral cells much dilated, Srom one to two lines in breadth. In 392 the upper lobe several tuberculous masses with some gray points ; also two small excavations, granular, not entirely opake, unequal; and two small cavities, one to two lines in diameter, filled with pus. The bronchia pale, thin, transparent. Mid- dle lobe containing tubercles, though less numerous than in the upper ; some cavities; two bronchia dilated, and little thicken- ed. Lower lobe has several bronchia extremely dilated, Srom three to five times their natural size, with a sort oS valvules in them ; these surrounded by a great number of gray, semi- transparent granulations, not opake, and smaller than else- where. Left lung, free from adhesions; less heavy than the right; hardened portions similar to those in the right; not so many vesicles dilated in the summit in front as on right; but as many behind, an inch from the summit; mucous membrane of the bronchia of the upper lobe pale, thin, transparent; an inch from the summit to the extent of an inch or two, the texture granu- lated, grey, and of a light livid color; also in this lobe gray gran- ulations from one to two lines in breadth, irregular, in some parts forming masses of half an inch in diameter. Lower lobe, nu- merous, grey, semi-transparent granulations, some slightly opake, but much smaller than those of upper lobe ; several bronchia dilated, from two to four times their natural size; their mucous membrane, thickened, and a little red; cartilagi- nous to their very extremities. Heart. — In pericardium, half an ounce of serous fluid. Volume moderate, and of sufficient firmness ; a white patch on the front; cavities and orifices natural. Abdomen. — Stomach, of moderate size ; contracted mid- way ; containing a yellow liquid, quite unctuous ; internal sur- face pale, except for one inch near the pylorus, where there is a very little redness, aborescent; mucous membrane rather 393 thin, giving strips from two to three lines in the great cul-de- sac, seven to eight in large curvature, ten to twelve in small curvature. Spleen small, natural in color and consistence. Small intestines, containing a yellow liquid, not very abun- dant in the first third ; then, a whitish liquid ; and in the last three feet, yellow, pultaceous fecal matter ; moderate in size ; very little mucus adheres after washing; the last half slightly injected, but this is mostly in the sub-mucous tissue; Brunner's glands quite numerous, and rather large in the last five feet; free from ulcerations and from tubercles; strips from six to eight lines in the whole extent. Mesenteric glands small, natural. Large intestines moderate in size ; feces pultaceous in the first part, moulded in the last part; mucous membrane inject- ed in many points ; Brunner's glands very uncommonly nu- merous, especially in the first half, where they may be said to be confluent; in the parts red from injections, the mucous membrane is not thickened, and its consistence is scarcely greater than that of mucus, the strips not more than one to two lines at most. Liver, measuring more in thickness than in breadth by an inch, reaching from the fifth rib to an inch below the crest of the ilium ; left lobe small; the right more light colored than the left ; not fatty ; gall-bladder natural, containing a little yellow liquid. Uterus and bladder, natural. By the Editor.—In this case we should note, 1st, the chronic headache for three years ; 2d, the hemoptysis on the 6th to 16th Jan.; 3d, the physical signs of disease in the lungs, viz.; on Jan. 7th, in the midst of the hemoptysis, a sub-crepitous, 50 394 a mucous, and a sonorous rale below the right clavicle. We may presume from this evidence, and all that follows, that there was at this period an afflux of blood to the upper right lobe, and that the hemorrhage was from this part. On the 13th the respiration in the same part was imperfect, not so loud nor so pure as at the left, and the percussion less so- norous. May we presume that now the bronchia were ob- structed, so that the air vesicles near the right summit in front did not take part in respiration ? Possibly this might be a tran- sient state at the moment of the exploration, for it is different from what preceded, and from what followed. On the 26th, after the immediate effect of the second hemoptysis had sub- sided, we have again a rale, (now sub-crepitous, which nearly corresponds with the mucous and crepitous rale of the 7th) in the right breast, extending from the clavicle to the mamma. This is not to be referred to the influence of tubercles alone, but to the vascular state of the surrounding parts, a state analo- gous, at least, to inflammation, either in the cellular, or mucous tissue, and perhaps in both. Corresponding to the summit of the right lung behind, we find similar signs. On the 28th of Jan. we find signs similar to those last stated, ob- served at the posterior part oS the summit of the leSt lung, even more at that moment than at the corresponding part of the right. At this time the sputa do not give evidence of suppuration or soStening of tubercles, but rather of an inflam- mation in the lungs. On the 1st and 3d of Feb. we have a more full account of the physical signs ; the examination seems to have been more complete than before; and as death oc- curred on the 4th, these signs should accord very nearly with the actual state of the organs discovered after death. With- out repeating the account of those signs, we may say that they lead us to look for more disease in the right lung, than in the 395 left; and that the results of percussion do not show an exclusion of air from various parts, so much as the auscultation shows defect or embarrassment in the respiration. These phenome- na lead us to look for emphysema; and especially in the right breast, immediately below the clavicle, we must pre- sume that emphysema exists in a well-marked degree. In the appearances post mortem, we find the results cor- responding with our expectations, as regards the lungs. Em- physema is found in various parts, in accordance with the so- norousness on percussion; and this is true, especially as to the summit of the right lung in front, and that of the left behind. The induration of the right lung, as compared with the left, (not uniformly, but with intervening portions emphysematous,) the tubercles and the tuberculous cavities, all correspond with the physical signs in a very perfect manner. The dilated bronchia and the emphysema render it most highly probable, if not certain, that this woman had been sub- ject to pulmonary catarrh and dyspnoea at many times in her life. Perhaps this is not disproved by the denial of the pa- tient on the 8th oS Jan., when we consider how often people mislead us, as to the past, from indifference, or an unwilling- ness to satisfy our inquiries, and recollect that her " disposition was peculiarly ugly;" a circumstance which is stated in stronger language than I have thought proper to copy. It should be particularly observed, that nothing found with- in the cranium explained the chronic headache of three years, unless we should attach some importance to the lilac color of the centrum ovale. As regards the functions of the alimentary canal, the notes are less full than usual, and we therefore will pass by the changes discovered in the digestive organs; except only to remark on the size of the liver, which surely might 39G have been detected during life, but which is not noticed in the case. CASE XXVI. PHTHISIS AND EMPHYSEMA OF THE LUNGS. Hospital la Pitie. Ward St. Charles, 21. Under the care of M. Louis. Feb. 12, 1833. —E. F., aet. 39, a day-laborer, was a found- ling and knows nothing oS her parents. No catamenia Sor Sour months ; never had leucorrhoea ; has not had any children. Has had palpitation Sor some years. Has been subject to ca- tarrh, but this has not lasted more than eight days at a time. Has had a cough since Jan. 1832, constantly getting worse ; emaciation slight in summer, but greater Sor Sour months; since August has worked with difficulty, and not at all the last two months ; Sor two or three months a little spitting of blood, and for two months severe pain in back; diarrhoea with nau- sea for fiSteen days during the prevalence oS cholera last spring; appetite variable; extremely Seeble; has kept her bed Sor some time. Now, Sace rather red ; tongue moist, whitish ; thirst Sor two months; no appetite ; natural dejection yesterday; abdomen a little painSu! on pressure, a little resistance on pressure in right hypochondrium, not circumscribed ; pain in neck at times ; voice Seeble, altered ; heat moderate, elevated ; p. 92, rather corded ; sputa moderately abundant, some of them tinged with blood, mostly greenish, opake, not Srothy, but covered in the eup with Srothy saliva ; copious night sweats. On auscultation, respiration good below leSt clavicle; the same below the right, except occasionally some crackling; be- 397 hind, at the summit on the left, crackling, amounting during cough to gargouillement, at some moments the cough cavernous; the same at the right summit behind, last evening, and now a bronchial inspiration and expiration, also resonance oS voice; resonance good on percussion in the clavicular regions and be- low scapula; percussion everywhere rather painSul; when she coughs she hears something crack low on the leSt side. (Gum potion.) Feb. 13. — Feels more Seeble ; two dejections ; counte- nance paler. Behind, at the right summit, respiration coarse, and bronchophony; at the lower two thirds, on the right, sub- crepitous rale ; at left, resonance oS voice much less, and no sub-crepitous rale; a very littie oS this rale below leSt clavicle ; more resonance on percussion at the upper part behind on the right, than on the leSt; decubiture Sormerly on the right, now very difficult on that side; sputa yellow, opake, with a little blood ; some resistance and a little pain on pressure in right hypochondrium, not in a circumscribed space. (A small opiate added to gum potion. Milk, soup.) Feb. 21. — Sputa more liquid since she has been in the hospital. Resonance on percussion greater below leSt clavicle, than below right; indeed quite flat below right, except near sternum ; no resonance oS voice below either ; behind, in the upper third on the right, and near the vertebrae some crackling, some bronchophony, and a superficial tracheal respiration ; in the same parts at the left, the same in less degree and more limited. (Gum potion with two drachms of syrup of ether. Half a grain of opium.) Feb. 26. — P. 96, at four, p. m. Face deeply flushed, tongue coated ; anorexy ; no diarrhoea ; headache. Gurgling, cavernous respiration, and especially expiration, at the right summit behind ; amphoric sound at left shoulder on cough. 398 March 5. — Of late diarrhoea. March 19.—P. 120, Sace flushed; heat; liver Selt two inches below the edge of ribs. Gurgling and pectoriloquy at both shoulders; respiration amphoric at right. On some days, since the 5th, the respiration has been noted as amphoric, and on others as only bronchial and not amphoric. On the 11th, nausea. March 23. — Pain at epigastrium; nausea and vomiting occasionally ; two dejections preceded by pain, palpitation. March 26. — Little sensibility where the liver projects be- low the ribs ; sensation since last evening oS something stick- ing in lower part of the neck, an inch below larynx; no tu- mor in neck. April 1. — Sputa, in part opake and yellow, in partSrothy; diarrhoea less. Respiration cavernous, or tracheal at leSt sum- mit behind. April 4.— Emaciation has been more marked ; countenance shrunk ; pain at epigastrium, and nausea on most days oS late; diarrhoea moderate and not constant; sputa diffluent, abundant, opake and yellow. April 6. —In the evening, after supper, suddenly a severe pain in the right side ; crying all night; anxiety; increased dyspnoea ; eyes more sunken ; face contracted. Percussion not very sonorous on that side; no amphoric respiration there. April 7. — Some flatness on percussion over right side. April 8, four, p. m. — Great groaning and distress. April 8, nine, p. m. — Death. Autopsy, April 10, ten, a. m., —twenty-three hours after death. Externally. — Nothing remarkable ; pale; no oedema; no discolored spots except green color of the parietes oS the ab- domen. Emaciation nearly oS the last degree. 399 Head. — Not examined. Neck. — Pharynx, epiglottis, larynx natural; trachea red in the lower halS, contains much mucus. Chest. — Pericardium contains two ounces oS slightly red serous fluid, without any flakes. Heart rather pale, oS natural size; excessively flaccid and soSt, so as to be easily penetrated by the finger; much coagulated blood in the auricles and coagu- lated fibrine in the aorta; inner surSace oS aorta and sigmoid valves, oS both arteries, oS a livid red color. Left lung does not pass beyond cartilage oS ribs; adheres almost throughout; old infiltration at base; a little emphysema oS a limited portion oS the Sront edge, or margin; at the posterior part oS apex, and covered by parietes oS only one line in thick- ness on the back, a tuberculous cavity, two inches in diameter, containing a thick reddish fluid ; bronchia leading to it dilated, and have their mucous membrane red and thickened; near this cavity another, rmailer, less advanced, and traversed by cords, (brides). Whole upper lobe thickly studded with tubercles in different stages; the lower lobe has the same, but generally less crowded and less advanced; bronchia, except those lead- ing to cavities, have their mucous membrane pale and thin. Not more than halS this lung, iS so much, could admit air. Right lung reaches nearly to middle oS sternum, and is emphysematous to the extent oS Sour or five inches along the Sree edge and to the depth oS one inch ; adhesion universal; the Salse membrane over the lower lobe, at the side and base, yellow, not organized, recent; the corresponding pleura oS a purplish red and injected ; no effusion into pleura. In apex two tuberculous cavities, not an inch in diameter, very recent, having no Salse membrane, but shreds oS loose pulmonary tissue; the bronchia leading to them have the mucous membrane red and thickened more than in other parts, but less than those 400 leading to the cavity in the left; tubercles numerous, most in the upper lobe, but generally less than in the left lung; lower lobe engorged with blood, in some parts destitute of air, though it has considerable quantity oS bloody fluid, is easily Sriable, not granulated, nor floating in water. Abdomen. — Stomach covered anteriorly in considerable part by liver; oS moderate size; parietes very thin, containing little liquid and scarcely any mucus; internally quite pale every where ; mamelonated in the great curvature to the extent oStwo inches; near pylorus mucous membrane very thin, not yielding a strip; in the great cul-de-sac and elsewhere, the strips and thickness as usual. Small intestines contain much yellow mucus above and pul- taceous matter in lower part; about twenty ulcers, small, mostly in the patches of Peyer's glands, pale, and not penetrating to muscular coat; some tubercles on a Sew oS the last patches; strip oS two lines only in the last foot of the ileum, and this por- tion a little red, elsewhere pale and affording good strips, except near the ulcers; sub-mucous membrane not injected. Mes- enteric glands healthy; one calcareous mass in the border of the mesentery. Large intestines contain very numerous ulcers; forty-six counted Srom a third oSan inch in diameter to a size very much larger, besides many small ones; these ulcers equally dis- tributed Srom caecum to rectum, except in the third quarter, where there is scarcely one; they are of a dark color, with edges very little raised, some having penetrated to the muscu- lar membrane, others to the cellular only; generally round, but not all of them perfectly so; the mucous membrane gene- rally pale, giving strips from three to four lines in the caecum, twelve to fifteen in the colon; very few solitary glands. 401 Liver large, not fatty, descending below the ribs ; the yellow substance predominating greatly over the red, giving to the organ generally a light yellow complexion. Gall-bladder greatly distended. Spleen, small, rather soft, of natural color. Uterus, small, natural. Right ovary had attached to it a little cyst containing a transparent fluid. By the Editor. — In this case we notice ; 1st, the palpita- tion for several years ; 2d, the cough for thirteen months be- fore entrance into the hospital, constantly growing worse; ac- companied at a late period by slight, but repeated hemoptysis and by purulent with other sputa ; also by progressive ema- ciation and debility. These symptoms demonstrate, perhaps, sufficiently, the existence of phthisis. 3d. Below the right clavicle a crackling in respiration and flatness on percussion, except near sternum ; at the left summit behind the same crackling, and, during cough, even gurgling ; the cough cav- ernous at some moments on Feb. 12th, subsequently respira- tion cavernous or tracheal, also gurgling and pectoriloquy there; at the right summit behind bronchial inspiration and expiration with resonance of voice Feb. 12th, and sub- sequently gurgling and pectoriloquy ; on percussion, more flat generally in the earlier days at the left summit behind, than at the right; below clavicles more flat at right than at left; at one period sub-crepitous rale below right scapula and at last flatness on percussion on right side, following pleuritic pain there ; 4th, some dyspnoea, and on March 26th, a sense of something sticking in the trachea; 5th, enlargement of liver, and at a later period soreness in epigastrium with nausea, vomiting and diarrhoea. 51 402 From these phenomena we should look Sor tubercles in both lungs, especially at the upper part, with tuberculous cav- ities there, of oldest standing at the left on the back part oS the apex; also more extensive tuberculous disease in the right lung than in the left, with recent pleurisy at its lower part ; some inflammation, or ulceration of the mucous membrane oS the trachea ; enlarged liver; perhaps disease in the mucous membrane of the stomach, and more certainly in that oS the in- testines. In regard to the heart, the palpitation of several years might raise a suspicion oS organic disease; but alone it would not justify such a suspicion; and, while the patient was under observation, nothing is noted to lead ultimately to such an expectation. IS we look now at what was discovered post mortem, we find ; 1st, less disease in the trachea and vocal organs, than might have been anticipated; nothing more than a redness in the lower halS of the trachea, and much mucus; 2d, a large tuberculous cavity at the posterior part of the apex oS the left lung, with another smaller cavity near it; the rest of the lung, especially the upper lobe, studded with tubercles; the mucous membrane diseased in those bronchia only, which led to the cavities; 3d, in the right lung an emphysema, oS which the signs had not been noted during liSe; the recent Salse membrane and deeply red pleura; two tuberculous cavities at the apex, more recent than the large one at the left; the bronchia leading to them diseased, like those leading to the cavity in the left, but not so much ; fewer tubercles, but more extensive disease of other kind, than in the left lung. Thus the whole disease in the lungs corresponds mainly, though less precisely than in some cases, with the indications furnish- ed by the physical signs. 4th, The liver enlarged; 5th, the stomach not much diseased; 6th, the intestines diseased as was 403 anticipated, but more extensively than could have been safely anticipated. On this point it may be remarked that the extent of disease in these organs cannot be decided by the symptoms, though its nature may be in most cases. Let it be noted that the mucous membrane was most dis- eased in those bronchia, which led to the tuberculous cavities ; a circumstance justly insisted upon by M. Louis as evidence that this inflammation is a consequence, not a cause of tu- bercles. Were it otherwise we should find the same thing in bronchia leading to crude tubercles, which we do not. CASE XXVII. PHTHISIS. Hospital la Pitie. Ward St. Charles, 36. Under the care of M. Louis. March 16, 1833. — F. G., aet. 29, seamstress, for sixteen years past. This woman was born at Rouen, of parents, neither of whom had ever suffered from palsy, or difficulty of breathing. The father died at the age of 79, of a disease which lasted only eight days. The mother, aet. 60, is still alive and well. She has had six brothers and five sisters; two of the former are alive and well, aet. 33 and 27 ; two sisters are also living and well, aet. 15 and 13. The patient has had three children, last six years ago; two died at ages of 18 and 3 months; the other is now 12 years old. Has never miscarried. Has not nursed children. Present disease first began to manifest itself fourteen months ago, by loss of appetite and imperfect health, though no ema- ciation for two months, when she came to Paris, and has been here since. The catamenia, which had been always regular 404 Srom the age oS 13, rather abundant, preceded by pains in abdomen and loins, and flow continuing Sour or five days, be- gan, eighteen months ago, to be preceded by leucorrhoea. They have not appeared Sor six past months, and patient has had occasionally slight leucorrhoea during this time. ASter arrival at Paris, ( i. e. one year since,) cough began, accom- panied by coryza Sor a month ; very little expectoration. Six weeks Srom this time, tried to wTork, (having done nothing since arrival,) and did so Sor three days, when hemoptysis came on. This was slight but Srequent for two months. Last three months never at all. Pain in left side of chest before hemop- tysis ; very severe during time of hemorrhage, but none when cough began. Has had occasional pain in right side also. Her voice was hoarse at the beginning of cough. Has never had diarrhoea, though for sometime has had one dejection daily, liquid. Six months since was in hospital, (St. Antonie,) and then had "jaundice,",and sweats in night. Heat of skin in evening for six weeks past. Now, lying on right side, great dyspnoea produced by lying on left, and patient hears a slight noise in chest when in latter position. This inability oS lying on left side has existed only since commencement of present disease. Tongue natural; no thirst; voice little less clear and strong than before illness. Cough has been very frequent, and expectoration abundant, until within six weeks; less since ; most so in morning. Some sputa now in cup, white, opake. Pulse 92 ; no headache ; intelligence and memory good ; eyes and hair black. On examination oS chest, parietes are a little more sunken under right clavicle, than left. Behind, on and below left clavicle, down whole of front of this side oS thorax, percussion gives a sound quite flat, and with that of a cracked jar. Respi- ration is bronchial, mingled with gurgling, for the space 405 of five inches, below left clavicle ; respiration pure below right. On back of chest percussion much flatter leSt than right. Respiration at summit is bronchial and cavernous; below is only coarse. Resonance oS voice well marked at left sum- mit, and in the space of three inches. Bronchophony, and very Seeble respiration at right summit. (Gum potion, one quart. Three cups oS soup.) Five, p. m. — P. 100, small; skin moderately hot. March 18. — Tongue natural; vomited; one dejection in night. Patient hears a gurgling sound under leSt clavicle ; loudest when lying on leStside ; she hears nothing under right. At top oS right shoulder, and in the space of five inches down back, is heard a slight gurgling. Bronchial respiration in up- per two thirds of same side, and, below this, respiration is louder than it is on other side, but it is coarse and mingled with a mucous rattle. On percussion left side of back of chest much less sonorous than right. March 19, five, p. m. — Face flushed ; skin hot; p. 108. March 26. — No pain in right hypochondrium. Four, p. m.—Has vomited a little bile every day Sor five or six days past, when coughing. April 1. —Vomiting continues. (Seltzer-water one botttle.) April 2. — No vomiting ; cough less ; has slight nausea, but thinks vomiting prevented by Seltzer-water. April 4. — No vomiting. April 7, Sour, p. m. — P. 84; gurgling heard below leSt clavicle ; a prolonged expiration below right. April 8, halSpast eight, a. m. —At halSpast 6, a. m., was as well as during evening previous. At that time was suddenly seized with an acute pain in left side of thorax, and great dyspnoea. Now, these symptoms continue; resp. 50 in a 406 minute, very high ; speech almost impossible ; face, and lips, and hands, violet; tongue and face cool, as in cholera; no vomiting ; no dejection this morning; abdomen not mete- orized, nor painful on pressure. On auscultation, respiration is heard at rigjht side of chest. (Antispasmodic potion. Sinapisms to legs*) Patient died at one, p. m. Autopsy at nine, a. m., April 9, twenty hours after death. Exterior of body. — Second degree of marasmus ; less than a line of fat on chest; no violet spots. The lower half of right side of chest is larger than left; and it is more sono- rous than corresponding parts of the other side. Head. — Glands of Pacchioni not large, nor numerous. Arachnoid injected over an extent of two inches on each side of anterior lobes, where it is a little more friable than else- where, though not thickened; slight infiltration under posterior part of membrane. Gray substance of brain is of the natural color; white rather more filled with red points, than usual, and it is a little softened. About one ounce of serous fluid in each ventricle. Cerebellum, medulla oblongata, protuberance an- nulare, healthy. Thorax. — Lungs are in their natural situation; nearly touching 'each other at their anterior edges. The right lung is large, and very slightly adherent at apex. Several hard spots felt in upper lobe, fewer in middle, still less in lower lobe. Some vesicles are dilated, near anterior edge, to the size oS a millet-seed. Three quarters oS the lung is elastic, crepitating, oS a light violet, or whitish color, externally. Some granulations are seen at the points, where adhesions have been ruptured at apex. On cutting this part, many granula- tions presented to view, oS various sizes; some little clear, gray masses ; others larger, and others intermediate. There 407 is also a small cavity, oS the size of a riut, lined with a Salse membrane, and containing tuberculous matter. The bronchial tube, leading to this cavity, is red, ecchymosed, thickened, dilated, and contains a Salse membrane within five or six lines oS its termination. The other tubes oS this lobe, leading to the parts filled with granulations, are pale, polished and healthy, as are also the bronchia oS the two lower lobes, which contain granulations, but less advanced; very Sew in lowest lobe, and there only at upper part. Left lung adheres in part at apex and behind, but the re- mainder oS it is Sree. The upper lobe is flaccid. At the apex oS lung there is an excavation, containing a little red liquid. It is oS an irregular Sorm, and without any divisions in it. It is lined by two Salse membranes, one soSt, as iS tubercu- lous, the other firm, and oS a reddish-gray color, one third oS a line in thickness. This excavation is about as large as a good sized apple. Adjoining it, though not communicating with it, is another, oS the same structure, but less in size. A third small excavation, Sour inches Srom apex, near anterior edge oS the lung, which is almost immediately continuous with a bronchial tube, and this last is dilated to more than halS an inch in breadth, to the extent oS halS an inch Srom its termination. One oS the bronchial tubes still lower in up- per lobe, leading to edge oS lung, is covered with a Salse tuberculous membrane ; its parietes are thickened, hardened, pale, opake, though they retain a certain degree oS polish. Throughout this lobe are many granulations, varying as in right luno-. Similar granulations are Sound in the lower lobe, but much more numerous than in right. At the top oS lower lobe is a cavity, oS the size oS a nut, filled with a reddish fluid, and portions oS tuberculous matter. It is lined with a Salse mem- brane, and the bronchial tube leading to it is reddened and 408 thickened. Another, tube leading to a smaller cavity, has many ulcerations on it. Scarcely one third of this lung is capable of containing air. Abdomen. — The liver is large, in consequence of in- crease of size of right lobe, which is ten inches in thickness. It covers part of the anterior face of stomach. There is a cicatrix toward right side, but the parts subjacent are natural. The exterior is of a fawn color, and internally it is spotted minutely with the same. It is moist, but is not fat. The Gall- bladder contains a small quantity of dark-green, moderately viscid bile. The stomach is of about half the usual size, and contains one ounce of white, unctuous fluid, mingled with mucus. This is adherent to the mucous membrane, but it can be entirely removed by the back of the scalpel. The mucous membrane is thrown into numerous folds along great curvature ; it is oSa pink hue, or color oS the parings oS onions, over part oS its surSace; more so on anterior face, where covered by liver, than elsewhere. It is more or less injected throughout whole extent of stomach ; but has no mamelonated appearance. Strips of the mucous membrane can be raised to the length oS twelve, or fifteen lines, along smaller curvature ; six to seven in part of great cul-de-sac ; five to six on anterior face ; three to four, and six to seven on posterior Sace. Sufficient thickness oS this membrane throughout stomach. Small intestines contain a small quantity of viscid mucus. In the latter half are seen numerous ulcers, from one to two lines in breadth, and situated, for the most part, on the patches of Peyer's glands, and more or less numerous on each. They seem due to numerous little yellow miliary granulations, some of which are seen around them. The patches, where not ul- cerated are reddened and thickened; some to the extent of 409 one or two lines. Beneath one of them there are evident tubercles in the muscular tissue. The mucous membrane is more or less injected and soStened in the intervals between the patches. In the first halS oS small intestines there is less gen- eral Sulness oS the vessels oS mucous membrane, and strips oS it, five or six lines in length, may be raised in the first three Seet, below duodenum; but below, towards ileum, the strips are much shorter. In the caecum are five large ulcerations, with some tuber- cles. The ulcers have raised edges, which are oS a reddish- gray color; they are rough at their centres. Three inches below caecum is one ulcer, two inches in diameter, surround- ing the whole gut. Its centre is oS a grayish-red color, and its edge is raised as those of the others above-mentioned. Its form is irregular, and it is covered with a sort oS detritus, beneath which is the sub-mucous cellular tissue, thickened and rough. A similar ulceration is Sound in the middle oS trans- verse colon, besides many smaller ones between it and caecum. Throughout intestine, strips oS mucous membrane may be raised to the length of eight to ten lines. Mesenteric glands large, red and soft, adjacent to lower half of intestine ; small and gray in upper half. The kidneys are of a violet hue, and of natural size. The spleen is pale with minute spots of red upon surface ; it is flaccid and soft. The bladder is small; its mucous membrane is pale and healthy. Fallopian tubes adherent to ovaries, and some slight old adhesions between uterus and rectum. Upon the surface of uterus, and underneath peritoneum, is a small, hard, white, shining, cartilaginous tumor, of the size of a pea; it is not 52 410 encysted. The mucous membrane of uterus is rugous and a viscid mucus is found at os tincae. By the Editor. — The whole history of this case shows that the disease was tuberculous, and worse in the left than in the right lung. Accordingly, tuberculous cavities are found in each, but more and larger in the upper left lobe, than in the right; also more tubercles and more compression of air-cells throughout the left lung, than in the right. The diseased mu- cous membrane in those bronchia, which led to the tubercu- lous cavities, so often noticed in other cases, is a circumstance not to be overlooked. There is, however, nothing noted in the autopsy to account for the violent pain, he., which occurred a few hours before death. The rupture of a softened tu- bercle, and a discharge of its contents into the cavity of the pleura, might have been suspected; but no evidence is afforded that this had happened. The disease found in the intestines is oS the kind, that, but greater in amount than, the history of the disease led us to anticipate. The enlargement of the liver seems not to have been discovered during life ; but prob- ably was connected with the affection under which jaundice occurred. CASE XXVIII. PHTHISIS. Hospital La Pitie. Ward St. Charles, 8. Under the care of M. Louis. G. H., aet. 38, a laborer. Born in the north of France, at Paris, about twenty-five years. Her father died in battle, mother also dead; she knows nothing more oS either oS them. One sister, near her own age, oS whom she knows nothing. 411 Has not lost any brother or sister. Has two children, aet. 6 and 7, well. Has not had any grave disease, that she remem- bers. Catamenia commenced at 14, always regular till 1st Jan. last, never abundant, continued eight days, and preceded by pains in loins and hypogastrium ; no leucorrhaea ; married at 24 ; no children for six years ; no abortions at any time ; not subject to catarrh, nor, before present disease, to short breath. Hair brown, eyes black, intelligence moderate. March 26, 1833. —Has been in the hospital since the 14th inst. A slight cough for two or three months before January, then became sick so as to give up work. From that time, loss of flesh and strength ; chills at evening, thirst, cough more frequent, pain in the left side of chest, pain in abdomen, and abdomen constantly growing larger; diarrhoea for three or four days only. Five days since, twenty-five leeches to ab- domen, after which pain and meteorism lessened ; yesterday, ten leeches. To-day, nothing peculiar in face, except emaciation; de- cubitus equally easy on either side ; respiration accelerated; p. 100, small; heat elevated ; tongue, not red, clean at edges, yellow coat at centre ; cough rather rare; abdomen large, and quite tympanitic, except at right flank, where it is flat on percussion, and pressure is very painful. On percussion on the right clavicle and above it, less sonorous than on the left; and below, though the sound is clear, not so much so as below the left. Respiration below the right clavicle very obscure ; on the back, at three inches from the apex, at the right, respiration bronchial; at the left, in corresponding point, a blowing (sifflement) at the same point; more flat on percus- sion on the right than on the left; above and below right clavicle more depressed than in same parts at left; the whole breast at the left, even the intercostal spaces prominent; res- 412 piration very dry there, but not very weak, and without any blowing. (Enema with laudanum, ten drops. Cataplasm to ab- domen.) March 27. — Tongue white, villous at centre, natural at edges ; dejections numerous ; abdomen tense, sonorous on per- cussion, except in right hypochondrium, beginning two inches from median line; no sleep ; pulse small, regular, feeble ; bronchial respiration as yesterday, near apex, behind, on both sides, and bronchophony at same points, over largest surface on the right; respiration rather coarse in front at the right, where percussion is also less sonorous; at left, in front, respiration more superficial than at right. Now states that more urgent symptoms began in December. (Same prescriptions.) March 29. — Numerous dejections in bed ; abdomen much less voluminous ; no sleep; no heat; p. 104 ; cough frequent. At four, p. m., skin cold; pulse thread-like; diarrhoea ex- treme ; much shrunk since morning, April 7. —To this day the diarrhoea has been very urgent, and on the 1st inst. there was vomiting; the suffering, the prostration and wasting have been very great; the swelling of the abdomen has subsided Srom day to day; and till to-day the right hypochondrium has been flat on percussion, but now it is sonorous, and also less painSul; to-day only two dejec- tions, and generally less suffering. (The remedies have been opiates, rhatania, and white de- coction.) April 15. — The diarrhoea has continued moderate; cough much more urgent; urine once a day, scanty, and with ex- treme pain. To-day groans oS suffering; extreme pain in ab- domen, which is quite retracted, and not sonorous on percus- 413 sion in any part; diarrhoea more urgent; tongue a little dry ; emaciation extreme. (Hydrochlor. Morph. a grain and a quarter in solution oS gum arabic. Enema with laudanum, twenty drops, twice in the day.) Died, April 19, at three, p. m. Autopsy, April 21, nine, a. m., Sorty-two hours aSter death. Exterior. — Marasmus in the greatest degree. No dis- colored spots. Chest very narrow. Abdomen retracted. No oedema. Upon percussion the sound oS a broken jar below the right clavicle, not so below the left. Chest.—Left lung free from adhesions, pale; no effu- sion in the cavity oS the pleura; vesicles excessively small; toward the edge the lung is rounded ; slight interlobular em- physema ; internally, some Sew, scattered, gray, semi-trans- parent granulations in the midst oS a healthy, spongy, crepita- ting, pale texture ; also, an inch Srom summit, a little tuber- culous cavity, halS an inch in diameter; in lower lobe some very Sew granulations like those in upper; bronchia, pale, healthy. Right lung adherent universally, pale as the left ; an inch above the division of the bronchia, a cavity the size of an apple, containing pus ; in this cavity two Salse membranes, the first rough on its surSace, yet soft; this covers the sec- ond, which is firm, a millimetre in thickness ; and this reposes upon a healthy texture ; two smaller cavities at the summit, also filled with a pretty consistent, greenish, homogeneous pus, and lined by a very thin, white, false membrane; the large cavity extends to the interlobular scissure. Immediate- ly at the summit of lower lobe a similar cavity, in size one quarter of the first mentioned. The bronchia entering the cav- ities, pale and not thickened ; none of the bronchia red. Per- icardium contains one ounce oS yellowish serous fluid. Heart 414 scarcely more than halS the usual size ; contains a moderate quantity oS blood. At the origin oS the aorta several yellow, opake spots. Larynx, epiglottis, trachea pale, natural. Abdomen. — Liver, right lobe enlarged, moderately moist, the light substance most abundant, not evidently Satty or greasy; bile viscid. The liver adheres to the peritoneum, adhesion easily broken. Below is a coherent mass, a little elastic, Sormed by an adhesion, the Salse membrane thick at some points, between the caecum and a part oS the ascending colon and a portion oS the small intestine. Near the lowest part oS the ascending colon is a little perSoration, two to three lines in diameter, the edges oS which are either raised, even and polished, or cut down sharp (coupe a pie;) this perSoration opens into a tumor containing Seces and purulent matter. Stomach oS halS the usual size ; containing a little mucus, rather viscid ; scarcely a Sold in the great cul-de-sac; the Solds pretty numerous in the pyloric halS, yet less than in propor- tion to the reduction in size; internal surface a little blueish along the small curvature, white or yellow elsewhere; some Sew points perhaps mamelonated near pylorus; Sour inches from pylorus three depressions, where the mucous membrane is entirely destroyed, these from one to three lines broad, reddish; on the anterior face, near great curvature, over some extent, mamelonated slightly, and in this part covered with mucus; in the same part a (fillon) depression or furrow, eight or ten lines in length and nearly a line in breadth; mucous membrane normal in consistence and thickness; at*the mam- elonated part, only, a little thicker. Small intestines. Adhe- sions at some few points; small in size; contain a moderate quantity oS mucus; mucous membrane natural, except in the last three Seet, where it is much softened and slightly reddish. Large intestines. Caecum oS an intense red, with a linear 415 destruction oS mucous membrane, which is thickened and softened. In the ascending colon the redness almost disap- pears ; in the transverse colon an incomplete linear destruction of the mucous membrane, which is generally pale, a little thick- ened and soSt as mucus ; the same alternation throughout the large intestine, which is generally white, but pink at certain points; no tubercles seen. The rectum, halS as broad again as common, in contact with a reddish, purulent fluid; more than halS its mucous membrane wanting; where this membrane exists it is in oval patches, Srom a quarter to halS an inch or more in length, oS a lively red color, and granulated; the in- tervals showing the naked cellular texture. Spleen, small, natural. Kidneys small, natural. Bladder turned to the right side by adhesion to the surrounding parts; oS the size oS a small apple; its mucous membrane a little violet, and rendered so by a somewhat fine injection oS its vessels; otherwise natural. Uterus, turned over in Sront and Solded in two, also turned to the right; so that very littie oS it (halS an inch) is on the left of the median line. Cavity natural, two and a half inches in length from the mouth; mucous membrane of neck injected and mucus on it, the substance rather red and firm. On the left of the uterus is a cyst, the size of a chesnut, firm, a line in thickness, not entirely opake, having some striae of a dull yellow color, containing an unctuous, greenish pus, with some parcels of opake, yellow matter. Behind this and a little above it, another cyst, rather larger, with blackish walls ; this commu- nicates at its upper part with the intestine, and has a gangrenous odour. Above and behind the uterus is another large cyst; and at one end several yellow, pretty firm, flocculent mem- branes, loose, or free at one edge; this cyst in one part is in contact with the uterus. 416 Head. — Arachnoid infiltration moderate, seen only be- tween the convolutions. Pia mater very moderately injected and of good consistence. At some points we detach with it a small portion of the gray substance, which is natural in color and in other respects, except that in front, on the right, it is a little softened. White substance very little injected, of natural tenacity. Other parts within cranium quite natural. By the Editor. —It does not seem to me clear whether the tuberculous cavities were all of them open in this case. If they were, the appropriate physical signs were not detected. After death the sound of a cracked jar, elicited by percussion, below right clavicle, might have been produced by the large cavity; but this was not noticed during life. The phenomena in the abdomen could not well have been anticipated. Chronic peritonitis might have been expected; still more ulceration in the mucous membrane of the intestines and tubercles in some part. The perforation of the intestines, and the limited mischief produced by it, are circumstances too rare to have been thought of. CASE XXIX. CHRONIC PERITONITIS ; TUBERCLES IN LUNGS AND IN ABDOMEN. Hospital la Pitie. Ward St. Charles, 36. Under the care of M. Louis, Jan. 12, 1833. — B. C, aet. —was born at Aix, and has lived in Paris since her ninth year. Small in stature, black eyes. Was never sick till now, except with the small-pox, at four years of age. Never had hemoptysis. Father died in 417 his 41st year, disease unknown to her ; mother alive and well in her 46th year; one brother, aet. 24, well; one sister died oS small-pox and one brother, of disease unknown to her; has not had any children. Menses commenced at 15, never reg- ular, occurring once in two to once in eight weeks, and usually continuing six to nine days, generally preceded, but not ac- companied by pain; no leucorrhaea in intervals. Not subject to catarrh. On 6th of June last, she received a fright on the third day of the catamenia, and these were suddenly suppressed. She was perfectly well at this time. Since that she has neither had the catamenia, nor the premonitory pains ; nor has leucor- rhoea occurred. On the 7th and 8th of June, she had dyspnoea, or oppres- sion at the breast. From that period she has had a little cough with very little expectoration ; also pain in right side, constant, but varying in severity, and obstructing respiration. Kept her bed the first five days, since then has been at work. Appetite diminished; has not eat more than a pound of bread daily, in health ate two; no thirst; diarrhoea uninterrupted from the beginning ; a dull pain in the bowels, not like colic ; tenesmus early in the disease, and occasionally of late; emaci- ation considerable ; for two months frequent alternations of cold and heat, and Sor six weeks night sweats. Present state, the morning oS Jan. 12. — Tongue moist, al- most natural; several dejections yesterday; slight meteorism ; no heat; p. 84, regular, not Sull. On and behind clavicles percussion not very sonorous. Respiration more pure below left clavicle than below right. A little resonance oS voice below right clavicle, also at the summit behind on both sides, especially on the right. 53 418 (Rice water sweetened with quince syrup. Two cups oS soup. Gum water with syrup of white poppy § ss.) Three, p. m. — Percussion less sonorous at the. right than at the left summit of the lungs behind. Jan. 14. — Sweat in the nights. Moderate diarrhoea with pain. Little sleep. P. 88 to 96. Heat. (Ten leeches to the thighs.) Jan. 16.—Leeches bled freely, without relief to the side. Now the pain has increased and is pulsating. (A cataplasm sprinkled with laudanum on the side ) Jan. 23. — Fever every night; last night much sweat. Right cheek very red, leSt not at all so. Respiration decid- edly Seebler below right clavicle than below left; below the former, expiration loud and bronchial, and a marked resonance of voice ; at the right summit behind respiration more feeble, than in front; resonance of voice there. Jan. 27. —To this day diarrhoea with griping has been in- creasing ; pain in abdomen, especially on left side, on pressure only; cough, without expectoration; respiration more Seeble, without any rale, and percussion more obscure, at the summit of the chest, both on Sront and back, on the right side than on left. Now, p. 108, extremely irregular in rythm and force; action oS heart also very irregular; its impulse strong and tumultuous ; percussion about its region to an inch above the mamma is decidedly less sonorous than on the opposite side ; respiration there much Seebler than on corresponding parts at the right; no palpitation, nor pain in that region. She has just got into bed. Jan. 28. — Pulse regular. Below right clavicle inspiration Seebler than below left, yet expiration heard in the former and not in the latter ; also resonance of voice below the right; at right summit behind, decided vibration felt by the hand lying 419 on it when she is speaking. Diarrhoea with griping ; pain in abdomen felt on motion, as rising in bed ; the abdomen swol- len, tympanitic, and painful on pressure. Loss of flesh and strength since entrance. Feb. 2, five, p. m.—Sweat every night of late; flushed usually at noon ; p. 108 ; pain in abdomen less, and only two dejections to-day ; twice to-day has vomited food with a littie bitter liquid ; sensation of weight in lower part of abdomen ; no cough, or scarcely any ; no oppression. Feb. 5. — Flushed, hot, much of the day ; p. 120, at four, p. m., with severe headache; diarrhoea and pain in abdomen less ; nausea this morning, but no vomiting since 2d, nor suf- fering from food ; rather more appetite; emaciation evident, especially on chest; all the physical signs before noticed, at the summit on the right, fully confirmed to-day. Feb. 6.—The respiration on right side of thorax feebler than the left; a vibration to the hand on the right, not on the left; the pain on the right began two inches below the clavi- cle, and passed round to the side, extending to the lower part. (White decoction ; prepared from phosphate of lime and gum arabic.) Feb. 8. — Some resonance of voice at left summit, behind, though less than at right. Feb. 10. — Diarrhoea has continued moderate. Pulse very irregular and intermittent; (has not been out of bed lately ;) almost perfect intermission of pulsation in heart, which is pre- ceded by a double beat; over a small extent in praecordial re- gion resonance slight on percussion. Feb. 11. — It is doubtful whether she has coughed con- stantly since June ; the only sure thing, on this point, is, that the cough has been very slight. Quite feeble, does not leave bed ; much sweat last night, appetite returning; a little meteo- 420 rism ; pulse regular. Above, below and on right clavicle, less sonorous on percussion than at the left; below right clavicle respiration bronchial; at the same place bronchophony ; bron- chophony also, extremely marked, at the right summit behind. (Four leeches to thighs.) In a clinical lecture on the 13th, M. Louis, remarked in substance that, 1st, the principal and most important symptom, since June, has been diarrhoea. Often, where a diarrhoea has lasted long, it is very easily and quickly cured. But this hap- pens, where there is neither fever nor emaciation. The dis- ease, in such cases, may be referred to a change in the secre- tory functions. This case has followed a different course, and may be reSerred to some other change in the intestines. Is there an ulceration oS the small intestines ? If so, there are tubercles in the lungs. 2d. Let us then look at the lungs. There we find the physical signs oS disease; especially at the summit oS the right lung. 3d. The symptoms of perito- nitis have existed for ten or twelve days or more. Feb. 16. — Diarrhoea has been increasing, Sor which a lit- tle opium has been administered in enema. To-day vomited once. Meteorism more constant. Face, especially about the eyes, has been getting yellow. Feb. 22. — Diarrhoea has continued; some sweats; now much meteorism and sensibility in abdomen. March 5. — No sputa. Diarrhoea has continued, and on 3d, vomitings oS bitter matter. Occasionally, transient acute pain in right side. Resonance oS voice and bronchial expira- tion half an inch from the apex at the right, behind ; the same phenomena at the left, a little lower, but less strongly marked than at the right. On percussion the right clavicular region flat, the left sonorous. Lies on the left side since the acute 421 pain on the right. Sound of the heart greater immediately below right clavicle, than two inches lower. March 11. —P. 90, small, Seeble, regular. No heat. No vomiting oS Sood Sor several days. Two to six dejections daily. Chills every day. An expiration can be heard and a little resonance oS voice below left clavicle. The other physical signs as before. Less meteorism. April 10. — Appetite has remained small, but variable; often nausea and occasionally vomiting of food and bitter mat- ter ; pain in abdomen always most at the right; diarrhoea not more urgent, though sometimes tenesmus; cough extremely slight. Meteorism has continued, and to-day a little fulness about the umbilicus, and resistance to pressure. April 22. — Increased emaciation lately. Tongue natural; no appetite ; for ten days constant vomiting after food, and sometimes of bile without it; thirst; diarrhoea with occasional griping ; some meteorism; a little cough for eight days, with- out expectoration; no oppression ; no pain in back nor in sides ; p. 120, small; resp. 24. I have heard her cough for the first time this day, at five, p. m. (Seltzer-water. Ten drops of laudanum in an enema.) April 27. — Emaciation increases ; vomits all her food; diarrhoea much increased ; cough slight; pain in abdomen, none in chest; p. 130, very small. Died, May 4th, at two, a. m., without agony. Has been sinking rapidly for three or four days. Autopsy, May 5, at nine, a. m., thirty-one hours after death. Externally.— Surface pale, except that the integuments of the abdomen have become a little green; both lower extremities very oedematous in their whole extent, the left hand slightly so ; not destitute of Sat under the integuments. 422 Head. — Membranes pale, very little injected; glands oS Pacchioni rather numerous; slight effusion under the arachnoid, behind only ; gray and white substance in every part pale, not injected, rather soft than firm ; no fluid in ventricles. Neck. — Epiglottis and larynx pale, healthy ; mucous membrane of trachea red, but of good consistence ; pharynx and oesophagus natural. Chest. — Right lung, adherent in its whole extent, even the trachea to the sternum; the false membrane over the lower lobe somewhat recent, yellow, pretty easily torn, nearly a line in thickness, containing some tuberculous matter; the lung larger and heavier than the left; at the apex of the upper lobe, the appearance of a cicatrix with nothing corres- ponding to it in the substance beneath; several small opake tubercles on the pleura ; no air, or very little, in this lobe ; its color a dark violet; its substance firm, and internally dark col- ored ; in the midst of this substance is tuberculous matter in masses of different shapes and sizes, from the head of a pin to that of a pea; among these substances is one, an inch in length and a third of an inch in breadth, lined with a Salse membrane, containing a white matter, which resembles cheese ; no cavern; few tubercles below; those above, some gray, some opake; mucous membrane of the bronchia of this lobe gene- rally red and thickened, without its natural smoothness and polish; one or two of the bronchia contain tuberculous mat- ter; the lower lobe contains blood in excess, is not granulated, nor hepatized, and its bronchia are pale and natural. Left lung adherent at its summit, but not elsewhere ; in the cavity oS its pleura six ounces of serous fluid; similar in its lesions and condition to the right lung, except that the part especially dis- eased extends two inches Srom the apex instead oS five, and the diseased processes are rather less advanced; a little inter- 423 lobular emphysema at the lower margin. More than two thirds oS the two lungs, taken together, Sree Srom important diseased change. Heart, small, natural in color and firmness, Sree Srom all lesion ; the pericardium natural, pale, contains six ounces oS citron colored liquid. Abdomen. — In peritoneal cavity eight or ten ounces oS citron colored liquid ; slight adhesions oS omentum to intes- tines, especially at the lower part, also to the parietes in Sront and lower part ; partial adhesions oS the intestines, small and large, especially the Sormer, at the Solds ; the adhesions most- ly corresponding to ulcerations internally; some Sew small opake tubercles upon the sub-serous surSaces. Stomach of a moderate size, containing a small quantity oS mucus, not adhe- sive ; internal surSace pale, except in the small curvature near each orifice, where the mucous membrane is red, injected; slightly mamelonated, to a small extent, in the large curvature near the pylorus; thickness oS mucous membrane natural everywhere ; the strips Sour to five lines in the great cul-de- sac, ten lines on each oS the Saces, ten to twelve in the small curvature. Small intestines oS a moderate size ; presenting externally some Sew tubercles at points oS adhesion ; very Sriable at these points, where generally the color is dark, cor- responding to ulcers within; internally containing a light yel- low liquid, not abundant in the first portion; in the last three Seet the liquid becoming oS a light reddish-gray color; mu- cous membrane pale in the whole extent, except the last three Seet, where it was injected and oS a bright red ; this col- ored part thickened, all the rest thin ; twenty-Sour ulcers on the mucous membrane, most Srom three quarters oS an inch to an inch in diameter; these ulcers vary in depth, some oS them having penetrated all the coats except the peritoneum ; others not having penetrated the mucous coat, this being ele- 424 vated at their edges ; some oS them in the longitudinal direc- tion oS the intestine, occupying the patches oS Peyer's glands ; others in the transverse direction, occupying the whole circum- ference ; these ulcers are surrounded by perfectly pale, healthy mucous membrane, yielding strips as long as elsewhere, ex- cept just at the edge of the ulcers, where the membrane is thickened; in the last five inches one large ulcer, with a Sew small patches in it, isolated or in bands, oS thickened mucous membrane. Some Sew tubercles under the mucous membrane, and tuberculous matter on some oS the ulcers. Mesenteric glands enlarged, tuberculous; many oS them of a bright red in the middle, with a flat, or not bright, yellow substance at their circumference. Large intestines of moderate size, con- taining a whitish-yellow, opake liquid, no feces; caecum red, like the lower part oS ileum, with one small ulcer; the mu- cous membrane of the colon pale, with three or Sour ulcers, Srom halS an inch to an inch in diameter, the cellular membrane at the bottom thickened ; one large ulcer three inches by one and a halS at the upper part oS rectum, the whole mucous membrane below oS a very bright red, with one small ulcer. Liver, extends three inches below the edge oS the ribs ; oS a light yellow color; somewhat Sat; very Sriable ; containing scarcely any blood. Gall-bladder contains light yellow liquid bile. Spleen, small; natural in color and consistence ; with twro or three little, supernumerary spleens, oS the size of mar- bles. Kidney, size natural; external membrane easily re- moved ; the surSace under it polished ; the substance rather soft, and of light color, containing little blood. Bladder, nat- ural; mucous membrane of natural consistence. Uterus, very small; pale; with a little mucus on the mouth. Ovaries natural. 425 Femoral veins on both sides, distended with coagula of blood ; fibrine in concentric layers ; the coagula not adhering to the veins, and having no pus in their centres ; the veins in- ternally smooth, polished, natural. By the Editor. —We have here a very extensive tuberculous affection, apparently owing to an accidental disturbance of the functions. There is no evidence that the patient belonged to a tuberculous race ; but, so Sar as it goes, we have evidence to the contrary. The patient believed that she was quite well to the 6th oS June, 1832, when her catamenia were sud- denly arrested by a moral cause. Diarrhoea ensued at once, among other consequences, and became the most constant and, much oS the time, the most prominent symptom. This diar- rhoea was not accompanied with much pain ; sometimes, early in the disease and even subsequently, tenesmus was added. Cough, pain in the right side and dyspnoea likewise ensued, but were not very urgent, and often ceased nearly, or entirely. Yet, on Jan. 12th, there were physical signs to show the ex- istence of tubercles, particularly in the upper part of the right lung. These signs were yet more decided on Jan. 23d, and 28th. At this period we should note especially the loud and bronchial expiration. On the value attached to this sign, see page 340. The intestinal symptoms clearly point to ulcers in the intes- tines, and probably in the patches of elliptical glands in the small intestines. ASter the patient's entrance into the hospital, there were obvious symptoms oS chronic peritonitis, which M. Louis has never Sound to occur except in a tuberculous patient. Hectic Sever was established Srom Nov. 1832. The pulse was 84 on Jan. 12th, and increased to 120 early in Feb.; a 54 426 number which it did not exceed till April 27th. Once or twice there were symptoms, which might arise from organic disease of the heart, but they were inconstant and infrequent; and ultimately proved to be functional only. The Srequent vomiting, at the latter period of the disease, might have led to an expectation of some greater change of structure in the stomach, than was actually discovered after death. The phy- sical signs obtained by percussion and auscultation, even to the last days, on which the chest was explored, together with the absence of expectoration and slight cough, pointed out with great exactness the state of the lungs as ascertained after death. It may be useful to review these signs in connexion with the appearances post mortem. Jan. 12th, percussion on and behind the clavicles, was not very sonorous ; and at the summit behind, was less sonorous on the right than on the left; also below the right clavicle, the respiration was less pure than below the left; and below the former and at both summits behind, though most at the right, there was a little resonance of the voice. All this in a chronic case was almost certain evidence of tubercles in the summit of both lungs, but in a greater extent and to a greater amount on the right, than on the left. The subsequent observations almost uniformly confirmed this diagnosis, and showed that the disease was extending more in the right lung, than in the left. Jan. 23d, there was added the important observation that, below the right clavicle, there was a loud and bronchial expiration and a marked resonance of voice. Jan. 27th, the greater disease at the summit of the right lung, than at the left is confirmed ; and it is expressly stated that there is no rale there. Likewise there was no expectoration. Thus Sar then there was no tuberculous cavity opened by softening, or suppuration. Jan. 28th, the same or similar results are ob- 427 tained, and they are confirmed on 5th oS Feb. On the 6th, the extension oS disease in the right thorax is shown. On the 11th, the greater disease at the apex oS the right lung is again shown by the physical signs. March 5th, the increase oSthe disease on the posterior part oS the upper lobe on the right is shown by the bronchial expiration, and the same, less strongly marked, on the left. On this day is noted the greater sound of the heart immediately below the right clavicle, than two inches lower; a circumstance which arose from the ' more solid medium of sound in the former place than in the latter. March 11th, the increase of disease, at the left summit in front, was shown by the expiration and resonance of voice heard there. After this time the physical signs of disease in the chest are not noted, though the patient lived till the 4th of May; no doubt, because the increased weakness and the trouble pro- duced in the abdomen by any motion, rendered the examina- tion too inconvenient to the patient. But to the last we find the cough rare, and no expectoration. Likewise there was never rale, nor gurgling, nor pectoriloquy. It was therefore to be inferred, that there was not any cavity in communication with the air passages; and, probably, not any extensive soft- ening, if any at all, in the tubercles. It could hardly happen that the morbid state oS the lungs, discovered after death, should correspond with the signs above recounted, more exactly than they did. In the bronchia there were some appearances, which, I believe, to be unusual; but these were such as could not be detected by percussion, nor by auscultation. 1st. The mucous membrane of the bron- chia of the upper lobe were, generally, red and thickened, al- though they were not connected with any tuberculous cavities. 2d. Tuberculous matter was detected in one or two of these bronchia. I leave it to the leading pathologists of the 428 day, to whom these phenomena will be interesting, to esti- mate the value oS them. CASE XXX. CHRONIC PERITONITIS. TUBERCLES IN LUNGS AND ABDOMEN. Hospital la Pitie. Ward St. Charles, 26. Under the care of M. Louis. Jan. 8, 1833. — C. D., aet. 20, has always been a nursery maid. She was born in the south oS France, and has been in Paris two years. Her father is living, aet. 60, and is well; he has never had asthma, nor palsy; her mother died, aet. 36, oS some epidemic disease ; a brother died of small-pox, aet. 4 ; she has one sister, who is always ill, and three others, who enjoy good health. She has always been in good health, till her present disease began; was nursed by her mother; has always been well nourished ; was never short-breathed in child- hood. Her catamenia appeared for the first time at 17, and have been regular until within the last three months; they have usually been preceded, for two or three days, and accom- panied by headache, general uneasiness and pains, but not suf- ficient to prevent work ; and have not been attended by diar- rhoea, nor by pain in the chest. She has never been given to excesses of any description. Her present disease began three months and a halS since, during a catamenial visitation. Bis, menstruarum prima, die, invita et absque voluptate, genitalibus etiam valde cruciatis, viri amplexum subivit. She applied hot water to the external organs, and the menstrual flux was suppressed. The day Sollowing she had severe pains in the abdomen, dysuria and difficulty in walking, accompanied by heat and swelling oS the pudenda ; two days aSterwards leu- 429 corrhoea commenced. During the fifteen succeeding days, the leucorrhoea was abundant, and the dysuria severe; there was also anorexy, though little thirst; there were daily two loose dejections, never bloody, and entirely without colic. Since the suppression, the catamenia have never recurred; the leucorrhoea has continued, though not so abundant as at first, but in quality always the same. The appetite has re- turned in some measure, since the leucorrhoea diminished, but she has never regained the flesh, which she lost at the first. The diarrhoea has been almost constant since it commenced, though she was never subject to this affection previously. A cough began three weeks aSter the diarrhoea commenced ; it ceased three weeks ago. She has always been able to work, and has never undergone treatment of any kind. Now, Jan. 10th, leucorrhoea continues, but has been very slight, the last eight days ; the urine is rendered with ease and without burning; countenance natural; tongue a little white, rather moist; a little pain in throat; slight redness, without swelling of velum palati; appetite small, less since entrance ; a quarter of a pound of bread sufficient for a day; abdomen sensible to pressure, in every part, and a little sono- rous on percussion at the centre, but no tumors in it; some complaint of pain in bowels ; two dejections daily ; pulse not accelerated, nor large; a little cough for six days past, without expectoration ; no pain in chest; respiration easy ; percussion and auscultation give no unnatural results. Yesterday took enema of infusion of flaxseed, and a semi- cupium. (Rice water sweetened with syrup of gum arabic. A cup and a half of beef tea. Hip bath. Four ounces of infusion of flaxseed with decoction of poppy-heads, for an enema.) 430 Jan. 11. — Two dejections. Did not take enema yesterday. (Continue treatment. Enema twice.) Jan. 12.—Five dejections, three in night; abdomen less painful; a little meteorized on the right; leucorrhoea almost ceased ; heat oS skin moderate ; p. 100, under excitement oS mind ; 90 last evening ; a little cough since entrance ; respi- ration equally pure below both clavicles. (Same prescriptions. Cataplasm over bowels.) Jan. 13. — Four dejections ; slight meteorism oS abdomen, which is slightly painful; most so towards right side. (Same prescriptions.) Jan. 14.—Three dejections. (Six drops oS laudanum in enema.) Jan. 15. — Seven dejections; pain in abdomen is limited to a small space just below umbilicus, where there is a little meteorism. (Ten drops oS laudanum in enema. Gum potion.) Jan. 16. —Five dejections; otherwise as usual. (Rice water as on 11th, two quarts, and in it syrup oS white poppy heads, one ounce. A cup and a half oS beeS tea, or soup. Hip bath.) Jan. 19. — Leucorrhoea nearly ceased ; urine not rendered with ease Sor three last days, as previously ; no itching, nor pain in genital organs. (Enema with ten drops of laudanum.) Jan, 20. — Two dejections. (Prescription as on 16th.) Jan. 24. — On percussion, near the left summit behind, more flat than in same part at right; below, at the left, suffi- ciently sonorous. On auscultation, near the left summit be- hind, respiration is a little soft, not exactly coarse. In front, 431 on percussion, equally sonorous on and below both clavicles; respiration a little soft below the left; no resonance of voice at this place. Behind the clavicles, the physical signs the same as below them. For three days past, pain between shoulders. (Same prescription. One grain of opium in two pills.) Five, p. m. — P. 108; skin hot; below left clavicle res- piration is a little less full and expansive than below right; but no difference in expiration there. Behind, expiration is louder at left summit than at right; same difference in axillae. Jan. 26. — No sleep ; pain in left side. On the back, at the upper part of the lower third of chest, right side, the res- piration is a little more Seeble than at corresponding part oS the left. (Six leeches to the left side. Continue prescriptions.) Jan. 27, five, p. m. — Percussion gives much less clear sound below left clavicle, for the space of four or five inches, than below right. Respiration is more feeble in same parts at left than at right, except immediately below left clavicle, where it is louder and coarse. Below right clavicle the expiration is heard, though feeble, but not below left. Jan. 28. — Sub-crepitous rale low down in back at the right. Jan. 31, five, p. m. — During three last days, leucorrhoea and dysuria ; no ardor urinae ; no itching of parts, except dur- ing the flow of urine ; more pain in abdomen ; diarrhoea less than last week; cough very slight, but causes pain along tra- chea; this pain exists also without cough ; p. 104 ; resp. 24. At right summit behind, respiration coarse, an expiration is heard, and also a little resonance of voice; below right clavi- cle respiration less audible than below left, but no expiration. Feb. 10. — Since last date leucorrhoea has continued, diar- rhoea has been slight, headache on 1st to 3d instant, pulse 432 accelerated, and skin generally hot. Now, on the back res- piration is a little stronger, and is more pure and perfect at left than at right, except that at the summit it is stronger at right than at left. The left post-clavicular region is a little more full than the right. (Rice water sweetened with syrup of quince. Gum mix- ture with syrup of white poppies. Infusion of marsh-mallows for enema.) Feb. 16. — For fifteen days, meteorism of abdomen. For twelve nights past, sweat universal, but most on sides of chest; one dejection yesterday. On percussion below scapula, sono- rous on both sides; at the right summit behind, a resonance of voice ; a little less of it at left, at a place corresponding to half an inch lower than where it is heard at right; a little flat on percussion below the right clavicle ; and there there is a resonance of voice, while the respiration is less freely expansive than below the left. Also, an expiration, though feeble, below right clavicle, and at right summit behind; the same, very slight, at the left summit behind, but not at all below left clav- icle. The respiration is no where very strong; it is audible over the whole sternum, but more strong in the upper than the lower part, while the sound on percussion is more clear in the latter part than above. At the lower part of leSt breast the sound on percussion is very clear, as iS from stomach and in- testines. On the right breast percussion is painSul. On the back, the respiration is Suller Srom top to bottom at leSt than at right. The sternum projects rather than otherwise; the usual depression below it is scarcely visible ; when the patient is sitting up in bed, neither of the post-clavicular regions is depressed; but the right is less sonorous on percussion than the left. Countenance pale; lips violet; tongue moist, thin, of a natural color, except some little red points at tip; bad 433 taste ; deglutition easy ; thirst; anorexy almost complete ; no pain in throat; speech not painful to throat, but causes distress in middle of chest; eats a little bread, with beef tea, and sometimes a small piece of meat; pain and heat in stom- ach, oppression and sense of stuffing after eating ; never nau- sea, nor vomiting, nor eructations ; loves warm drinks ; two or three dejections, liquid, not very abundant, daily, with colics; pain in abdomen almost constant, especially at right side, with sensibility on pressure ; meteorism; frequent borborygmi; urine passed with difficulty, with slight pain and burning, two or three times a day ; discharge from vagina, either white or yellow, not very abundant, but constant; no pain, but great heat in parts, with occasional itching; no pain, nor swelling in groins ; no sense of weight at fundament; resp. 30, not very abdominal; p. 100, small; surface of body cool; headache and unpleasant sleep continue. Feb. 17. — Vomited yesterday for the first time since ab- dominal pains began ; matter rejected was bitter and greenish. Was cold after bath ; face flushed. (Same prescription as on 10th.) Feb. 18. — Not much sleep ; sweat. Tongue natural; meteorism and pains in abdomen continue; feels worst at night; p. 112, regular, feeble ; formerly rested equally well on both sides, but now lies on the right. Respiration a little more coarse at left summit behind than at right; slight resonance of voice there ; on percussion over post-clavicular and clavicular regions more sonorous at left than at right; respiration good at left; a slight blowing below right clavicle, without reso- nance of voice. (May take milk. Three porringers of beef tea.) From this time till the 26th, the prominent symptoms were 55 434 as Sollows: — vomiting oS bitter, green liquid, every day; pains and meteorism in abdomen as beSore; two or three de- jections daily ; chills and heat. (On the 23d, twelve grains oS Dover's powder were ordered daily; on the 25th, that was omitted, and halS a grain oS ex- tract oS opium substituted.) Feb. 26. — Pain about the region of the liver ; no vomit- ing ; pain in abdomen not increased by sitting up; skin hot. Other symptoms as beSore. Depression of parietes of chest much more marked behind and below right clavicle, and per- cussion less sonorous there than at left. Respiration heard below right clavicle, more feeble about the left; coarse and stronger at right summit behind ; at this last point resonance of voice mingled with a crackling sound; at the left summit behind, expiration more marked than at right. March 1. — Vomited yesterday twice without cough or difficulty; cough very slight; tongue a little thickened, whitish; heat slight; p. 100. March 2. — No vomiting ; cough in night only; pain in right side oS chest constantly. Form of the post-clavicular regions about the same ; percussion below the clavicles gives various results; sometimes at one, sometimes at the other, most sonorous ; on the back, at the middle third, in the right, percussion is obscure ; in the lower third it is entirely flat; and in this third the respiration is extremely feeble, without aegophony, or bronchophony; at this summit the inspiration is strong with expiration; at the left the inspiration is feeble, but very near the summit there is a deep bronchial expi- ration. From this time to the 18th, the reports are brief, mostly like those before, but the following should be noted. On the 14th, legs a little swollen ; urine only once for three days ; 435 catheter on 15th ; on 14th, a decidedly long expiration was heard below right clavicle, none below left. (Treatment was as before.) March 18. — No vomiting except when she sits up ; face a littie swollen ; p. 120; inclined to drowsiness; skin not hot. Respiration very obscure low down on back at left; coarse be- low right clavicle in both inspiration and expiration; percus- sion more sonorous on and behind left, than right clavicle. March 19. —Discharge from vagina continues in large quan- tity. March 20, five, p.m. — Extreme suffering this morning and now; resp. 60; pulse irregular, scarcely perceptible, cannot be counted ; much green vomiting ; does not answer ; takes no notice. Died on 21st, at one, a. m. Autopsy. Externally. — Right thigh very large ; some livid spots on the external face of each thigh; most on the right; round and deep blue spots on right side of abdomen ; same about the breast, of one or two lines in diameter. The fat on chest and abdomen about a line in thickness; on thighs it is three or four lines ; muscles rather pale. Head. — Slight effusion under arachnoid, and very slight injection of pia mater. Cortical substance pale, and of good consistence ; medullary substance of its ordinary color; halS an ounce of serous fluid in each lateral ventricle; corpora striata, cerebellum, medulla, oblongata, fyc, have all a healthy aspect. Chest. — Left lung elastic, soft; not indurated in any part; vesicles small. Both lungs are perfectly Sree Srom ad- hesions, but do not collapse, are rather light. Their lower lobes contain very little air, are slightly oedematous, flaccid and 436 of a violet red color. The upper lobe oS each contains a Sew tubercles and semi-transparent granulations ; the right contains more than the leSt, and in the Sormer there is one mass oS halS an inch in diameter. In the cavity oS the pleura, on each side, there are five or six ounces oS reddish serous fluid. The mucous membrane oS the bronchia is thin, pale, and polished; there are small tuberculous masses in the bronchial glands. On the epiglottis there are two or three little red spots; the mucous membrane oS the trachea is very slightly red through its whole extent, but is oS good consistence and oS its usual thickness. The heart is smaller by one half than usual, but natural as to its texture in every part, and as to its valves. The pericar- dium contains four ounces of clear serous fluid. Abdomen.—Four quarts of a troubled liquid in peritoneal cavity. The right iliac fossa is generally of a red color, mingled with yellow; the yellow spots are Srom one to two lines in diameter, they are round and projecting. The redness is owing to a Salse membrane which is thin and can be raised in strips. In this membrane the tuberculous matter is softened, and beneath it the peritoneum is pale and still covered with some few tu- bercles. The adjacent parts of the small intestines, Sor the space oS Sour or five Seet, present on their surSace a multitude of little projections oS yellow bodies, Srom one to two lines thick, some confluent, others separated and distinct. They are developed beneath the peritoneum, and in this part the con- volutions of intestines Sorm three partial adhesions, whereby the calibre oS the tube is evidently lessened. The stomach is of middling size; internal surSace covered with considerable quantity of very adhesive mucus, and which cannot be removed without great difficulty. The surface is generally of a whitish or greenish hue ; its mucous membrane 437 is very thin ; strips Srom one to two lines in length in the great cul-de-sac ; two to three along the great curvature; and of good consistence in small curvature. The surSace is not mam- elonated anywhere. There are many little points oS a dark green hue in various parts, but especially on the posterior Sace without corresponding depressions or elevations ; but the ap- pearance recalled that produced by Peyer's glands when in a healthy state. Small intestines are one third larger than usual Srom disten- tion with gas. They are decidedly shorter than usual; the pa- rietes through the whole length are twice as thick as common. They contain a large quantity oS green liquid with much mucus. In the last Sour feet are eight transverse ulcers, all but one oS which goes entirely round the organ ; three solitary ; five are near together. They are generally halS an inch broad; their edges are hard and elevated in consequence of the tubercles and semi-transparent granulations contained in them. The edges of the ulcers are gray, — their surfaces grayish or greenish. The mucous, sub-mucous and muscular membranes are very much thickened. The mucous membrane of the intestine is a little softened towards duodenum, and becomes more so on descend- ing, where the strips are almost nothing. Large intestines are pale throughout whole extent. There is a large ulceration in the caecum, and some tubercles there. Mucous membrane is so soft, that it may be scraped up like mucus, and has many little grayish spots with central points. There is a thickening, owing to an infiltration of the serous and muscular coats. The liver is large, fatty, with some red lines internally. On its external surface are numerous little gray, semi-transparent bodies like starch, which can be removed, and are found to be in a false membrane. 438 Gall-bladder, thickened in consequence oS infiltration oS tuberculous matter. It contains a green viscid bile. The spleen contains a few, little, semi-transparent granula- tions. The kidneys are natural. The bladder is, at its urethra, oS a deep red ; otherwise it is pale and natural. The uterus is healthy. Between the uterus and rectum is a Salse membrane, red, thickened and covered with tubercles, as in right iliac Sossa. The Semoral vein oS the right thigh is filled and distended through its whole extent by firmly coagulated blood, which does not contain any pus and is not adherent to parietes. These parietes are redder and a little thicker, than those oS the opposite side, where the vein was very slightly distended, and by liquid blood. By the Editor. — This case should be compared with the preceding. In both^ there was a sudden suppression oS the menses in subjects apparentiy healthy. It will, not however, be easily believed that the consequences would have follow- ed in any one, not predisposed to tuberculous disease. It is to be noted that the genital organs were very tender, at the first, in this case. There was produced an inflammation pro- bably, a morbid state certainly, of those organs ; and this was an exciting cause of a distinct disease in the abdomen. It is impossible to decide whether tubercles were formed first in the lungs. IS we regard the history oS this case alone, it would seem probable that they were formed first in the abdo- men. But there is much evidence to show that, usually, tu- bercles are formed in the lungs, beSore they are Sormed in any other part, and this would lead us to doubt, as to this case. 439 It would seem, 1st, that the disease within the intestines was developed very early, causing the diarrhoea; 2d, that the dis- ease in the peritoneum was Sormed soon afterwards in the ricrht iliac fossa, causing tenderness in that part. Possibly the tuberculous disease between the rectum and uterus occur- red at the very first, when the genital organs were the seat of an acute inflammatory affection. The connexion of some subsequent abdominal symptoms, such as the meteorism, may easily be traced out. The rational and physical symptoms both indicated the ex- istence of tubercles in the lungs, but the latter much more strongly than the former. Meanwhile symptoms of both kinds forbad the belief that the tubercles had softened; or, if they had, that they had any communication with the bronchia. There was no expectoration, or none of a purulent character; there was no gurgling, and once only a slight crackling sound even ; and no pectoriloquy was discovered, though some re- sonance of voice was observed at the summit of both lungs, especially the right. This sign was referrible to crude tuber- cles compressing the vesicles. The physical signs, which gave evidence of tubercles at the summits of the two lungs, but most in the right, were, 1st. The resonance of voice already noticed ; 2d. The expira- tion, at times quite prolonged; 3d. The absence of full and expansive murmur of respiration ; 4th. The flatness, or want of full resonance, on percussion. These signs were found, back and front, over the apex of the right lung, on the back only over that of the left. The post mortem appearances corresponded to these signs. These are by far the most important points, as regards the lungs. It may, however, be fair to remark that the other physical signs might have justified an expectation of some morbid phe- 439 nomena not found within the thorax. In the two lower lobes oS the right lung, or in the lower, at least, we ought not to have expected perSectly natural appearances; and under the sternum, projecting as it was, we were authorized to look for emphysema in the margin of at least one lung. Yet the oedema may account for the physical signs which were notic- ed ; and we should think this would be admitted very easily, were it not that there was not the difference in the two lungs, which was indicated beSore death. May it not be, that the oedema in the left lung occurred at a much later period, than that at the right ? NOTE BY THE EDITOR. At page 199, it is stated, that some explanatory remarks might appear to me necessary, after seeing the cases in print. Very few, however, have occurred to me as requisite, and those not important. At page 198, it is said, " I have omitted cases, which did not terminate fatally, &c." It should have been said," I have, for the most part, omitted, &c." It will be seen that all the cases inserted did not terminate fatally. Those which did not, were admitted on account of their peculiar interest. In stating the results of auscultation and percussion of the chest, various questions occurred as to the phraseology to be employed. The thorax has been divided into several regions by some physicians of the day, such as the acromial, infra- clavian, mammary, he., with a view to a more definite refer- ence to its various parts. It would, no doubt, be useful, if some arrangement of this kind were universally adopted. But, if adopted, the terms must be employed in the original notes of the observations. My son did not employ such terms, and if I had substituted them, it would have been with a risk of in- accuracy, as the words he has used are not always synonymous 56 442 with those above referred to. I have therefore adhered to the words employed by him, or to such as are precisely equivalent. In speaking oS the right and left side of the thorax, he does not refer to the lateral regions; thus, by the right side he means the right thorax, or right half of the thorax. He then divides the thorax into the front and back, but Sor the last word he uses always another, viz. ; behind. Thus he says, " right side, behind," instead oS saying the right side of the back. The last expression would have been more imme- diately understood by all readers, and I thought oS adopting it. But in copying there is a difficulty in changing words, which are Srequently recurring ; one Sorgets to make the change once in three or Sour times, and then the conSusion is greater. When there is uniSormity in the language, it soon explains it- selS, or rather is explained by the context. Thus, I think the reader cannot Sail to discover that, by the words " summit, behind," the writer means the post-acromial region, or the portion oS the back above the scapula, considering this as ex- tending inward as Sar as the vertebrae. English writers have differed as to the translation oS the word rale ; some have adopted the French word itselS, others have substituted rattle, and others have adopted rhonchus. The objections to the word rattle have been so obvious, that it has not been much employed. For the word rhonchus we have some respectable authority, yet it has not met with very general Savor, and I have Sound it hard to adopt it, though at one time willing to do so. The word rale is, in truth, em- ployed in common parlance among us, and I believe in Eng- land ; and I cannot see any objection to its being Sully adopt- ed. There are good reasons in Savor oS it, such as its easy ut- terance, compared with rhonchus, and a respect Sor the inventor oS auscultation, which will justiSy the introduction oS a word 443 Srom his vernacular tongue. I wish there had been as good a reason Sor the introduction of all the French words we employ. Besides, rale is the word employed in the original notes of these cases. I have, thereSore, continued it. In looking over the medicines prescribed in the Soregoing cases, I find less occasion Sor explanation than was anticipa- ted, when 1 wrote the note on page 199. The most impor- tant remedies are venesection and tartarized antimony. When the latter is directed, the number of grains is mentioned, but the division of doses is not pointed out. As I understand it, when a certain quantity of this medicine is ordered, it is meant that that quantity should be taken in the course of the day, so divided as that a dose may be taken once in six hours. Of other remedies, there are none very powerful except opium, and this is usually given in very moderate doses. Where the dose is equal to half a grain, it is specified. The syrup of gum and solution of this syrup, are nothing else than a solution oS gum arabic sweetened, with the addition oS something to give it an agreeable flavor. I believe that it is the solution which is meant, when the former name is used. The gum potion varies in different hospitals and in the hands of different practitioners, as the white mixture for a cough does among us. In some instances it has a little opiate with it. One of the simplest Sormulae Sor it is as Sollows, from which that used at the Hospital de la Pitie does not probably differ essentially. Take of gum arabic half an ounce, syrup of orange flowers an ounce, mix and rub together in a mortar, gradually adding of infusion of wild poppy Sour ounces. This quantity would usually be given to the patient at once, with directions to sip it in the course oS the day as he should find agreeable. The articles first named, syrup oS gum, &c. 444 are to be taken ad libitum, only the quantity to be used in one day is limited. An enema is understood to mean an enema oS the infusion of flaxseed, of which a pint is usually given. Sometimes the half only is ordered, but I have not been precise in noting this. There is not any other article, in respect to which any doubt will arise; and as to the strength of the preparation and the doses, I find nothing worthy any further remark. By strict diet; sometimes the word diet being used alone, it is meant that the patient should abstain Srom all nourishment except in a liquid Sorm, and of the least nutritious character. Gum water and barley water would be the best articles permit- ted under this prescription. END. ol r. ~*~ 4&&^9k -"N £ 'WZ 100 J137J 1835 opening: pg^. IS E openiny. py=- * - -• ac_ i :|ubUeJ f.um J— 23rd-M-y 15th 1?^ Thy Bifth of Clinical MedKi.*, Paris 179h-1=^6j *■''. NATIONAL LIBRARY OF MEDICINE NLM 00^66783 1 «*V yj\- &*■ 'm m < rr $? ^ *v« ,#•. #' NLM009887831